Rash and Fever in a Returned Traveler.

Case Presentation: A 21-year-old, otherwise healthy female presented to the emergency department with fever among other nonspecific symptoms after recently returning from Ghana. On physical exam, she had a characteristic upper extremity rash, and a tourniquet test revealed numerous petechiae. The diagnosis of dengue was suspected and subsequently confirmed. Discussion: Dengue is one of many viral illnesses that should be considered in returning travelers presenting with fever and other nonspecific symptoms. Emergency physicians must keep a broad differential when evaluating fever in returned travelers and prioritize history and physical exam findings to help narrow the diagnosis and provide appropriate management and supportive care while awaiting further confirmatory testing.

Massive Hiatal Hernia With Acute Gastric Volvulus Masked as a Suspected Food Poisoning: A Case Report.

We describe the case of a 69-year-old female who thought she had "food poisoning", which prompted her visit to the Emergency Department for evaluation of her vomiting and abdominal discomfort. Contrasted computed tomography imaging with contrast of the abdomen subsequently revealed the diagnosis of gastric volvulus, and the patient was promptly taken for surgical intervention. Gastric volvulus is rare and presents with a nonspecific history, exam, and laboratory findings. In the acute care setting, it is important to maintain a high clinical suspicion for this diagnosis, as timely imaging and intervention are crucial to decreasing patient morbidity and mortality.

Female with Atraumatic Abdominal Bruising.

CASE PRESENTATION: We describe the case of a 38-year-old female patient with a history of lupus presenting with atraumatic abdominal pain and ecchymosis. The ultimate diagnosis of abdominal lupus erythematous panniculitis was determined based on physical exam and imaging findings. DISCUSSION: Lupus erythematous panniculitis is a rare diagnosis, but consideration is important as early recognition and treatment is important to reduce pain and lessen the possibility of irreversible disfigurement and unnecessary costs to affected patients.

Feasibility of a Multifaceted Social Emergency Medicine Curriculum for Emergency Medicine Residents.

INTRODUCTION: Emergency physicians are in a unique position to impact both individual and population health needs. Despite this, emergency medicine (EM) residency training lacks formalized education n the social determinants of health (SDoH) and integration of patient social risk and need, which are core components of social EM (SEM). The need for such a SEM-based residency curriculum has been previously recognized; however, there is a gap in the literature related to demonstration and feasibility. In this study we sought to address this need by implementing and evaluating a replicable, multifaceted introductory SEM curriculum for EM residents. This curriculum is designed to increase general awareness related to SEM and to increase ability to identify and intervene upon SDoH in clinical practice. METHODS: A taskforce of EM clinician-educators with expertise in SEM developed a 4.5-hour educational curriculum for use during a single, half-day didactic session for EM residents. The curriculum consisted of asynchronous learning via a podcast, four SEM subtopic lecture didactics, guest speakers from the emergency department (ED) social work team and a community outreach partner, and a poverty simulation with interdisciplinary debrief. We obtained pre- and post- intervention surveys. RESULTS: A total of 35 residents and faculty attended the conference day, with 18 participants completing the immediate post-conference survey and 10 participants completing the two-month delayed, post-conference survey. Post-survey results demonstrated improved awareness of SEM concepts and increased confidence in participants' knowledge of community resources and ability to connect patients to these resources following the curricular intervention (25% pre-conference to 83% post-conference). In addition, post-survey assessment demonstrated significantly heightened awareness and clinical consideration of SDoH among participants (31% pre-conference to 78% post-conference) and increased comfort in identifying social risk in the ED (75% pre-conference to 94% post-conference). Overall, all components of the curriculum were evaluated as meaningful and specifically beneficial for EM training. The ED care coordination, poverty simulation, and the subtopic lectures were rated most meaningful. CONCLUSION: This pilot curricular integration study demonstrates feasibility and the perceived participant value of incorporating a social EM curriculum into EM residency training.

Can Emergency Physicians Diagnose Cirrhosis by Ultrasound: A Prospective Single-Arm Educational Intervention.

Background and purpose Liver cirrhosis is common, and timely diagnosis of decompensated cirrhosis may impact acute care and resuscitation. Point-of-care ultrasound is a core competency of US emergency medicine training and is increasingly available in many acute care settings, including those where usual diagnostic modalities of cirrhosis may not be available. Only a few works of literature exist that evaluate the ultrasound diagnosis of cirrhosis and decompensated cirrhosis by emergency physicians (EPs). We aim to evaluate whether EPs can diagnose cirrhosis by ultrasound after a brief educational intervention and determine the accuracy of EP-interpreted ultrasound compared to the radiology-interpreted ultrasound as a gold standard. Methods This single-center prospective single-arm educational intervention evaluated the accuracy of EPs diagnosing cirrhosis and decompensated cirrhosis on ultrasound before and after a short educational intervention. Responses were paired across the three assessments, and paired sample t-tests were performed. Sensitivity, specificity, and likelihood ratios were calculated using attending radiology-interpreted ultrasounds as the gold standard. Results EPs scored a mean of 16% higher on a delayed knowledge assessment one month after the educational intervention than on the pre-intervention assessment. EP-interpreted ultrasound revealed a sensitivity of 0.90, specificity of 0.71, positive likelihood ratio of 3.08, and negative likelihood ratio of 0.14 compared to radiology-interpreted ultrasound. The sensitivity of our cohort was 0.98 for decompensated cirrhosis. Conclusions After a brief educational intervention, EPs can significantly increase their sensitivity and specificity in diagnosing cirrhosis using ultrasound. EPs were particularly sensitive in their diagnosis of decompensated cirrhosis.

A Woman with Abdominal Pain After Lap-belt Trauma.

Case presentation: A 24-year-old female presented to the emergency department with diffuse abdominal pain after involvement as a restrained driver in a motor vehicle collision (MVC). Computed tomography of the abdomen revealed a traumatic abdominal wall hernia due to rectus wall rupture with complete bowel herniation. Discussion: A traumatic abdominal wall hernia is a rare complication of blunt abdominal trauma that is typically associated with injury from a motorcycle handlebar but is more commonly seen after a MVC. It is important to consider this diagnosis when evaluating patients with abdominal pain after blunt abdominal trauma from either of these mechanisms.

Race and Other Disparate Demographic Variables Identified Among Emergency Department Boarders.

INTRODUCTION: Emergency department (ED) boarding, the process of holding patients in the ED due to a lack of inpatient beds after the decision is made to admit, has profound consequences. Increased ED boarding times are associated with adverse patient outcomes, including increased mortality. While previous studies have demonstrated racial disparities with regard to ED boarding, current literature lacks insight into discrepancies that may exist among other demographic groups as it pertains to ED boarding. We sought to review ED boarding times differentiated by demographic characteristics. METHODS: We conducted a retrospective review of all ED admissions from an academic ED in the Southeast from April-September 2019. The primary outcome assessed was boarding time, defined as time from decision to admit to ED departure. Patient demographic data including race, gender, and age were collected and analyzed. We performed descriptive statistics and chi-square analyses. RESULTS: The study population included 17,606 patients with a mean age of 56.3. Nearly half (49.8%) of the patients were female. Additionally, 43.8% of patients were Black and 48.6% White. For all admissions, there was no difference in mean boarding time among Black and White patients (5.2 ± 8.8 vs 5.2 ± 8.2 hours, P = 0.11). Among Emergency Severity Index (ESI) level I admissions, Black patients boarded longer than White patients (4.1 ± 0.3 vs 2.7 ± 0.3 hours, P = 0.009). Black patients also boarded significantly longer than White patients for psychiatric admissions (22.7 ± 23.7 vs 18.5 ± 19.4 hours, P <0.05). For all admissions, males boarded longer than females (5.5 ± 8.5 vs 4.9 ± 8.2 hours, P <.0001). Patients older than 75 boarded for less time (3.8 ± 6.2 hours) compared to younger groups (15-24: 6.4 ± 10.8 hours; 25-44: 6.6 ± 10.8; 45-64: 5.0 ± 7.6; and 64-75: 4.7 ± 6.7; all P <.05). CONCLUSION: This analysis demonstrated significant differences in ED boarding times between races among psychiatric and ESI I admissions, gender, and age. This data provides insight into differences in ED boarding times among demographic groups and provides a focal point for examining possible factors contributing to the observed differences.

Educational Intervention in the Emergency Department to Address Disparities in Stroke Knowledge.

OBJECTIVES: In the United States, Black individuals have higher stroke incidence and mortality when compared to white individuals and are also at risk of having lower stroke knowledge and awareness. With the need to implement focused interventions to decrease stroke disparities, the objective of this study is to evaluate the feasibility and efficacy of an emergency department-based educational intervention aimed at increasing stroke awareness and preparedness among a disproportionately high-risk group. MATERIALS AND METHODS: Over a three-month timeframe, an emergency department-based, prospective educational intervention was implemented for Black patients in an urban, academic emergency department. All participants received stroke education in the forms of a video, written brochure and verbal counseling.  Stroke knowledge was assessed pre-intervention, immediately post-intervention, and at one-month post-intervention. RESULTS: One hundred eighty-five patients were approached for enrollment, of whom 100 participants completed the educational intervention as well as the pre- and immediate post- intervention knowledge assessments. Participants demonstrated increased stroke knowledge from baseline knowledge assessment (5.35 ± 1.97) at both immediate post-intervention (7.66 ± 2.42, p < .0001) and one-month post-intervention assessment (7.21 ± 2.21, p < .0001). CONCLUSIONS: Emergency department-based stroke education can result in improved knowledge among this focused demographic. The emergency department represents a potential site for educational interventions to address disparities in stroke knowledge.

Evaluation of a novel handheld point-of-care ultrasound device in an African emergency department.

BACKGROUND: Many point-of-care ultrasound devices are now "pocket-sized" or handheld, allowing easy transport during travel and facilitating use in crowded spaces or in austere low-resource settings. Concerns remain about their durability, image quality, and clinical utility in those environments. METHOD: Five emergency physicians with training in point-of-care ultrasound employed the Butterfly iQ, a novel handheld ultrasound device, in routine clinical care in a busy, high-acuity African emergency department over a period of 10 weeks. We retrospectively evaluated the performance of the Butterfly iQ from the perspectives of both the clinicians using the device and expert ultrasound faculty reviewing the images. RESULTS: We found advantages of the Butterfly iQ in a high-acuity African emergency department include its use of a single probe for multiple functions, small size, ease of transport, relatively low cost, and good image quality in most functions. Disadvantages include large probe footprint, lower, though still adequate, cardiac imaging quality, frequent overheating, and reliance on internet-based cloud storage, but these were surmountable. We also report a wide variety of patient presentations, pathology, and procedures to which the device was used. CONCLUSION: We conclude the Butterfly iQ is an effective, though imperfect, point-of-care ultrasound device in a low-resource emergency setting. We will continue to employ the device in clinical emergency care and teaching in this setting.

Clinical ultrasonography in patients who inject drugs (the CUPID protocol): an illustrated case series.

In 2017, there were ≈47,600 opioid overdose-related deaths in the United States. US emergency department (ED) visits for suspected opioid overdose increased by 30% between July 2016 and September 2017.2 The current US opioid epidemic makes it critical for emergency physicians to be aware of common and uncommon infectious and non-infectious complications of injection drug use. Point-of-care ultrasound has become a widely available, non-invasive diagnostic tool in EDs across the United States and worldwide. The increasing population of injection drug use patients is at risk for serious morbidity and mortality from an array of disease states amenable to ultrasound-based diagnosis. We propose a protocol for clinical ultrasonography in patients who inject drugs (the CUPID protocol), a focused, 3-system point-of-care ultrasound approach emphasizing cardiovascular, thoracic, and musculoskeletal imaging. The protocol is a screening tool, designed to detect high risk infectious and noninfectious complications of injection drug use.

Young Man With Suspected Foreign Body Ingestion.

As United States emergency departments (ED) and hospitals continue to contend with increasing numbers of patients presenting with complications of substance abuse, emergency physicians should also be aware of patients who may be smuggling illicit drugs. We report the case of a 26-year-old man who was transported to the ED for suspected drug smuggling. Abdominal computed tomography was notable for the presence of multiple tubular foreign bodies throughout the colon that were later identified as packets containing heroin. Body-packing patients present a high-risk clinical scenario that may result in massive, inadvertent drug exposure.