Less encouraging lessons from the front lines: barriers to implementation of an emergency department-based HIV screening program.

Objective: We describe barriers to, and discuss recommendations for, implementing a limited emergency department (ED)-based HIV screening program.

Methods: A pilot program was designed to study the feasibility of integrating HIV screening into ED care among patients aged 18 to 64 years at an urban academic emergency department with an annual census of 50,000 patients.

Results: During the first 12 weeks of the pilot program, 395 patients were screened.

Right atrial thrombus secondary to pacemaker wires.

Background: Pacemaker-induced right atrial thrombus is a rare condition that has not been described in the Emergency Medicine literature. This is a potentially fatal condition that is diagnosed with an echocardiogram and treated with surgical removal, thrombolytics, or long-term anticoagulation.

Objectives: This case report is designed to increase awareness among emergency physicians of this potentially fatal condition.

In-flight automated external defibrillator use and consultation patterns.

Background: Limited information exists about the in-flight use and outcomes associated with automated external defibrillators (AEDs) on commercial airlines.

Objective: To describe the characteristics and outcomes of AED use during in-flight emergencies including in-flight cardiac arrest and the associated ground medical consultation patterns.

Methods: We collected cases of AED use that were self-reported to an airline consultation service from three U.

How much force is required to dislodge an alternate airway?

Introduction: Endotracheal tube (ETT) dislodgment is a potentially catastrophic adverse event. Newer alternate airway devices-esophageal-tracheal Combitube (ETC), King laryngeal tube disposable airway (King LT), and laryngeal mask airway (LMA)-are easier to insert, but their relative extubating forces remain unknown.

Objective: To examine the applied forces required to dislodge an ETC, King LT, LMA, and ETT.

Management of prehospital seizure patients by paramedics.

Background: Seizure patients are frequently encountered in the prehospital environment and have the potential to need advanced interventions, though the utility of advanced life support (ALS) interventions in many of these patients has not been proven.

Objective: Our goals were to assess the management of prehospital seizure patients by paramedics in an urban EMS system with an existing ALS-based prehospital seizure protocol and to assess characteristics and short-term outcomes that may aid in addressing the utility of specific ALS interventions.

Methods: This was a retrospective study of 97 EMS cases with the chief complaint of seizure.

Lumbar puncture and post-dural puncture headaches: implications for the emergency physician.

Lumbar puncture is a diagnostic procedure commonly performed by emergency physicians. Post-dural puncture headaches occur frequently after this procedure and can be associated with significant morbidity and, occasionally, even death. There is also a lot of variation in how post-dural puncture headaches are treated once they occur.

Case series: diverticulitis in the young.

Diverticulitis has long been regarded as a disease of the elderly, but its incidence has been increasing in those under age 40. Younger patients with diverticulitis are more likely to be male and obese. They often have atypical presentations, and 25% may have right lower quadrant pain.

Evaluation of respiratory function during Reeves stretcher use.

Objective: We were aware of a small number of cases in our EMS system where patients in respiratory distress had a worsening of their condition after being removed from the home on a Reeves stretcher (RS). We sought to determine if this prehospital lifting device causes additional respiratory effort used in normal subjects by describing changes in heart rate, pulse oximetry, tidal volume, minute ventilation, and respiratory rate.

Methods: Forty-nine subjects were entered into this study.

Drug-assisted effects on protective airway reflexes during out-of-hospital endotracheal intubation (preliminary report).

Objective: Out-of-hospital rescuers often use drug-assisted intubation (DAI) to facilitate endotracheal intubation (ETI) of nonarrest patients. However, the relationship between the ablation of individual protective airway reflexes and resulting DAI success has not been defined. We sought to describe the relationship between the depression or ablation of protective airway reflexes and DAI success.

Limited opportunities for paramedic student endotracheal intubation training in the operating room.

Background: Paramedics, who often are the first to provide emergency care to critically ill patients, must be proficient in endotracheal intubation (ETI). Training in the controlled operating room (OR) setting is a common method for learning basic ETI technique.

Objectives: To determine the quantity and nature of OR ETI training currently provided to paramedic students.

Quality of BLS decreases with increasing resuscitation complexity.

Objective: Multiple procedures performed in parallel may cause each procedure to be performed less effectively than if performed in isolation. BLS performed by prehospital providers potentially includes artificial ventilations, chest compressions, and application of an automated external defibrillator (AED). This study examines the effectiveness of artificial ventilation and chest compressions both with and without an AED.

Errors of omission in the treatment of prehospital chest pain patients.

Objective: Despite the widespread use of standard treatment protocols, there are few published data regarding paramedic protocol adherence. In this descriptive study, the authors sought to assess the frequency and nature of deviations from a standardized treatment protocol for the chief complaint of chest pain. They also sought to quantify any time delays in treatment of potential ischemic cardiac chest pain.

Use of an emergency department by nonurgent patients.

Objectives: The objectives of this study are (1) to determine whether patients seeking emergency department (ED) nonurgent care have primary care providers (PCP) or know of other care sources and (2) to determine the reasons why they choose to use the ED.

Methods: A cross-sectional survey in a university ED was administered to self-referred nonurgent patients for 6 weeks. Use of a PCP, knowledge and attempts to seek other care, past use of the ED, urgency self-report, time of visit, and reasons for choosing an ED were recorded.

Two-thumb vs. two-finger chest compression in an infant model of prolonged cardiopulmonary resuscitation.

Objective: Previous experiments in the authors' swine lab have shown that cardiopulmonary resuscitation (CPR) using two-thumb chest compression with a thoracic squeeze (TT) produces higher blood and perfusion pressures when compared with the American Heart Association (AHA)-recommended two-finger (TF) technique. Previous studies were of short duration (1-2 minutes). The hypothesis was that TT would be superior to TF during prolonged CPR in an infant model.

Patients' perceptions of route of nonsteroidal anti-inflammatory drug administration and its effect on analgesia.

Objective: There is a commonly held belief among health care providers that patients respond better to parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) than to oral forms by virtue of the patients' belief that getting an injection means they are receiving "stronger" medicine. To the authors' knowledge, this effect has never been adequately documented in the literature. The objective of this study was to compare the effects of a placebo analgesic injection vs placebo oral analgesia on patients with acute musculoskeletal pain.

The myth of the fecalith.

A radiographically demonstrated fecalith is widely considered a virtually pathognomonic sign of acute appendicitis. This case report describes a patient with a clinical presentation suggestive of appendicitis and a well-defined right lower quadrant fecalith who was found to have a normal appendix at surgery. This case calls into question the venerable dogma surrounding the fecalith and highlights the necessity for the physician to continue to rely on clinical judgment in making the diagnosis of appendicitis.

Radiographic interpretation in the emergency department.

This study examined the concordance of radiographic readings between emergency department (ED) attending physicians and radiologists in a community teaching hospital. In addition, the incidents of misinterpretations leading to an alteration in patient care were also reviewed. All radiographs obtained from January through October 1993 were initially interpreted by ED attending physicians with subsequent final review by attending radiology staff.

A meta-analysis of blunt cardiac trauma: ending myocardial confusion.

The purpose of this study was to use a meta-analysis of the current literature to identify which patients with blunt cardiac trauma develop complications. All studies on myocardial contusion since 1967 were reviewed. Three separate meta-analyses were performed: one with only prospective studies, one with only retrospective studies, and one with all studies combined.

The use of propofol for sedation in the emergency department.

Objective: To evaluate the effectiveness of propofol and fentanyl when used by emergency physicians (EPs) for systemic sedation and analgesia in the ED.

Methods: Over an eight-month period, a convenience sample of consenting patients at an urban teaching hospital ED who required sedation for painful procedures were enrolled in a descriptive study of therapeutic propofol sedation. After receiving 2 micrograms/kg of fentanyl i.

The esophageal detector device: accuracy and reliability in difficult airway settings.

Introduction: The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult.

Methods: This was a prospective, randomized, single-blinded, controlled laboratory investigation.

A comparison of chest compressions between mechanical and manual CPR by monitoring end-tidal PCO2 during human cardiac arrest.

Study Objective: To compare the use of mechanical and manual chest compressions during cardiac arrest based on continuous monitoring of end-tidal PCO2 (PETCO2).

Design: Prospective, randomized, crossover design.

Setting And Participants: Fifteen consecutive adults ranging in age from 33 to 78 years who presented in nontraumatic cardiac arrest to the emergency department of a large teaching hospital.

Intravenous adenosine in the prehospital treatment of paroxysmal supraventricular tachycardia.

Study Objective: To determine the clinical efficacy and safety of IV adenosine administration in the field for the treatment of paroxysmal supraventricular tachycardia (PSVT).

Design: Prospective, consecutive case series.

Setting: An urban emergency medical services system.

Complete recovery following an unusual cardiac stab wound.

A 17-year-old female was stabbed in the chest and found by paramedics in extremis. She arrived at the receiving hospital with spontaneous respirations and an improved blood pressure. Upon thoracotomy in the operating room, lacerations through the main pulmonary artery and the left atrium were found.