Outcomes in Hispanics With COVID-19 Are Similar to Those of Caucasian Patients in Suburban New York.

BACKGROUND: Despite reported higher rates and worse outcomes due to COVID-19 in certain racial and ethnic groups, much remains unknown. We explored the association between Hispanic ethnicity and outcomes in COVID-19 patients in Long Island, New York. METHODS: We conducted a retrospective cohort study of 2,039 Hispanic and non-Hispanic Caucasian patients testing positive for SARS-CoV-2 between March 7 and May 23, 2020, at a large suburban academic tertiary care hospital near New York City. We explored the association of ethnicity with need for intensive care unit (ICU), invasive mechanical ventilation (IMV), and mortality. RESULTS: Of all patients, 1,079 (53%) were non-Hispanic Caucasians and 960 (47%) were Hispanic. Hispanic patients presented in higher numbers than expected for our catchment area. Compared with Caucasians, Hispanics were younger (45 years vs. 59 years), had fewer comorbidities (66% with no comorbidities vs. 40%), were less likely to have commercial insurance (35% vs. 59%), or were less likely to come from a nursing home (2% vs. 10%). In univariate comparisons, Hispanics were less likely to be admitted (37% vs. 59%) or to die (3% vs. 10%). Age, shortness of breath, congestive heart failure (CHF), coronary artery disease (CAD), hypoxemia, and presentation from nursing homes were associated with admission. Male sex and hypoxemia were associated with ICU admission. Male sex, chronic obstructive pulmonary disease, and hypoxemia were associated with IMV. Male sex, CHF, CAD, and hypoxemia were associated with mortality. After other factors were adjusted for, Hispanics were less likely to be admitted (odds ratio = 0.62, 95% confidence interval = 0.52 to 0.92) but Hispanic ethnicity was not associated with ICU admission, IMV, or mortality. CONCLUSIONS: Hispanics presented at higher rates than average for our population but outcomes among Hispanic patients with COVID-19 were similar to those of Caucasian patients.

Emergency department and hospital crowding: causes, consequences, and cures.

Overcrowding with associated delays in patient care is a problem faced by emergency departments (EDs) worldwide. ED overcrowding can be the result of poor ED department design and prolonged throughput due to staffing, ancillary service performance, and flow processes. As such, the problem may be addressed by process improvements within the ED. A broad body of literature demonstrates that ED overcrowding can be a function of hospital capacity rather than an ED specific issue. Lack of institutional capacity leads to boarding in the ED with resultant ED crowding. This is a problem not solvable by the ED and must be addressed as an institution-wide problem. This paper discusses the causes of ED overcrowding, provides a brief overview of the drastic consequences, and discusses possible cures that have been successfully implemented.

Sinusitis Update.

Rhinosinusitis affects many pediatric patients as well as 1 in 6 adults in any given year, resulting in ambulatory care, pediatric, and emergency department visits. Uncomplicated rhinosinusitis requires no imaging or testing and does not require antibiotic treatment. Using strict clinical diagnostic criteria may minimize unnecessary antibiotics. When indicated, amoxicillin with or without clavulanate for 5 to 10 days remains the first-line antibiotic, despite increasing incidence of staphylococcal sinusitis in the post-pneumococcal conjugate vaccine era. Emergency providers also need to recognize atypical cases in which uncommon but serious complications of sinusitis cause both morbidity and mortality.

Medication Overdoses at a Public Emergency Department in Santiago, Chile.

INTRODUCTION: While a nationwide poison control registry exists in Chile, reporting to the center is sporadic and happens at the discretion of the treating physician or by patients' self-report. Moreover, individual hospitals do not monitor accidental or intentional poisoning in a systematic manner. The goal of this study was to identify all cases of intentional medication overdose (MO) that occurred over two years at a large public hospital in Santiago, Chile, and examine its epidemiologic profile. METHODS: This study is a retrospective, explicit chart review conducted at Hospital Sótero del Rio from July 2008 until June 2010. We included all cases of identified intentional MO. Alcohol and recreational drugs were included only when they were ingested with other medications. RESULTS: We identified 1,557 cases of intentional MO and analyzed a total of 1,197 cases, corresponding to 0.51% of all emergency department (ED) presentations between July 2008 and June 2010. The median patient age was 25 years. The majority was female (67.6%). Two peaks were identified, corresponding to the spring of each year sampled. The rate of hospital admission was 22.2%. Benzodiazepines, selective serotonin reuptake inhibitors, and tricyclic antidepressants (TCA) were the causative agents most commonly found, comprising 1,044 (87.2%) of all analyzed cases. Acetaminophen was involved in 81 (6.8%) cases. More than one active substance was involved in 35% of cases. In 7.3% there was ethanol co-ingestion and in 1.0% co-ingestion of some other recreational drug (primarily cocaine). Of 1,557 cases, six (0.39%) patients died. TCA were involved in two of these deaths. CONCLUSION: Similar to other developed and developing nations, intentional MO accounts for a significant number of ED presentations in Chile. Chile is unique in the region, however, in that its spectrum of intentional overdoses includes an excess burden of tricyclic antidepressant and benzodiazepine overdoses, a relatively low rate of alcohol and recreational drug co-ingestion, and a relatively low rate of acetaminophen ingestion.

HOT WAX.

High-potency marijuana wax smoked via dabbing is a newly encountered phenomenon with relevance to prehospital care providers and emergency physicians.The extract is only recently described in current peer-reviewed literature. The drug may produce paranoia and psychosis and mimic psychiatric problems. The synthetic process for this drug poses a risk for both fire and explosions creating burns and blast injuries. These four cases were encountered in a single ED in Los Angeles in a three-week period, suggesting this could be the tip of an emerging public health problem. All four of these patients were complex cases requiring advanced imaging and ICU care. Emergency personnel need to appreciate this new trend and the implications for pre-hospital care, disposition and ED treatment of these patients.

Nebulized Tranexamic Acid as a Noninvasive Therapy for Cancer-Related Hemoptysis.

BACKGROUND: Many patients with cancer involving the respiratory system suffer from the frequent recurrence of significant, submassive hemoptysis, which may result in invasive procedures, hospital stays, and a reduction in quality of life. Currently, there are no widely accepted noninvasive therapeutic options. Few case studies have looked at the benefit of tranexamic acid (TXA) as a noninvasive therapy in the treatment of hemoptysis. METHODS: A patient with an invasive airway malignancy presented to the emergency department with substantial hemoptysis. A nebulized TXA solution was used as a noninvasive therapy to control the hemorrhage. RESULTS: The patient's hemoptysis resolved fifteen minutes after the nebulized TXA therapy was initiated. There were no known adverse events. CONCLUSION: Nebulized TXA seems to be a safe, effective, and noninvasive method for controlling, or at least temporizing, hemoptysis in select patients. Nebulized TXA may be useful as a palliative therapy for chronic hemoptysis and as a tool in the acute stabilization of hemoptysis.

Chikungunya fever in Los Angeles, California.

We report the case of a 33-year-old woman returning from Haiti, presenting to our emergency department (ED) with fever, rash and arthralgia. Following a broad workup that included laboratory testing for dengue and malaria, our patient was diagnosed with Chikungunya virus, which was then reported to the Centers for Disease Control and Prevention for initiation of infection control. This case demonstrates the importance of the ED for infectious disease case identification and initiation of public health measures. This case also addresses public health implications of Chikungunya virus within the United States, and issues related to the potential for local spread and autochthonous cases.

A survey of the beliefs regarding international emergency medicine among fourth-year medical students planning on matching in emergency medicine.

BACKGROUND: With the recent growth of fellowships in international emergency medicine, the authors sought to evaluate medical students' attitudes toward international emergency medicine and to determine the effects these attitudes have on their residency selection. STUDY DESIGN: Cross-sectional survey. DATA COLLECTION: An anonymous, eight-question online survey was distributed to all members of the American Academy of Emergency Medicine Resident and Student section. This survey was also distributed to fourth-year medical students rotating through the Emergency Department at Los Angeles County and the University of Southern California. RESULTS: Ninety-eight surveys were collected, 61 from rotating students and 37 from the AAEM mailing. There were no statistically significant differences in responses between the two groups. Of the respondents, 49.4% of have been exposed to IEM, and 46.9% have participated in international health projects. Ninety-four percent agree that IEM is an exciting career option. Seventy-nine percent said programs with IEM opportunities are more appealing than those without, and 45% said the presence of IEM opportunities would be an important factor in rank list; 53% believe that IEM requires formal public health training, and 63% believe it requires tropical medicine training; 68.3%of respondents speak a language in addition to English. This subset was more likely to have participated in IEM projects previously (p = 0.026) but not more likely to make match choices based on IEM. CONCLUSIONS: Half of medical students surveyed had prior experience in international health, and most agree that international emergency medicine is an exciting career option. Over two thirds believe that the presence of IEM opportunities will be a factor in their match list decision.

Financial impact of emergency department crowding.

OBJECTIVE: The economic benefits of reducing emergency department (ED) crowding are potentially substantial as they may decrease hospital length of stay. Hospital administrators and public officials may therefore be motivated to implement crowding protocols. We sought to identify a potential cost of ED crowding by evaluating the contribution of excess ED length of stay (LOS) to overall hospital length of stay. METHODS: We performed a retrospective review of administrative data of adult patients from two urban hospitals (one county and one university) in Brooklyn, New York from 2006-2007. Data was provided by each facility. Extrapolating from prior research (Krochmal and Riley, 2005), we determined the increase in total hospital LOS due to extended ED lengths of stay, and applied cost and charge analyses for the two separate facilities. RESULTS: We determined that 6,205 (5.0%) admitted adult patients from the county facility and 3,017 (3.4%) patients from the university facility were held in the ED greater than one day over a one-year period. From prior research, it has been estimated that each of these patient's total hospital length of stay was increased on average by 11.7% (0.61 days at the county facility, and 0.71 days at the university facility). The increased charges over one year at the county facility due to the extended ED LOS was therefore approximately $9.8 million, while the increased costs at the university facility were approximately $3.9 million. CONCLUSION: Based on extrapolations from Krochmal and Riley applied to two New York urban hospitals, the county hospital could potentially save $9.8 million in charges and the university hospital $3.9 million in costs per year if they eliminate ED boarding of adult admitted patients by improving movement to the inpatient setting.

Identification of subcutaneous myiasis using bedside emergency physician performed ultrasound.

BACKGROUND: Subcutaneous myiasis, a maggot infiltration of human tissue, is common in tropical countries. However, physicians in the United States may be unlikely to consider this etiology of dermatologic abnormalities even when a travel history suggests the diagnosis should be included in the differential. CASE REPORT: We report the case of a patient who returned from Sierra Leone with an infestation of a maggot of Cordylobia anthropophaga (tumbu fly) that was diagnosed and appropriately treated based on ultrasound findings. CONCLUSION: As international travel increases, clinicians should maintain a high level of suspicion for tumbu fly infestation in returned travelers from endemic areas. The increasing use of ultrasound in the Emergency Department for evaluation of skin and soft tissue infections may aid the physician in making the diagnosis of subcutaneous myiasis.

Severe hypokalemia, paralysis, and AIDS-associated isospora belli diarrhea.

BACKGROUND: Hypokalemia of clinical significance, severe enough to cause paralysis and cardiac dysrhythmias, is an uncommon life-threatening medical disorder. Hypokalemic periodic paralysis (HPP), where an abrupt intracellular shift of potassium has occurred, must be distinguished from hypokalemic non-periodic paralysis (non-HPP), where a total body potassium deficit exists. The challenge for emergency physicians is to swiftly and accurately differentiate disease etiology and institute prompt treatment. Aggressive potassium repletion, required in non-HPP etiologies, may predispose HPP patients to dangerous and potentially fatal rebound hyperkalemia as the intracellular potassium shift resolves. OBJECTIVES: Describe the process by which HPP and non-HPP can be differentiated on clinical and laboratory grounds leading to appropriate resuscitation from severe and clinically relevant hypokalemia. Chronic diarrhea syndromes and possibly normal alkaline phosphatase levels alert the clinician to the potential for non-HPP. CASE REPORT: A case of HIV/AIDS-associated isospora belli diarrheal illness with severe hypokalemia of the non-HPP type is presented. Historical, laboratory, and clinical findings, which assisted in the differentiation from HPP, are emphasized. Clinical progression and treatment strategies, as well as electrocardiogram findings with T-U-P fusion waves, are described in detail. CONCLUSION: The history, especially the time course of disease, is essential in differentiating HPP and non-HPP, allowing treatment to proceed without overcorrection and rebound hyperkalemia. Although other infectious diseases have been linked to non-HPP, to our knowledge this is the first report linking non-HPP to isospora belli diarrheal illness.

Enoxaparin-induced bleeding resulting in compartment syndrome of the thigh: a case report.

BACKGROUND: Enoxaparin-related bleeding has usually been described as excess minor bleeding. OBJECTIVES: To describe a case of major bleeding with a compartment syndrome secondary to enoxaparin. The utility of bedside emergency department ultrasonography as a diagnostic tool is evident. CASE REPORT: A 62-year-old patient presented with swelling and pain in the left thigh with no history of trauma. Examination revealed a swollen extremity with a tense muscle compartment. A bedside ultrasound by the emergency physician was performed, showing a large pocket of fluid accumulation. Upon aspiration, the fluid was found to be blood. Computed tomography imaging was performed, which revealed a large hematoma, with active bleeding. Subsequent angiography showed several extravasations from the profunda artery. The patient was then taken for embolization of the bleeding, and then an anterolateral fasciotomy. The patient had an increased partial thromboplastin time, and final diagnosis was compartment syndrome due to spontaneous bleeding from enoxaparin. CONCLUSIONS: Enoxaparin can spontaneously cause serious bleeding with associated compartment syndrome.

Tattoos and piercings: a review for the emergency physician.

Tattoos and piercings are increasingly part of everyday life for large sections of the population, and more emergency physicians are seeing these body modifications (BM) adorn their patients. In this review we elucidate the most common forms of these BMs, we describe how they may affect both the physical and psychological health of the patient undergoing treatment, and also try to educate around any potential pitfalls in treating associated complications.

Reimbursement for emergency department electrocardiography and radiograph interpretations: what is it worth for the emergency physician.

BACKGROUND: Physician reimbursement laws for diagnostic interpretive services require that only those services provided contemporaneously and /or contribute directly to patient care can be billed for. Despite these regulations, cardiologists and radiologists in many hospitals continue to bill for ECG and plain film diagnostic services performed in the emergency department (ED). The reimbursement value of this care, which is disconnected in time and place from the ED patient encounter, is unknown. In a California community ED with a 32,000 annual census, the emergency physicians (EPs) alone, by contract, bill for all ECG readings and plain film interpretations when the radiologists are not available to provide contemporaneous readings. OBJECTIVES: To determine the impact of this billing practice on actual EP reimbursement we undertook an analysis that allows calculation of physician reimbursement from billing data. METHODS: An IRB-approved analysis of 12 months of billing data cleansed of all patient identifiers was undertaken for 2003. From the data we created a descriptive study with itemized breakdown of reimbursement for radiograph and ECG interpretive services (procedures) and the gross resultant physician income. RESULTS: In 2003 EPs at this hospital treated patients during 32,690 ED visits. Total group income in 2003 for radiographs was $173,555 and $91,025 for ECGs, or $19/EP hour and $6/EP hour respectively. For the average full-time EP, the combined total is $2537/month or $30,444 per annum, per EP. This is $8/ED visit (averaged across all patients). CONCLUSION: As EP-reimbursement is challenged by rising malpractice premiums, uninsured patients, HMO contracts, unfunded government mandates and state budgetary shortfalls, EPs are seeking to preserve their patient services and resultant income. They should also be reimbursed for those services and the liability that they incur. The reimbursement value of ECGs and plain film interpretations to the practicing EP is substantial. In the ED studied, it represents $30,444 gross income per full-time EP annually. Plain film interpretation services produce three times the hourly revenue of ECG reading at the hospital studied.

Rocuronium vs. succinylcholine in the emergency department: a critical appraisal.

BACKGROUND: Two methods of paralysis are available for rapid sequence intubation (RSI) in the emergency department (ED): depolarizing agents such as succinylcholine, and non-depolarizing drugs such as rocuronium. Rocuronium is a useful alternative when succinylcholine is contraindicated. Contraindications to succinylcholine include allergy, history of malignant hyperthermia, denervation syndromes, and patients who are 24-48 h post burn or crush injury. Non-depolarizing drugs have the advantage of causing less pain due to post-paralysis myalgias. CLINICAL QUESTION: Can rocuronium replace succinylcholine as the paralytic of choice for RSI in the ED? EVIDENCE REVIEW: Four relevant studies were selected from an evidence search and a structured review performed. RESULTS: For the outcomes of clinically acceptable intubation conditions and time to onset, the two agents were not statistically significantly different. Succinylcholine seems to produce conditions that have higher satisfaction scores. CONCLUSION: Succinylcholine remains the drug of choice for ED RSI unless there is a contraindication to its usage.

Takotsubo cardiomyopathy: a case series and review of the literature.

Takotsubo cardiomyopathy (TCM) is an unusual form of acute cardiomyopathy showing left ventricular apical ballooning. It is often triggered by intense physical or emotional distress. We report here four cases of TCM and a review of the literature on the topic.

Emphysematous pyelonephritis: clues to rapid diagnosis in the Emergency Department.

Emphysematous pyelonephritis (EPN) is an acute life-threatening bacterial infection. EPN leads to rapid necrotizing destruction of the renal parenchyma and peri-renal tissue, requiring early and aggressive care to reduce morbidity and mortality. Previous studies have described the use of computed tomography scan and radiology-performed ultrasound to make the diagnosis of EPN We report a case of EPN diagnosed by bedside Emergency Department (ED) ultrasound performed by emergency physicians, allowing a more rapid diagnosis and subsequent treatment.