Informed consent for invasive procedures in the emergency department.

BACKGROUND: Informed consent for procedures in the emergency department (ED) challenges practitioners to navigate complex ethical and medical ambiguities. A patient's altered mental status or emergent medical problem does not negate the importance of his or her participation in the decision-making process but, rather, necessitates a nuanced assessment of the situation to determine the appropriate level of participation. Given the complexities involved with informed consent for procedures in the ED, it is important to understand the experience of key stakeholders involved. METHODS: For this review, we searched Medline, the Cochrane database, and Clinicaltrials.gov for studies involving informed consent in the ED. Inclusion and exclusion criteria were designed to select for studies that included issues related to informed consent as primary outcomes. The following data was extracted from included studies: Title, authors, date of publication, study type, participant type (i.e. adult patient, pediatric patient, parent of pediatric patient, patient's family, or healthcare provider), number of participants, and primary outcomes measured. RESULTS: Fifteen articles were included for final review. Commonly addressed themes included medical education (7 of 15 studies), surrogate decision-making (5 of 15 studies), and patient understanding (4 of 15 studies). The least common theme addressed in the literature was community notification (1 of 15 studies). CONCLUSIONS: Studies of informed consent for procedures in the ED span many aspects of informed consent. The aim of the present narrative review is to summarize the work that has been done on informed consent for procedures in the ED.

FOAM Impact: The Influence of Open-access Medical Education on Practice Uptake.

OBJECTIVES: The FOAM Impact study sought to examine baseline rates of intravenous (IV) lidocaine usage for the treatment of renal colic and to compare rates of use between FOAM utilizers and nonutilizers. We sought to measure the effect of FOAM resources on clinical practice by timing the release of FOAM content with publication of the LIDOKET trial. METHODS: A cross-sectional before-and-after survey was conducted and disseminated on two social media platforms. The 13-question, anonymous survey was posted for 1 week prior following the release of the LIDOKET study. Descriptive statistics, Mann-Whitney t-test, and chi-square test statistics were used to describe survey respondent characteristics and Likert responses. RESULTS: There were a total of 472 survey respondents. A total of 321 physicians (75.7% of total respondents) provided pre- and postpublication survey answers. There was no significant change in the use of analgesics before and after publication of LIDOKET and concurrent REBEL EM blog post. A total of 197 (42%) survey respondents reported using lidocaine for renal colic, of which 60 respondents (13%) reported frequent or occasional use. The mean difference in perceived efficacy of lidocaine before and after publication was -0.30 (95% confidence interval [CI] = -0.80 to 0.19, p = 0.15). Being a FOAM user was not associated with changes in mean difference in perception of lidocaine efficacy (F = 0.127, p = 0.72); however, there was a significant difference in perception of lidocaine's efficacy following LIDOKET and REBEL EM publication (F = 4.718, p = 0.03). CONCLUSIONS: Using an online survey-based technique, no appreciable impact of FOAM resources was immediately apparent; however, engagement with FOAM was associated with a change in perception of IV lidocaine's efficacy. To our knowledge, this is the first study of its kind to evaluate the impact of FOAM on clinical practice. The unique method of coordinating FOAM distribution with traditional medical publication may provide future opportunities for measuring the impact of asynchronous medical education resources on medical practice.

A Young Patient with Painful Penile Lesions.

Chancroid is a rare infection in the United States and many other developed countries. Infrequently identified as a cause of genital ulcer disease, chancroid's atypical presentation has only been reported in approximately 20 cases annually in the United States since 2011. Infection with the causative organism, Haemophilus ducreyi, leads to an erythematous papule that rapidly evolves into a pustule. Infected individuals commonly have more than one ulcer about 2 cm in diameter that is typically noted as painful. The base of the ulcer is usually covered with a gray or yellow purulent exudate and bleeds when scraped. Despite a heavy focus in preclinical medical education, the notably rare chance to see and diagnose chancroid in clinical practice adds to the complicated profile of this infection's identification and subsequent treatment. Such lack of familiarity contributes to reports of accuracy of clinical diagnosis ranging from 30% to 80%.

A Case of Lactation Anaphylaxis.

We describe the case of a patient who presented multiple times to the emergency department (ED) with recurrent episodes of anaphylaxis in the immediate postpartum period. It was initially thought to be idiopathic in nature on previous visits, but was ultimately diagnosed as lactation anaphylaxis and successfully managed. The diagnosis was suspected when the detailed history revealed recurrent allergic symptoms with each episode of breastfeeding. Following emergency treatment of anaphylaxis, the patient was advised to transition to formula feeding and had no further allergic episodes from the time of discharge to the three-month follow-up period.

A Case of Thiazide-induced Hypokalemic Paralysis.

We describe the case of a patient presenting with odd neurologic symptoms initially thought to represent somatization who was found to have critical hypokalemia manifesting as hypokalemic non-periodic paralysis. It was determined that the patient had baseline hypokalemia as a function of alcohol abuse, exacerbated by self overmedication with hydrochlorothiazide for elevated blood pressure readings at home. The diagnosis was suspected when an electrocardiogram was obtained demonstrating a pseudo-prolonged QT interval with ST depression, consistent with T-U wave fusion and a QU interval with an absent T wave.1 The patient received oral and intravenous potassium and magnesium supplementation with resolution of symptoms.

Evidence-Informed Practice: Diagnostic Questions in Urinary Tract Infections in the Elderly.

INTRODUCTION: Routine interventions in the practice of medicine often lack definitive evidence or are based on evidence that is either not high quality or of only modest-to-marginal effect sizes. An abnormal urinalysis in an elderly patient presenting to the emergency department (ED) with non-specific symptoms represents one condition that requires an evidence-informed approach to diagnosis and management of either asymptomatic bacteriuria or urinary tract infection (UTI). The emergency provider often will not have access to urine cultures, and the risks associated with antibiotic use in the elderly are not without potentially significant side effects. METHODS: We performed a historical and clinical review of the growing body of literature suggesting measurable differences in the systemic immune response manifest among patients with asymptomatic pyuria and UTI, including increases in the pro-inflammatory cytokine interleukin-6 and the acute phase reactant procalcitonin. RESULTS: Serum procalcitonin, a peptide that undergoes proteolysis into calcitonin, has been demonstrated to quickly and reliably rise in patients with severe bacterial infections, and may serve as a potentially sensitive and specific marker for identification of bacterial illness. CONCLUSION: In the absence of validated risk scores for diagnosing UTI in elderly patients presenting to the ED, there may be a role for the use of procalcitonin in this patient population.

Search Engine Queries for Pediatric Fever During "Cold and Flu" Season.

Introduction Pediatric fever is the most common chief complaint in patients under 15 years old. The objective of this paper is to characterize public search trends for pediatric fever in the United States using Google search engine queries. Methods and materials A cross-sectional survey of Google Trends searches for "toddler fever" was conducted from October 2018 to January 2019 during "cold and flu" season. Information collected included "Related Topics" and "Related Queries", which includes additional searches by individuals who searched for "toddler fever". Data are described in the results using Google's relative popularity. Results For this study, 91 weeks of data were queried. The median relative popularity over this time period was 65 (interquartile range, 58 - 74.5) out of 100. Individuals searching for this term also searched thematically for characterizations and descriptors of fever, types of symptoms associated with fever, and various treatments for fever. Conclusion The results of this study revealed an increased frequency of search engine queries for descriptors and qualifiers of symptoms associated with pediatric illness during the "cold and flu" season. Frequently queried terms suggest a need for increased health literacy regarding pediatric fever in the United States and may represent a need for further national educational resources.

Public interest in gun control in the USA.

To characterise public interest in gun control in the USA using internet search queries, we undertook a cross-sectional study of the relative popularity Google Trends searchers for 'Gun Control', 'Second Amendment', 'National Rifle Association' and 'Mass Shooting' from May 2015 to December 2018. 740 weeks of data were queried. Graphed data revealed nine major inflection points. Seven of the nine (78%) major inflection points were associated with mass shootings, while two of the nine (22%) were related to political events by either the president of the USA or a presidential candidate. Our exploration of Google Trends shows the frequency of national searches related to gun control peaks with mass shootings over a 1-2-week period and then stabilises to nominal relative popularity thereafter suggesting a need to engage the public on gun control during 'trough' periods in order to sustain national interest and dialogue.

Financial relationships with industry among guideline authors for the management of acute ischemic stroke.

OBJECTIVE: To characterize the prevalence of industry relationships among authors of acute ischemic stroke (AIS) guidelines and its association with graded evidence. METHODS: A cross-sectional study of five policy papers on AIS published by the American Heart Association (AHA)/American Stroke Association (ASA), American Academy of Emergency Physicians (AAEM), and American College of Emergency Physicians (ACEP). Financial conflicts of interest (FCOI) data were obtained using the Open Payments Database for the years 2013 through 2017. A search of publicly available information was done to determine post-guideline employment. We characterized the prevalence of FCOI, as well as employment with industry engaged in thrombolysis or neurointerventional treatment of AIS after guideline publication. RESULTS: 76 unique authors were identified in 5 policy statements. The prevalence of FCOI among authors of AAEM, ACEP, and AHA/ASA guidelines was 0%, 0%, and 35%, respectively. Post-publication increase in FCOI was 0% for authors of the AAEM and ACEP guidelines, and a 300% increase for authors of the 2013 AHA/ASA guidelines with data unavailable to assess post-publication FCOI for authors of the 2018 AHA/ASA guidelines. 2 authors were found to engage in new industry employment following recommendation publication. Finally, 9% (n = 3) authors of the 2013/2018 AHA/ASA guidelines were employees of the Genentech Speakers Bureau. CONCLUSIONS: Our results suggest an association between current Graded Evidence and FCOI of major academic societies for the management of AIS. Due to the bias inherent to such conflicts, future recommendation groups should take steps to insulate against FCOI both during and following guideline publication.

Examination of EMS Decision Making in Determining Suitability of Patient Diversion to Urgent Care Centers.

Widespread use of Emergency Medicine Services (EMS) for non-emergency care has increased recently, causing overcrowding of the Emergency Department (ED). The increased availability of urgent care centers (UCCs), with their ability to see large numbers of unscheduled patients with more acute presentations, may offer a viable option for many EMS systems to divert non-emergent cases. Using a survey-based study combined with retrospective chart review, EMS provider ability to determine patient suitability for diversion to UCCs was assessed. Results indicated a rate of inappropriate diversion of 11.6%. UCCs may be an alternative option for EMS transport, however strict protocols with medical direction are needed.

Temporary Memory Steal: Transient Global Amnesia Secondary to Nephrolithiasis.

Transient global amnesia (TGA) is typified by an abrupt and transient anterograde amnesia, "with repetitive questioning and often variable retrograde amnesia persisting up to 24 hours." A 54-year-old male presented to our emergency department with paroxysms of left-sided flank pain, suggestive of renal colic. Computed tomography (CT) of the abdomen/pelvis revealed a three-millimeter left ureterovesicular-junction calculus. Pain control proved difficult, necessitating multiple doses of opioid and non-opioid analgesia. Subsequently, the patient developed repetitive questioning and perseveration with anterograde amnesia with a negative CT brain and unremarkable further workup. He experienced a complete resolution of symptoms within a 24-hour period, with a discharge diagnosis of TGA secondary to nephrolithiasis. This is the third case of TGA attributed to nephrolithiasis in the medical literature.

Managing Shoulder Injuries in the Emergency Department: Fracture, Dislocation, and Overuse.

The complex structures of the shoulder can be injured by fracture, dislocation, and overuse, and correctly identifying and classifying injury is essential to avoiding pain, disability, and life- and limb-threatening complications. This issue presents a systematic approach to classifying shoulder injuries based on the mechanism of injury and clinical presentation, choosing appropriate imaging, and determining the best strategies for treatment, including reduction, surgical consultation, or outpatient referral. Newer recommendations on intra-articular versus intravenous analgesia are presented to increase patient comfort and improve reduction outcomes.