Positive Predictive Value of Noninvasive Stress Testing Is Poor in the Real World.

Abnormal noninvasive stress test (NIST) findings do not always correlate with angiographically significant (luminal obstruction ≥50%) coronary artery disease. Positive predictive value (PPV) of NIST in the real clinical practice is not well known. The goal of this retrospective study was to determine the PPV of NIST and assess the factors affecting PPV in a US community hospital. This study included all consecutive patients (n = 355) who underwent invasive coronary angiography after a positive NIST within ~1-year duration at our institution. Three hundred twenty-four patients were included in the analysis after exclusion of 31 patients. Sixty percent of patients were female and mean age was 63.2 (SD 12.4). Myocardial perfusion imaging, echocardiogram (treadmill or dobutamine), and treadmill electrocardiogram were the tests of choice in 95% (n = 307), 4% (n = 14), and 1% (n = 3) of patients, respectively. Overall PPV of NIST was 36.4% (118/324). When patients were stratified by age (<50 years, 50-65 years, ≥65 years), older age groups had significantly higher PPV (<0.001). When patients were grouped by body mass index (<25, 25-30, ≥30), those in lower body mass index groups had higher PPV (P = 0.01). Stress echocardiogram had significantly higher PPV compared with myocardial perfusion imaging stress test (71% vs. 35%; P < 0.005). Stress test site (in-hospital vs. outpatient office) or specialty of interpreting physician did not significantly impact PPV. Multivariable logistic regression analysis revealed that older age, male sex, and total number of cardiac risk factors were significant determinants of higher PPV. Our single-center study revealed that overall PPV of NIST is poor (36.4%), more notably in young, female, or obese patients.

Pyuria and Urine Cultures in Patients with Acute Renal Colic.

BACKGROUND: Renal colic caused by stone(s) is common in the emergency department. Often, urinalysis reveals white blood cells, but it is unknown how frequently pyuria is sterile or infectious. OBJECTIVES: We sought to determine the incidence of pyuria in patients with renal colic and to correlate the incidence with a positive urine culture. METHODS: A 1-year retrospective review of adult patients with renal colic presenting to three community emergency departments was performed. Patients without confirmed renal stone(s) or completed urinalysis were excluded. Hematuria is defined as ≥5 red blood cells per high power field (RBC/HPF) and pyuria as >10 white blood cells per high power field (WBC/HPF). A positive urine culture is defined as >100,000 colony forming units per milliliter. Student's t-test, chi square, or Fisher's exact tests were performed as appropriate, with significance set at 0.05. RESULTS: There were 339 patients who satisfied the inclusion and exclusion criteria, and 14.2% of these patients had associated pyuria. There were 153 (45.1%) urine cultures performed, and 16 (10.5%) were positive. Patients with pyuria were more likely to have a positive urine culture (36.4% vs. 3.3%, respectively; p < 0.001). The percentage of positive urine cultures increased (p < 0.001) with increasing pyuria from 9.1% (10-20 WBC/HPF) to 60.0% (>50 WBC/HPF). Positive cultures also increased (p < 0.001) with increased leukocyte esterase observed on macroscopic samples, from 1.6% (small or less leukocyte esterase) to 77.8% (large-volume leukocyte esterase). CONCLUSION: Pyuria was found in 14.2% of patients with renal colic. Patients with pyuria had 36.4% positive cultures compared to 3.3% of patients without pyuria. The degree of pyuria or leukocyte esterase was significantly associated with the risk of a positive culture. Urine cultures are recommended for all patients with renal colic and pyuria.

Assessing knowledge base on geriatric competencies for emergency medicine residents.

INTRODUCTION: Emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. Older adults often require distinctive assessment, treatment and disposition. Emergency medicine (EM) residents should develop expertise and efficiency in geriatric care. Older adults represent over 25% of most emergency department (ED) volumes. Yet many EM residencies lack curricula or assessment tools for competent geriatric care. Fully educating residents in emergency geriatric care can demand large amounts of limited conference time. The Geriatric Emergency Medicine Competencies (GEMC) are high-impact geriatric topics developed to help residencies efficiently and effectively meet this training demand. This study examines if a 2-hour didactic intervention can significantly improve resident knowledge in 7 key domains as identified by the GEMC across multiple programs. METHODS: A validated 29-question didactic test was administered at six EM residencies before and after a GEMC-focused lecture delivered in summer and fall of 2009. We analyzed scores as individual questions and in defined topic domains using a paired student t test. RESULTS: A total of 301 exams were administered; 86 to PGY1, 88 to PGY2, 86 to PGY3, and 41 to PGY4 residents. The testing of didactic knowledge before and after the GEMC educational intervention had high internal reliability (87.9%). The intervention significantly improved scores in all 7 GEMC domains (improvement 13.5% to 34.6%; p<0.001). For all questions, the improvement was 23% (37.8% pre, 60.8% post; P<0.001) Graded increase in geriatric knowledge occurred by PGY year with the greatest improvement post intervention seen at the PGY 3 level (PGY1 19.1% versus PGY3 27.1%). CONCLUSION: A brief GEMC intervention had a significant impact on EM resident knowledge of critical geriatric topics. Lectures based on the GEMC can be a high-yield tool to enhance resident knowledge of geriatric emergency care. Formal GEMC curriculum should be considered in training EM residents for the demands of an aging population.

Multidimensional attitudes of emergency medicine residents toward older adults.

INTRODUCTION: The demands of our rapidly expanding older population strain many emergency departments (EDs), and older patients experience disproportionately high adverse health outcomes. Trainee attitude is key in improving care for older adults. There is negligible knowledge of baseline emergency medicine (EM) resident attitudes regarding elder patients. Awareness of baseline attitudes can serve to better structure training for improved care of older adults. The objective of the study is to identify baseline EM resident attitudes toward older adults using a validated attitude scale and multidimensional analysis. METHODS: Six EM residencies participated in a voluntary anonymous survey delivered in summer and fall 2009. We used factor analysis using the principal components method and Varimax rotation, to analyze attitude interdependence, translating the 21 survey questions into 6 independent dimensions. We adapted this survey from a validated instrument by the addition of 7 EM-specific questions to measures attitudes relevant to emergency care of elders and the training of EM residents in the geriatric competencies. Scoring was performed on a 5-point Likert scale. We compared factor scores using student t and ANOVA. RESULTS: 173 EM residents participated showing an overall positive attitude toward older adults, with a factor score of 3.79 (3.0 being a neutral score). Attitudes trended to more negative in successive post-graduate year (PGY) levels. CONCLUSION: EM residents demonstrate an overall positive attitude towards the care of older adults. We noted a longitudinal hardening of attitude in social values, which are more negative in successive PGY-year levels.

Education on prehospital pain management: a follow-up study.

INTRODUCTION: The most common reason patients seek medical attention is pain. However, there may be significant delays in initiating prehospital pain therapy. In a 2001 quality improvement (QI) study, we demonstrated improvement in paramedic knowledge, perceptions, and management of pain. This follow-up study examines the impact of this QI program, repeated educational intervention (EI), and effectiveness of a new pain management standard operating procedure. METHODS: 176 paramedics from 10 urban and suburban fire departments and two private ambulance services participated in a 3-hour EI. A survey was performed prior to the EI and repeated one month after the EI. We reviewed emergency medical services (EMS) runs with pain complaints prior to the EI and one month after the EI. Follow-up results were compared to our prior study. We performed data analysis using descriptive statistics and chi-square tests. RESULTS: The authors reviewed 352 surveys and 438 EMS runs with pain complaints. Using the same survey questions, even before the EI, 2007 paramedics demonstrated significant improvement in the knowledge (18.2%; 95% CI 8.9%, 27.9%), perceptions (9.2%; 95% CI 6.5%, 11.9%), and management of pain (13.8%; 95% CI 11.3%, 16.2%) compared to 2001. Following EI in 2007, there were no significant improvements in the baseline knowledge (0%; 95% CI 5.3%, 5.3%) but significant improvements in the perceptions of pain principles (6.4%; 95% CI 3.9%, 9.0%) and the management of pain (14.7%; 95% CI 11.4%, 18.0%). CONCLUSION: In this follow up study, paramedics' baseline knowledge, perceptions, and management of pain have all improved from 6 years ago. Following a repeat educational intervention, paramedics further improved their field management of pain suggesting paramedics will still benefit from both initial and also ongoing continuing education on the topic of pain management.

Restraint use in the elderly emergency department patient.

BACKGROUND: The elderly frequently suffer from altered mental status and other medical conditions requiring physical or chemical restraint for safety in the Emergency Department (ED). OBJECTIVE: This study examined outcomes of restrained elderly patients in the ED. METHODS: A 2-year retrospective study was conducted in an urban community teaching hospital ED. Included were patients ≥65 years of age who were physically restrained in the ED and hospitalized. Data collected included age, gender, restraint indications, restraint type, restraint duration, adverse outcomes, ED discharge diagnosis, ED disposition, hospital length of stay, and disposition. RESULTS: There were 83 patients in the study. Forty-seven (56.6%) were nursing home residents. Twenty-seven (32.5%) were admitted to the intensive care unit. Thirty-five (42.2%) received both chemical and physical restraint. The average number of patient medications on arrival to the ED was eight, and 3 patients were on a medication that could adversely interact with a chemical restraint medication. The mean inpatient length of stay was 7.2 days (SD 5.7 days). Ten patients expired, 14 were discharged home, and 59 were discharged to a nursing facility (8 with new behavioral medications). Of the 36 patients originally presenting to the ED from home, only 11 (30.6%) were discharged back to home. There were no significant differences in outcome between patients who received a combination of both chemical and physical restraints and patients who received physical restraint alone. CONCLUSION: In this 2-year retrospective study, elderly patients placed in physical restraints in the ED had no recorded adverse outcomes. In addition, there were no adverse outcomes when they received both physical and chemical restraint. Elderly patients who were originally admitted from home and subsequently required physical restraint were unlikely to return home.

Rapid progression of Wellens syndrome in the emergency department.

BACKGROUND: In 1982, Wellens and colleagues described characteristic electrocardiogram (ECG) findings in angina patients virtually pathognomonic for significant stenosis of the proximal left anterior descending coronary artery and associated with a high risk of acute anterior wall myocardial infarction. CASE REPORT: We present the case of a 74-year-old emergency department patient with classic ECG findings of Wellens syndrome and progression to acute ST elevation within 55 min. SUMMARY: We present this case to increase awareness among emergency physicians of the characteristic findings of Wellens syndrome.

Malpractice claims on emergency physicians: time and money.

BACKGROUND: Emergency medicine, with its limited time for patient encounters, unpredictable flow, and lack of a continuing patient-physician relationship, is a particularly high-risk field with regards to the issue of medical liability. There have been limited studies on the financial and time exposure emergency physicians face when confronted with a liability suit. OBJECTIVES: Provide practicing physicians with guidance as to what can be expected if they are confronted with a medical malpractice claim, and contribute to the literature as the issue of tort reform is debated. METHODS: Retrospective study of all closed malpractice claims involving emergency physicians insured by the Illinois State Medical Inter-insurance Exchange covering the 10-year period 1995 to 2004. RESULTS: Of 450 claims, there were 200 cases served. The median incident-to-close time was 45.5 months (interquartile range [IQR] 30.6-69.9). The median expense per claim served was $14,091 (IQR $3448-$44,363); 19.5% of cases resulted in an indemnity with a median of $220,000 (IQR $117,500-$700,000). Cases in which an indemnity was eventually made tended to be filed 7.7 months faster (p = 0.065) and took 14.1 months longer to close (p < 0.05). In cases with a payout of ≥ $1,000,000, 80% were in the ≤ 1-year age group. CONCLUSION: In this study, emergency physicians with malpractice suits can expect resolution of the case to take over 45 months after an alleged incident, and their malpractice insurer will incur over $14,000 in expenses regardless of the suit outcome. Cases involving patients aged ≤ 1 year may incur higher indemnity payments.

Molar pregnancy in the emergency department.

A 15-year-old female presented to the emergency department with complaints of vaginal bleeding. She was pale, anxious, cool and clammy with tachycardic, thready peripheral pulses and hemoglobin of 2.4g/dL. Her abdomen was gravid appearing, approximately early to mid-second trimester in size. Pelvic examination revealed 2 cm open cervical os with spontaneous discharge of blood, clots and a copious amount of champagne-colored grapelike spongy material. After 2L boluses of normal saline and two units of crossmatched blood, patient was transported to the operating room. Surgical pathology confirmed a complete hydatidiform mole.

Pulmonary embolism despite negative ELISA D-dimer: a case report.

Pulmonary embolus (PE) can be fatal, but is often treatable if recognized early. Unfortunately, the clinical presentation of PE is often variable and misleading. The D-dimer assay has recently come into favor as a method to exclude PE; however, this test has an acceptable safety margin only in low-risk populations. What is unclear is the exact composition of this low risk population. This is the report of a 26-year-old woman with over 2 weeks of chest pain and intermittent dyspnea. The patient was initially seen in the Emergency Department (ED) and hospitalized. She returned to the ED 2 weeks later with similar symptoms. Although enzyme-linked immunosorbent assay (ELISA) D-dimer assays were normal on the initial and subsequent ED visits, pulmonary embolism (PE) was diagnosed by computed tomography scan on the second visit. This report highlights the risk of misdiagnosing PE if relying solely on ELISA D-dimer for exclusion. The approach to PE should include a measure of clinical probability. This report documents the presentation of PE despite having two unremarkable ELISA D-dimer measurements, and highlights the importance of clinical suspicion.

Pneumoperitoneum without peritonitis: a case report.

Pneumoperitoneum (PP), or air within the abdominal cavity, is frequently the harbinger of serious abdominal pathology and frequently represents visceral perforation. Most cases of PP ultimately need surgical exploration and intervention. In addition, cases of nonsurgical PP have also been described in the literature, and it has been suggested that these cases can be managed conservatively. This report documents the occurrence of incidentally found PP. However, it is unclear how often PP is found incidentally, and more importantly how to manage the patient with clinically unsuspected PP without peritoneal signs. Future research could help to better determine the incidence of unsuspected PP and to validate the various diagnostic and treatment algorithms in the literature.

Patient satisfaction and return to daily activities using etomidate procedural sedation for orthopedic injuries.

OBJECTIVES: With regard to sedative agents used in procedural sedation and analgesia (PSA), such as etomidate, the focus has been on variables usually related to side effect profile and the success rates of various procedures, with both variables specifically taking place during the patients' stay in the emergency department (ED). There have been no extensive data on the functional status of patients after they leave the ED following PSA. METHODS: Prospective questionnaire evaluating functional status among consecutive adult patients discharged from the ED after undergoing etomidate PSA for orthopedic procedures. RESULTS: The study sample consisted of 26 cases using only etomidate for closed orthopedic reductions. The mean age was 50.1 years (SD: 20.5), mean weight 86.3 kg (SD: 17.2), and 61.5% were males. The average dose of etomidate given was 0.14 mg/kg with 26.9% requiring a second dose of 0.11 mg/kg. The average dose of analgesic given was 0.11mg/kg in morphine equianalgesic units. The median time between procedural sedation and return to normal sleep was 36 hours, while return to operating a motor vehicle or return to work was 72 hours. Overall, 80% to 100% of respondents felt that any temporary dysfunction was secondary to the orthopedic problems and not to the procedural sedation. CONCLUSION: In this small follow-up study, adult patients undergoing PSA with etomidate for orthopedic closed reduction attribute post-discharge functional disability to the injury sustained and not to the PSA itself.

Tinnitus as a measure of salicylate toxicity in the overdose setting.

INTRODUCTION: The development of tinnitus and/or hearing loss (THL) in patients receiving chronic salicylate therapy has been demonstrated. However, to date, little scientific data validates this relationship in the large single overdose setting. OBJECTIVE: To correlate salicylate levels in patients with the subjective complaint of THL, following an acute salicylate overdose. METHODS: A retrospective chart review of cases of acute salicylate toxicity and THL reported to the Illinois Poison Control Center (IPC) from 2001-2002 was performed. Data abstracted included age, gender, ingestion time, salicylate levels, and arterial blood gases. RESULTS: Ninety-nine cases of THL were reviewed and analyzed with mean age of 23.7 years (SD: 10.9), 30.3% male, and 82.2% intentional overdoses. The average dose ingested was 20.0 grams (SD:20.2) and the mean time from ingestion to medical care was 12.4 hours (SD: 11.1). The mean initial ASA level was 48.3 mg/dl (SD: 16.4) with 86.9% having initial level >/=30mg/dl and 40.4% >/=50 mg/dl. 85.9% of cases presented to the hospital with their ASA level at or past peak. The mean pH was 7.45, pO2 = 108, pCO2 = 28.0, and HCO3 = 19.9. CONCLUSION: In this limited study, 85.9% of patients presenting with tinnitus and/or hearing loss following a single salicylate ingestion had initial salicylate levels at or past their peak and 86.9% were in the toxic range.

Injuries sustained at Yellowstone National Park requiring emergency medical system activation.

OBJECTIVE: Outdoor-related activity has been on the rise in recent years, and hiking and backpacking are among those activities with the largest growth in participation. As the number of participants with varying experience increases, it is expected that there will be an increase in injuries related to these activities. Little empirical data exist related to outdoor injury types and rates. Our objectives were to determine incidence and frequency of injuries related to outdoor activity and requiring emergency medical system (EMS) activation at a national park. METHODS: This retrospective study examines injuries within Yellowstone National Park. Subjects were selected from a database containing all EMS calls within Yellowstone National Park from calendar year 2003 through 2004. Data collected included age, gender, type of injury, location, activity at the time of injury, and EMS response. RESULTS: There were 306 injuries reviewed. The mean age of patients was 40.9 years (SD: 23.0), and the group comprised 49.0% males. Emergency medical system transport was not required in 59.2% of injuries, and of those transported, 58.4% of patients required basic life support only. Of all injuries, 77.4% involved soft tissue, including lacerations. Hiking and walking accounted for 38.0% of all injuries, and 56.0% of those injuries involved the lower extremity. Only 8.8% of the injuries involved fractures and/or dislocations. CONCLUSIONS: In this study of EMS responses at a national park, the majority of injuries sustained were minor in nature. More than one third of injuries occurred while patients were hiking or walking, and most of those injuries involved the lower extremity. These results will help optimize resource planning in the national park setting.

Effects of an educational intervention on prehospital pain management.

INTRODUCTION: Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. OBJECTIVES: To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. METHODS: All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. RESULTS: The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%; p < 0.001). Paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p < 0.001), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p < 0.001) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%; p < 0.001) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%; p < 0.001) improvement in pain reassessment following intervention. CONCLUSION: As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.