Emergency Department Well-being Initiatives During the COVID-19 Pandemic: An After-action Review.

The COVID-19 pandemic has significantly impacted the well-being of our health care professionals, particularly frontline providers in the emergency department (ED). Our ED, located in New York City, was severely affected, exposing the staff to a combination of unique stressors. Our ED Wellness Committee responded by implementing various initiatives focusing on the physical, mental, and social needs of our providers to support them through this difficult time. The initiatives we describe offer a framework that may help other departments understand the importance of provider well-being during a pandemic.

Protecting the front line: a cross-sectional survey analysis of the occupational factors contributing to healthcare workers' infection and psychological distress during the COVID-19 pandemic in the USA.

OBJECTIVE: The COVID-19 pandemic has been associated with significant occupational stressors and challenges for front-line healthcare workers (HCWs), including COVID-19 exposure risk. Our study sought to assess factors contributing to HCW infection and psychological distress during the COVID-19 pandemic in the USA. DESIGN: We conducted a cross sectional survey of HCWs (physicians, nurses, emergency medical technicians (EMTs), non-clinical staff) during May 2020. Participants completed a 42-item survey assessing disease transmission risk (clinical role, work environment, availability of personal protective equipment) and mental health (anxiety, depression and burn-out). SETTING: The questionnaire was disseminated over various social media platforms. 3083 respondents from 48 states, the District of Columbia and US territories accessed the survey. PARTICIPANTS: Using a convenience sample of HCWs who worked during the pandemic, 3083 respondents accessed the survey and 2040 participants completed at least 80% of the survey. PRIMARY OUTCOME: Prevalence of self-reported COVID-19 infection, in addition to burn-out, depression and anxiety symptoms. RESULTS: Participants were largely from the Northeast and Southern USA, with attending physicians (31.12%), nurses (26.80%), EMTs (13.04%) with emergency medicine department (38.30%) being the most common department and specialty represented. Twenty-nine per cent of respondents met the criteria for being a probable case due to reported COVID-19 symptoms or a positive test. HCWs in the emergency department (31.64%) were more likely to contract COVID-19 compared with HCWs in the ICU (23.17%) and inpatient settings (25.53%). HCWs that contracted COVID-19 also reported higher levels of depressive symptoms (mean diff.=0.31; 95% CI 0.16 to 0.47), anxiety symptoms (mean diff.=0.34; 95% CI 0.17 to 0.52) and burn-out (mean diff.=0.54; 95% CI 0.36 to 0.71). CONCLUSION: HCWs have experienced significant physical and psychological risk while working during the COVID-19 pandemic. These findings highlight the urgent need for increased support for provider physical and mental health well-being.

Novel Use of Telepalliative Care in a New York City Emergency Department During the COVID-19 Pandemic.

BACKGROUND: Coronavirus-2 (COVID-19) is a global pandemic. As of August 21, mortality from COVID-19 has reached almost 200,000 people, with the United States leading the globe in levels of morbidity and mortality. Large volumes of high-acuity patients, particularly those of advanced age and with chronic comorbidities, have significantly increased the need for palliative care resources beyond usual capacity. More specifically, COVID-19 has changed the way we approach patient and family member interactions. DISCUSSION: Concern for nosocomial spread of this infection has resulted in strict visitation restrictions that have left many patients to face this illness, make difficult decisions, and even die, alone in the hospital. To meet the needs of COVID patients, services such as Emergency Medicine and Palliative Care have responded rapidly by adopting novel ways of practicing medicine. We describe the use of telepalliative medicine (TM) implemented in an emergency department (ED) setting to allow family members the ability to interact with their loved ones during critical illness, and even during the end of life. Use of this technology has helped facilitate goals of care discussions, in addition to providing contact and closure for both patients and their loved ones. CONCLUSION: We describe our rapid and ongoing implementation of TM consultation for our ED patients and discuss lessons learned and recommendations for others considering similar care models.

Anaphylaxis induced bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia: A-BRASH in the emergency department.

The emergency department (ED) is responsible for managing a variety of acute illnesses including undifferentiated shock. A newer less recognized syndrome termed BRASH - bradycardia, renal failure, AV-node blockers, shock and hyperkalemia - is a cycle of synergy between hyperkalemia and AV-blockade that can result in shock. This entity is more common amongst the elderly, considering polypharmacy and co-morbid diseases. Some cases have an inciting trigger of hypovolemia. Anaphylaxis is a potentially lethal form of shock that most emergency physicians (EP) treat in the ED. The two entities have never occurred simultaneously. Herein, we report a case of anaphylaxis induced BRASH syndrome occurring in an elderly diabetic man. The EP should be aware of this unique presentation of BRASH. It was concluded that the patient's anaphylaxis, caused hypovolemia, coupled with polypharmacy, and physiological stress, precipitated this severe form of shock and multi-organ system failure.

Conscious Proning: An Introduction of a Proning Protocol for Nonintubated, Awake, Hypoxic Emergency Department COVID-19 Patients.

The novel coronavirus, or COVID-19, has rapidly become a global pandemic. A major cause of morbidity and mortality due to COVID-19 has been the worsening hypoxia that, if untreated, can progress to acute respiratory distress syndrome (ARDS) and respiratory failure. Past work has found that intubated patients with ARDS experience physiological benefits to the prone position, because it promotes better matching of pulmonary perfusion to ventilation, improved secretion clearance, and recruitment of dependent areas of the lungs. We created a systemwide multi-institutional (New York-Presbyterian Hospital enterprise) protocol for placing awake, nonintubated, emergency department patients with suspected or confirmed COVID-19 in the prone position. In this piece, we describe the background literature and the approach we have taken at our institution as we care for a high burden of COVID-19 cases with respiratory symptoms.

Intravenous Lidocaine Provides Similar Analgesia to Intravenous Morphine for Undifferentiated Severe Pain in the Emergency Department: A Pilot, Unblinded Randomized Controlled Trial.

OBJECTIVES: We compared the analgesic effects of intravenous (IV) lidocaine and IV morphine for the treatment of severe pain in the emergency department (ED). METHODS: This was a pilot, unblinded randomized controlled study comparing the efficacy of IV lidocaine vs IV morphine for patients aged ≥18 years with severe pain (numerical rating scale [NRS] ≥ 7). Participants were randomized to receive IV lidocaine (75 mg if <50 kg, 100 mg if 50-100 kg, and 150 mg if >100 kg) over 10 minutes, followed by a 50-minute IV lidocaine infusion of the same dose or provider-chosen dose of morphine. Participants were eligible for rescue morphine. The primary outcome was the difference in patients' mean reported pain at 60 minutes. Secondary outcomes included total morphine consumption, patient satisfaction, and side effects. RESULTS: Thirty-two patients were enrolled. The lidocaine arm's mean pain NRS at 60 minutes was 5.1 (95% confidence interval [CI] = 3.3 to 6.8) compared with 4.2 (95% CI = 3.0 to 5.4) in the morphine arm, and the absolute difference was 0.9 (95% CI = -1.2 to 2.9). Among participants in the lidocaine and morphine arms, 13% and 38%, respectively, had side effects. Patient satisfaction was similar in both arms (87% and 88%). Lidocaine arm patients averaged 4.5 mg of IV morphine (95% CI = 3.0 to 6.0) compared with 8.4 mg (95% CI = 6.9 to 9.8) in the morphine arm, an absolute difference of 3.9 mg (95% CI = 1.8 to 5.9). CONCLUSIONS: We found similar pain relief and satisfaction in both study arms. Lidocaine arm participants had fewer side effects and required less morphine. Lidocaine is a potential opioid-sparing analgesic that deserves further study for severe pain in ED patients.

Slow Infusion of Low-dose Ketamine Reduces Bothersome Side Effects Compared to Intravenous Push: A Double-blind, Double-dummy, Randomized Controlled Trial.

OBJECTIVE: We compared the analgesic efficacy and incidence of side effects when low-dose (0.3 mg/kg) ketamine (LDK) is administered as a slow infusion (SI) over 15 minutes versus an intravenous push (IVP) over 1 minute. METHODS: This was a prospective, randomized, double-blind, double-dummy, placebo-controlled trial of adult ED patients presenting with moderate to severe pain (numerical rating scale [NRS] score ≥ 5). Patients received 0.3 mg/kg ketamine administered either as a SI or a IVP. Our primary outcome was the proportion of patients experiencing any psychoperceptual side effect over 60 minutes. A secondary outcome was incidence of moderate or greater psychoperceptual side effects. Additional outcomes included reduction in pain NRS scores at 60 minutes and percent maximum summed pain intensity difference (%SPID). RESULTS: Fifty-nine participants completed the study. A total of 86.2% of the IVP arm and 70.0% of the SI arm experienced any side effect (difference = 16.2%, 95% confidence interval [CI] = -5.4 to 37.8). We found a large reduction in moderate or greater psychoperceptual side effects with SI administration-75.9% reported moderate or greater side effects versus 43.4% in the SI arm (difference = 32.5%, 95% CI = 7.9 to 57.1). Additionally, the IVP arm experienced more hallucinations (n = 8, 27.6%) than the SI arm (SI n = 2, 6.7%, difference = 20.9%, 95% CI = 1.8 to 43.4). We found no significant differences in analgesic efficacy. At 60 minutes, the mean %SPID values in the IVP and SI arms were 39.9 and 33.5%, respectively, with a difference of 6.5% (95% CI = -5.8 to 18.7). CONCLUSION: Most patients who are administered LDK experience a psychoperceptual side effect regardless of administration via SI or IVP. However, patients receiving LDK as a SI reported significantly fewer moderate or greater psychoperceptual side effects and hallucinations with equivalent analgesia.

Ultrasound-guided Greater Auricular Nerve Block for Emergency Department Ear Laceration and Ear Abscess Drainage.

BACKGROUND: Adequate emergency department (ED) anesthesia for painful ear conditions, such as ear lacerations or ear abscesses, can be challenging. Much of the sensory innervation of the ear is supplied from the anterior and posterior branches of the greater auricular nerve (GAN). The GAN is a branch of the superficial cervical plexus, which arises from the C2/C3 spinal roots. The GAN innervation includes most of the helix, antihelix, the lobule, and the skin over the mastoid process and parotid gland. Anesthesia of the GAN is commonly performed in emergency medicine as part of a landmark-based ear "ring" block. Recently, a selective ultrasound-guided GAN block has been described. CASE REPORT: We report the first cases of ultrasound-guided greater auricular nerve block (UGANB) successfully performed in the ED as the sole procedural anesthesia for both an ear laceration and abscess drainage. In addition, we review the relevant anatomy and technical details of the procedure. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our cases suggest that UGANB is a potentially effective nerve block for ED management of acute ear pain related to procedures involving the tail of the helix and the lobule, such as ear lacerations or ear abscess incision and drainage. Advantages include real-time visualization of the GAN that may increase block success and the decreased volume of local anesthetic required for a block.

Horner's Syndrome after Superficial Cervical Plexus Block.

Ultrasound-guided nerve blocks are becoming more essential for the management of acute pain in the emergency department (ED). With increased block frequency comes unexpected complications that require prompt recognition and treatment. The superficial cervical plexus block (SCPB) has been recently described as a method for ED management of clavicle fracture pain. Horner's syndrome (HS) is a rare and self-limiting complication of regional anesthesia in neck region such as brachial and cervical plexus blocks. Herein we describe the first reported case of a HS after an ultrasound-guided SCPB performed in the ED and discuss the complex anatomy of the neck that contributes to the occurrence of this complication.

Ultrasound-guided dorsal penile nerve block for ED paraphimosis reduction.

Adequate anesthesia for emergency department management of painful penile conditions such as paraphimosis or priapism is often both technically challenging and inconsistent using traditional landmark-based techniques of the dorsal penile block (DPB). The pudendal nerves branch to form the paired dorsal nerves of the penis providing sensory innervation to the skin of both the dorsal and ventral aspects of the penis. "Blind" DPB techniques tend to rely on subtle tactile feedback from the needle and visual landmark approximation to identify the appropriate subpubic fascial compartment for injection. The landmark-based DPB is not standardized with options including "10 o'clock and 2 o'clock" infrapubic injections with or without ventral infiltration or a ring block. Given the lack of standardization and inherent technical imprecision with the landmark-based DPB, large volumes of local anesthetic (up to 50 mL) are sometimes required to achieve a clinically adequate block. In addition, inadvertent injection into the corpora cavernosa may occur. More recently, an ultrasound-guided approach has been developed. Using ultrasound, the dorsal penile nerves can be precisely targeted in the fascial compartment just deep to Buck fascia, potentially increasing block success rate and reducing the need for large local anesthetic volumes. Herein, we report the first adult case of an ultrasound-guided dorsal penile nerve block performed in the emergency department for the reduction of a paraphimosis and review the relevant penile anatomy and technical details of the procedure.

Outcomes of crural ligation surgery for isolated crural venous leak.

INTRODUCTION: Venous ligation surgery results for diffuse venous leak have been disappointing, although in isolated crural venous leak (ICVL) cases, efficacy for crural ligation surgery (CLS) has been demonstrated. AIM: The purpose of this study was to present our experience with treatment of ICVL with CLS. METHODS: All patients underwent preoperative cavernosometry. Cavernosography (CG) or perineal compression (PC) was used to define the diagnosis of ICVL. If CG demonstrated ICVL or flow-to-maintain values normalized with PC, the patient was counseled regarding CLS. Baseline and postoperative erectile function (EF) was assessed by the International Index of Erectile Function (IIEF) questionnaire. MAIN OUTCOME MEASURES: EF, using the EF domain (EFD) score of the IIEF, a domain with six questions with a maximum score of 30 and a minimum score of 6 in the sexually active male. All patients completed the questionnaire preoperatively and in a serial fashion after surgery at a time point after 12 months postoperatively. RESULTS: 14 patients underwent CLS. Mean age was 29 ± 7 years. Also, 64% had primary erectile dysfunction. Mean baseline IIEF-EF score was 18 ± 6. Furthermore, 71% of patients had failed phosphodiesterase type 5 (PDE5) inhibitors and 6/10 (60%) failed intracavernosal injections (ICI). Mean postoperative EFD score was 24 ± 3 representing a mean change of 6.5 points per patient. No patient needed ICI after CLS; however, 4/14 patients needed PDE5 inhibitors, all of whom had been using ICI preoperatively. In addition, 71% experienced unassisted sexual intercourse after CLS. CONCLUSIONS: In a highly selected population of young men with ICVL, CLS cures 70% and improves EF in more than 90% of men. Surgical treatment of ICVL by CLS can be performed safely and with sufficient efficacy that larger and longer term studies should be undertaken.

Erectile dysfunction after plaque incision and grafting: short-term assessment of incidence and predictors.

INTRODUCTION: Plaque incision and grafting (PIG) surgery for Peyronie's disease (PD) is a recognized management strategy. One of the recognized complications of PIG surgery is the development of postoperative erectile dysfunction (ED). AIM: To determine the incidence of ED after PIG surgery and attempt to define predictors of ED development. METHODS: All patients underwent preoperative cavernosometry. Grafting was performed with either cadaveric pericardium (Tutoplast) or intestinal submucosa (Surgisis). Prior to 2006, the procedure used an H-type incision, whereas after this date, the Egydio approach has been used. MAIN OUTCOME MEASURES: Men undergoing PIG completed preoperative and 6-month postoperative International Index of Erectile Function (IIEF) questionnaires. RESULTS: 56 patients were analyzed. Mean patient and partner ages were 57 ± 22 and 54 ± 18 years, respectively. Mean duration of PD at the time of PIG was 22 ± 9 months. Seventy-five percent had curvature alone, 11% had hourglass/indentation deformity, and the remainder had combined curvature/indentation. Mean preoperative curvature was 52 ± 23°. Fifty-two had grafting with Tutoplast, while four had grafting with Surgisis. All men at baseline were capable of generating a penetration rigidity erection. Preoperatively, 50% of men had cavernosal insufficiency and 21% had venous leak (baseline and postoperative erectile function [EF] domain scores were 23 ± 4 and 17 ± 9, respectively [P < 0.01]). Forty-six percent of men experienced a ≥6-point decrease in EF domain score after PIG. The predictors of a ≥6-point reduction in IIEF-EF domain score on multivariable analysis were degree of preoperative curvature, type of plaque incision, patient age, and baseline venous leak. Conclusions. Almost one-half of men had significant reduction in their erectile rigidity after PIG. Reduction was predicted by larger baseline curvature, the Egydio plaque incision technique, older patient age, and the presence of venous leak at baseline. Based on these data, we discourage older men, those with venous leak, and those with profound curvature from considering PIG surgery.