Upper Extremity Musculoskeletal Injuries Presenting to an Emergency Department Before and During the Initial COVID-19 Pandemic Surge.

Study Objective: The SARS-CoV-2 (COVID-19) pandemic significantly impacted emergency department volume and acuity. The Delta and Omicron variants contributed to additional surges. We describe the impact that the initial pandemic phase had on frequency and severity of typically non-life-threatening emergencies using upper extremity injuries as a model for other potentially emergent presentation as compared to pre-pandemic times. We do this using the epidemiology of pre-defined significant upper extremity injuries at our facility as a specific example of what occurred at an urban trauma center. Methods: We conducted a comparison of two 6-month periods: between March 2019 and August 2019 (prior to COVID-19) and between March 2020 and August 2020 after the onset of the initial COVID-19 wave. We performed a retrospective chart review of patients who presented with upper extremity injury chief complaints using analysis of the electronic medical record at a single urban tertiary care trauma center in the Midwestern United States. We investigated examination findings, imaging, frequency of surgical procedures and final diagnosis. Results: In the 2019 study period, there were 31,157 ED patients, including 429 with upper extremity injuries, of which 108 patients had significant injuries. In the 2020 study period, there were 24,295 patient presentations, of which 118 of 296 upper extremity presentations were significant. We a priori defined significant injury as follows: fractures, dislocations, neurovascular injuries, or need for operative intervention within 24 hours of ED presentation. Specifically, 25.2% of injuries were significant pre-COVID-19 and 39.9% (p < 0.001) during the initial COVID-19 surge. The absolute number and percentage of significant injuries increased from pre-COVID-19 compared to the initial COVID-19 surge despite an overall 22% decrease in total patient volume. Conclusion: The incidence of significant upper extremity musculoskeletal injuries increased during the pandemic even though the overall number of ED presentations for upper extremity musculoskeletal injuries decreased.

Atypical High-Altitude Cerebral Edema Presentation at an Altitude of Less Than 3000 Meters Elevation: A Case Report.

Introduction: Atypical presentations of high altitude cerebral edema may have a stuttering course that can be similar to more common and benign pathology at a lower altitude than typically causes high altitude cerebral edema. Case Report: A healthy 27-year-old male presented to a medical clinic situated at an altitude of 2829 meters with a "migraine" headache and nausea. He reported several episodes of 'blurry vision' each lasting seconds to a minute over the previous day. Symptoms had started four to five days after ascending from his home at sea level. The visual symptoms did not recur while he was in the clinic and his headache and nausea improved after oral medication. The physician recommended advanced imaging at the local hospital, but he declined and was discharged. The following day while riding a ski lift between 2830 and 3782 meters, he had a one-hour episode of visual disturbance with an intense headache. He was directed to proceed to the hospital for magnetic resonance imaging of the brain which demonstrated changes in his corpus callosum consistent with high altitude cerebral edema and he was evacuated to 1609 meters. Conclusion: An index of suspicion for high altitude cerebral edema must be maintained for any new neurological symptoms in unacclimatized individuals presenting to high alpine environments even those lower than typically associated with this high mortality condition.

High Altitude Pulmonary Edema in a Healthy Pediatric Patient Traveling from Denver to Breckenridge.

A healthy 11-year-old boy presented with headache, nausea, and cough to a clinic at 2926 meters of altitude one day after ascending from his home altitude of 1578 meters. The patient had made multiple trips to the same altitude without any symptoms or sequelae throughout his childhood. Physical examination was significant for rales, tachycardia, and pulse oximetry level of 86% on room air. Radiographic evaluation with plain films revealed patchy alveolar opacities throughout the right lung. He received treatment with dexamethasone and high-flow face mask supplemental oxygen. In less than two hours, his rales had resolved, and his oxygen saturation had dramatically improved. He was discharged back to his native altitude and was at his baseline later the same day. High altitude pulmonary edema is a rare occurrence in children, but it is exceedingly rare for a healthy child with no history of pulmonary hypertension ascending only 1348 meters.

Students' Perceptions of Trigger Warnings in Medical Education.

Phenomenon: Trigger warnings are verbal statements or written warnings that alert students in advance to potentially distressing material. Medical education includes numerous subjects frequently identified as triggers, such as abuse, rape, self-injurious behaviors, eating disorders, drug and alcohol addiction, and suicide. Thus, exploring medical students' perceptions of trigger warnings may provide a valuable perspective on the use of these warnings in higher education. APPROACH: As part of a larger descriptive, cross-sectional survey study on medical education, we assessed 1st- and 2nd-year medical students' perceptions of trigger warnings in the preclinical curriculum. Five questions specific to trigger warnings explored students' knowledge, prior experience, and perceptions of trigger warnings in medical education. Frequencies of individual question responses were calculated, and qualitative data were analyzed via content and thematic analyses. FINDINGS: Of the 424 medical students invited to participate, 259 completed the survey (M = 24.8 years, SD + 3.4, 51.4% female, 76.1% White, 53.7% 1st-year students). Few students (11.2%) were aware of the term trigger warning and its definition. However, after being presented with a formal definition on the online survey, 38.6% reported having had a professor use one. When asked whether they supported the use of trigger warnings in medical education, respondents were distributed fairly equally by response (yes = 31.0%, maybe = 39.2%, no = 29.7%). Qualitative analysis revealed three themes: (a) Trigger Warnings Allow Students to Know What is Coming and Prepare Themselves: Respondents believed that trigger warnings would benefit students with a history of trauma by providing them additional time to prepare for the material and, if appropriate, seek professional help; (b) Students Need to Learn How to Handle Distressing Information: Respondents agreed that they needed to learn and cope with highly sensitive material because they would be confronted with difficult and unexpected situations in clinical practice; and (c) Trigger Warnings Help Students Understand the Severity of the Material: Respondents felt that trigger warnings may help students understand the severity of the material being covered and increase awareness about trauma and its effects on health and well-being. Insights: Findings did not reach consensus for or against the use of trigger warnings in medical school; however, students emphasized the importance of learning how to cope with distressing material. Trigger warnings may represent a teaching tool to facilitate classroom discussions about the severity of trauma-related material and problem-focused coping strategies.