Results of a Randomized Trial of Screening, Brief Intervention, and Referral to Treatment (SBIRT) to Reduce Alcohol Misuse Among Active-Duty Military Personnel.

OBJECTIVE: Rates of heavy alcohol use among active-duty military personnel in the United States are high and negatively affect individuals within the service branches. This study tested the effectiveness of a military-focused screening, brief intervention, and referral to treatment (SBIRT) intervention for reducing risky alcohol use among active-duty patients. METHOD: We used a randomized, parallel, two-group design to test the effectiveness of the SBIRT intervention in a convenience sample of service members recruited from the emergency department of a military hospital. A total of 791 participants were randomized to the SBIRT or usual care conditions, and 472 participants (59.7%) completed a 6-month follow-up. Fifteen percent of the sample was female. Self-reported Alcohol Use Disorders Identification Test (AUDIT), controlled drinking self-efficacy (CDSE), and readiness to change drinking behaviors were assessed at baseline and follow-up. RESULTS: Among higher risk participants (i.e., AUDIT ≥8), results of a complete case analysis showed a significant reduction in scores on the AUDIT-C (consumption questions from the AUDIT) and a significant increase in CDSE. Null findings were observed for intent-to-treat analyses testing the effectiveness of the SBIRT intervention; significant decreases in AUDIT and AUDIT-C scores and significant increases in CDSE were observed over time, irrespective of condition assignment for both complete case and intent-to-treat analyses. CONCLUSIONS: Results of a complete case analysis provided some support for the effectiveness of the SBIRT intervention for higher risk participants. The results of the more conservative intent-to-treat analyses did not support any of the study hypotheses. Future SBIRT effectiveness trials should also test electronic SBIRT intervention approaches.

Intravenous Recombinant Tissue Plasminogen Activator and Ischemic Stroke: Focused Update of 2010 Clinical Practice Advisory From the American Academy of Emergency Medicine.

BACKGROUND: Stroke treatment is a continuum that begins with the rapid identification of symptoms and treatment with transition to successful rehabilitation. Therapies for acute ischemic stroke (AIS) may vary based on anatomic location, interval from symptom onset, and coexisting health conditions. Successful therapy requires a seamless systematic approach with coordination from prehospital environment through acute management at medical facilities to disposition and long-term care of the patient. The emergency physician must balance the benefits and risks of alteplase recombinant tissue plasminogen activator (rtPA) for AIS management. OBJECTIVE: We review the recent medical literature on the topic of AIS and assess intravenous rtPA for the following questions: 1) is there any applicable, new, high-quality evidence that the benefits of intravenous rtPA are justified in light of the harms associated with it, and 2) if so, does the evidence clarify which patients, if any, are most likely to benefit from the treatment. METHODS: A MEDLINE literature search from January 2010 to October 2016 and limited to human studies written in English for articles with keywords of cerebrovascular accident and (thromboly* OR alteplase). Guideline statements and nonsystematic reviews were excluded. Studies targeting differences between specific populations (males vs. females) were excluded. Studies identified then underwent a structured review from which results could be evaluated. RESULTS: Three hundred twenty-two papers on thrombolytic use were screened and nine appropriate articles were rigorously reviewed and recommendations given. CONCLUSIONS: No new studies published between 2010 and 2016 meaningfully reduced uncertainty regarding our understanding of the benefits and harms of intravenous rtPA for AIS. Discussions regarding benefit and harm should occur for patients, and risk prediction scores may facilitate the conversation.

Adaptation of Screening, Brief Intervention, Referral to Treatment to Active Duty Military Personnel in an Emergency Department: Findings From a Formative Research Study.

BACKGROUND: The transient nature of military life coupled with environmental and psychosocial stressors increase the risk for alcohol misuse and abuse among active duty (AD) military service members and recent epidemiological studies demonstrate high rates of heavy drinking among AD personnel. Over the past decade, Department of Defense health care systems have observed increases in the utilization of substance use services among military personnel demobilizing from Operation Enduring Freedom and Operation Iraqi Freedom. Given the high rates of heavy drinking and increased use of substance use services in this population of AD personnel, the purpose of this study was to investigate how to best translate and implement an effective alcohol abuse prevention intervention tool (screening, brief intervention, and referral to treatment [SBIRT]) used in civilian populations to a military emergency department (ED) setting. METHODS: We conducted focus groups with ED staff as well as short interviews with AD personnel at a Naval Medical Center in the southwestern United States to determine the suitability of SBIRT with military populations as well as how to best translate SBIRT to a military hospital setting. FINDINGS: Participants expressed support for utilizing civilian health educators to conduct the SBIRT intervention; however, many were concerned with issues of confidentiality and were skeptical of whether AD would speak truthfully about alcohol consumption. CONCLUSIONS: Results of this formative research study clearly indicate the implementation and translation of SBIRT into a military medical setting require attention to issues related to confidentiality, the veracity of alcohol reporting, as well as use of civilians over AD military personnel to deliver the SBIRT intervention. Furthermore, most participants expressed support for the SBIRT model and felt it could be implemented, with caveats, into a military health care setting such as an ED.

Navy En Route Care: A 3-Year Review of 428 Navy Air Evacuations.

BACKGROUND: Navy medical personnel have been recording en route care (ERC) missions through Search and Rescue (SAR) reports since the 1970's. Our objective was to report clinical ERC cases treated by Navy operational assets from January 2012 to January 2015. METHODS: The Search and Rescue Model Manager office collects SAR reports for all patient transports involving Navy personnel and equipment. From these reports, descriptive statistics to include total number of patients transported, percentages of Advanced Life Support versus Basic Life Support transports, time of transport, and type of ERC provider for the transport were collected. Data reported as median (interquartile range) or percentages. RESULTS: During a 3-year period, 428 patients were transported. Transport time was 54 (30-78) minutes. Missions were staffed by more than one provider 22% of the time. Individual providers included 76% Search and Rescue Medical Technicians, 25% Flight Surgeons, and 21% Other. Patients required ALS transport 54% of the time. Less than half (48%) of the patients were trauma related. CONCLUSION: In our review of 428 SAR reports from Navy ERC (2012-2015), we found that 76% of the missions were performed by Search and Rescue Medical Technicians and 54% met Advanced Life Support transport criteria.

Military Emergency Medical Service System Assessment: Application of the National Park Service Needs Assessment and Program Audit to Objectively Evaluate the Military EMS System of Okinawa, Japan.

INTRODUCTION: As part of a Military Emergency Medical Services (EMS) system process improvement initiative, the authors sought to objectively evaluate the U.S. military EMS system for the island of Okinawa. They applied a program evaluation tool currently utilized by the U.S. National Park Service (NPS). METHODS: A comprehensive needs assessment was conducted to evaluate the current Military EMS system in Okinawa, Japan. The NPS EMS Program Audit Worksheet was used to get an overall "score" of our assessment. After all the data had been collected, a joint committee of Military EMS physicians reviewed the findings and made formal recommendations. RESULTS: From 2011 to 2014, U.S. military EMS on Okinawa averaged 1,345 ± 137 patient transports annually. An advanced life support (ALS) provider would have been dispatched on 558 EMS runs (38%) based on chief complaint in 2014 had they been available. Over 36,000 man-hours were expended during this period to provide National Registry Emergency Medical Technician (EMT)-accredited instruction to certify 141 Navy Corpsman as EMT Basics. The NPS EMS Program Audit Worksheet was used and the program scored a total of 31, suggesting the program is well planned and operating within standards. CONCLUSION: This evaluation of the Military EMS system on Okinawa using the NPS program assessment and audit worksheet demonstrates the NPS evaluation instruments may offer a useful assessment tool for the evaluation of Military EMS systems.

Disaster Preparedness among Active Duty Personnel, Retirees, Veterans, and Dependents.

BACKGROUND: With the increase in natural and manmade disasters, preparedness remains a vital area of concern. Despite attempts by government and non-government agencies to stress the importance of preparedness, national levels of preparedness remain unacceptably low. A goal of commands and installations is to ensure that US Navy beneficiaries are well prepared for disasters. This especially is critical in active service members to meet mission readiness requirements in crisis settings. OBJECTIVE: To evaluate active duty Navy personnel, dependents, veterans, and retirees regarding disaster preparedness status. METHODS: The authors conducted an anonymous 29-question survey for US Navy active duty, dependents, veterans, and retirees of the Greater San Diego Region (California, USA) evaluating actual basic disaster readiness as determined by the Federal Emergency Management Agency (FEMA) standards of 3-day minimum supply of emergency stores and equipment. Descriptive statistics and regression analysis were used to analyze data. RESULTS: One thousand one hundred and fifty surveys were returned and analyzed. Nine hundred and eight-three were sufficiently complete for logistic regression analysis with 394 responding "Yes" to having a 72-hour disaster kit (40.1%) while 589 had "No" as a response (59.9%). CONCLUSION: The surveyed population is no more prepared than the general public, though surveyed beneficiaries overall are at an upper range of preparedness. Lower income and levels of education were associated with lack of preparedness, whereas training in disaster preparedness or having been affected by disasters increased the likelihood of being adequately prepared. Unlike results seen in the general public, those with chronic health care needs in the surveyed population were more, rather than less, likely to be prepared and those with minor children were less likely, rather than more likely, to be prepared. Duty status was assessed and only veterans were emphatically more probable than most to be prepared.

Safety and efficacy of milk and molasses enemas in the emergency department.

BACKGROUND: Increased scrutiny is occurring from regulatory agencies about the use of nonsterile enema preparations in the emergency department (ED) for constipation. This includes the "off-label" use of milk and molasses (M&M) enemas, as there are no reported data in the medical literature to determine safety and efficacy. OBJECTIVES: To evaluate the success and complication rates of administering M&M enemas in the ED. METHODS: This was a structured retrospective study at two EDs over 8 years. Primary success was defined as the patient having a bowel movement. Secondary measures of success included improved pain score by 2 or more points or lowering of a heart rate initially over 100 beats/min by 20 or more beats/min. Complications included: hemodynamic compromise, increased pain, electrolyte disturbances, bacteremia, bowel perforation, rectal pain or bleeding, cardiac dysrhythmias, anaphylaxis, electrolyte disturbances, dizziness or syncope, or hospital admission for issues surrounding enema. RESULTS: There were 2013 enemas given, of which 261 were M&M enemas; 214 were given alone. Success rates defined only as bowel evacuation for M&M enemas alone were 87.9% (188/214) and, when used after other treatment failures, were 82.4% (28/34) successful. Five additional patients improved with the secondary measures (90.2% success). There were 8/261 complications (3.1%), of which four had an increased heart rate, two had decreased blood pressure, one had an increased pain score, and one subsequently developed a fever. CONCLUSION: M&M enemas have a low complication rate when used in the ED.

American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department.

BACKGROUND: Droperidol (Inapsine®, Glaxosmithkline, Brent, UK) is a butyrophenone used in emergency medicine practice for a variety of uses. QT prolongation is a well-known adverse effect of this class of medications. Of importance to note, QT prolongation is noted with multiple medication classes, and droperidol increases QT interval in a dose-dependent fashion among susceptible individuals. The primary goal of this literature search was to determine the reported safety issues of droperidol in emergency department management of patients. METHODS: A MEDLINE literature search was conducted from January 1995 to January 2014 and limited to human studies written in English for articles with keywords of droperidol/Inapsine. Guideline statements and nonsystematic reviews were excluded. Studies identified then underwent a structured review from which results could be evaluated. RESULTS: There were 542 papers on droperidol screened, and 35 appropriate articles were rigorously reviewed in detail and recommendations given. CONCLUSION: Droperidol is an effective and safe medication in the treatment of nausea, headache, and agitation. The literature search did not support mandating an electrocardiogram or telemetry monitoring for doses < 2.5 mg given either intramuscularly or intravenously. Intramuscular doses of up to 10 mg of droperidol seem to be as safe and as effective as other medications used for sedation of agitated patients.

Disaster preparedness of poison control centers in the USA: a 15-year follow-up study.

There is limited published literature on the extent to which United States (US) Poison Control Centers (PCCs) are prepared for responding to disasters. We describe PCCs' disaster preparedness activities and compare and contrast these results to those previously reported in the medical literature. We also describe the extent to which PCCs are engaged in disaster and terrorism preparedness planning and other public health roles such as surveillance. An electronic questionnaire was sent via email to the managing directors of the 57 member PCCs of the American Association of Poison Control Centers. Collected data included the population served and number of calls received, extent of disaster preparedness including the presence of a written disaster plan and elements included in that plan, the presence and nature of regular disaster drills, experience with disaster including periods of inability to operate, involvement in terrorism and disaster preparedness/response policy development, and public health surveillance of US PCCs. Descriptive statistics were performed on collected data. Comparisons with the results from a previously published survey were performed. A response was obtained from 40/57 (70 %) PCCs. Each PCC serves a larger population (p < 0.0001) and receives more calls per year (p = 0.0009) than the previous descriptions of PCC preparedness. More centers report the presence of a written disaster plan (p < 0.0001), backup by another center (p < 0.0001), regular disaster drills (p < 0.0001), and comfort with ability to operate in a disaster (p < 0.0001) than previously described. PCCs are involved in disaster (34/40, 85 %) and terrorism (29/40, 73 %) preparedness at the local, state, or federal levels. PCCs (36/40, 90 %) are also involved in public health functions (illness surveillance or answering "after hours" public health calls). Despite an increase in calls received and population served per center as compared to previous descriptions, more PCCs report the presence of a written disaster plan, backup by another center, regular disaster drills, and comfort in ability to operate in a disaster. PCCs are actively involved in terrorism and disaster preparedness and response planning and traditional public health responsibilities such as surveillance.

Secure scalable disaster electronic medical record and tracking system.

INTRODUCTION: Electronic medical records (EMRs) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass-casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. Report As the prehospital disaster EMR allows for more robust content including protected health information (PHI), security measures must be instituted to safeguard these data. The Wireless Internet Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld, linked, wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. This system has been field tested in a number of exercises with excellent results, and future iterations will incorporate robust security measures. CONCLUSION: A secure prehospital triage EMR improves documentation quality during disaster drills.

Tissue plasminogen activator and stroke: review of the literature for the clinician.

BACKGROUND: Alteplase (tPA) is a United States (US) Food and Drug Administration-approved treatment for acute ischemic stroke, though there are significant barriers to thrombolytic use, including Emergency Physicians' (EPs') concern for level of supporting evidence. STUDY OBJECTIVES: To review the medical literature on the topic of acute cerebrovascular accident (CVA) management and to offer EPs evidence-based recommendations for patients who present to the Emergency Department with an acute CVA. METHODS: A MEDLINE literature search from 1990 to 2011 and limited to human studies written in English for articles with keywords of: CVA AND (thromboly* OR alteplase). Guideline statements and non-systematic reviews were excluded. Studies targeting differences between specific populations (males vs. females) were excluded. Studies identified then underwent a structured review from which results could be evaluated. RESULTS: There were 407 papers on thrombolytic use screened, and 15 appropriate articles were rigorously reviewed and recommendations given. CONCLUSIONS: tPA is an effective treatment for stroke when given in prepared stroke centers; EPs and hospitals treating stroke patients with tPA need to have the necessary resources in place and a specific plan for timely care of patients with acute stroke.

Ultrasound evaluation of cranial and long bone fractures in a cadaver model.

BACKGROUND: Ultrasound has been utilized in various settings for evaluation and treatment of skeletal injuries. Bone has different tissue acoustic impedance than soft tissue allowing visualization of the cortical disruption found in fractures. OBJECTIVE: To determine emergency physicians' accuracy in diagnosing cranial and long bone fractures using ultrasound. METHODS: This multi-center prospective double-blinded study used high-frequency linear ultrasound to detect induced fractures among eight test locations from eight cadaver models. After a standard orientation, blinded emergency physicians interpreted real-time sonographic images of test locations. RESULTS: Proximal tibia combined sensitivity (SE)/specificity (SP) was 87.3/69.8% with a combined positive predictive value (PPV)/negative predictive value (NPV) of 84.6/74.3%. Distal radius combined SE/SP was 93.7/93.5% with a combined PPV/NPV of 93.4/90.8%. Frontal combined SE/SP was 84.1/88.9% with a PPV/NPV of 84.9/88.3%. Temporal-parietal combined SE/SP was 95.2/87.9% with a PPV/NPV of 94.8/88.2%. Time to decision varied from less than 10 seconds to 357 seconds. Mean time to decision was 43 to 63 seconds depending on fracture site. CONCLUSION: Ultrasound by trained emergency medicine physicians can reliably identify fractures in the radius, tibia, frontal, and temporal bones in a very short amount of time, allowing for triage, treatment, and resource management.

Paraganglioma causing a myocardial infarction.

Paragangliomas, extra-adrenal pheochromocytomas, are rare and classically associated with sustained or paroxysmal hypertension, headache, perspiration, palpitations, and anxiety. A 49-year-old male, parachute instructor, likely developed a hypertensive emergency when deploying his parachute leading to a myocardial infarction. A para-aortic tumor was incidentally discovered during the patient's emergency department work-up and was eventually surgically resected. He had no evidence of coronary disease during his evaluation. This case shows that a myocardial infarction may be the initial manifestation of these neuroendocrine tumors. Hypertensive emergency, much less elevated blood pressure may not be present at time of presentation.

Excited delirium syndrome (ExDS): treatment options and considerations.

The term Excited Delirium Syndrome (ExDS) has traditionally been used in the forensic literature to describe findings in a subgroup of patients with delirium who suffered lethal consequences from their untreated severe agitation.(1-5) Excited delirium syndrome, also known as agitated delirium, is generally defined as altered mental status and combativeness or aggressiveness. Although the exact signs and symptoms are difficult to define precisely, clinical findings often include many of the following: tolerance to significant pain, rapid breathing, sweating, severe agitation, elevated temperature, delirium, non-compliance or poor awareness to direction from police or medical personnel, lack of fatiguing, unusual or superhuman strength, and inappropriate clothing for the current environment. It has become increasingly recognized that individuals displaying ExDS are at high risk for sudden death, and ExDS therefore represents a true medical emergency. Recently the American College of Emergency Physicians (ACEP) published the findings of a white paper on the topic of ExDS to better find consensus on the issues of definition, diagnosis, and treatment.(6) In so doing, ACEP joined the National Association of Medical Examiners (NAME) in recognizing ExDS as a medical condition. For both paramedics and physicians, the difficulty in diagnosing the underlying cause of ExDS in an individual patient is that the presenting clinical signs and symptoms of ExDS can be produced by a wide variety of clinical disease processes. For example, agitation, combativeness, and altered mental status can be produced by hypoglycemia, thyroid storm, certain kinds of seizures, and these conditions can be difficult to distinguish from those produced by cocaine or methamphetamine intoxication.(7) Prehospital personnel are generally not expected to differentiate between the multiple possible causes of the patient's presentation, but rather simply to recognize that the patient has a medical emergency and initiate appropriate stabilizing treatment. ExDS patients will generally require transfer to an emergency department (ED) for further management, evaluation, and definitive care. In this paper, we present a typical ExDS case and then review existing literature for current treatment options.

Pneumomediastinum caused by isolated oral-facial trauma.

Pneumomediastinum from isolated blunt or penetrating oral-facial trauma is a rare occurrence, which can be associated with facial fractures or may be iatrogenic. We present two cases caused by high-pressure-induced facial injuries that had very different management and outcomes. The first patient had asymptomatic pneumomediastinum and an uncomplicated recovery, whereas the second had a complicated clinical course requiring extensive surgical debridement. Neither patient developed mediastinitis as a complication of pneumomediastinum. This case series illustrates isolated facial trauma causing pneumomediastinum and reviews the literature over last 20 years for similar cases. The authors advocate emergency department management of pneumomediastinum from facial trauma.