Bloody tears: Ocular pyogenic granuloma inducing hemolacria during pregnancy.

Hemolacria, or bloody tears, is a symptom caused by several ocular disorders ranging from trauma to hormonal changes. We describe a case in which a 21-year-old, 28-week pregnant patient presented to the emergency department (ED) following her second occurrence of nocturnal left eye bleeding in a week. During her examination in the ED, a small abrasion to the lateral edge of the upper left lid was noted. No other injuries, traumatic mechanisms, or relevant past medical history were noted. Due to her pregnancy, the nascent pyogenic granuloma responsible for her hemolacria was managed conservatively. Despite management, the pyogenic granuloma rapidly grew within a few weeks causing ocular irritation and conjunctival injection. Due to concerns about ocular irritation, inability to close the affected eyelid, and decreasing visual acuity, the pyogenic granuloma was removed surgically. This case highlights the difficulty in managing pregnant patients with ocular complaints who initially present to the ED. In this case, the patient's pregnancy complicated her initial treatment plan, requiring more conservative initial management strategies. While conservative first-line treatment options for pregnant patients are recommended, they should be paired with constant risk-benefit assessment for the patient and her fetus.

Acute Chest Pain Following Bravo Device Placement.

A Bravo device is a continuous pH monitor, produced by Medtronic (Minneapolis, MN), that is placed on the esophageal mucosa during endoscopy and can be used in the evaluation of gastroesophageal reflux disease (GERD). The device detaches by itself and passes with feces in approximately 7-10 days. Because of its brief presence in the body, the device is an unusual finding on imaging and could easily be mistaken for a more ominous foreign body. The Bravo device is typically well tolerated but can be a source of severe discomfort. Its presence is an important consideration in the differential of chest pain and a contraindication to MRI. Here, we discuss a case of a patient presenting to the emergency department (ED) with acute chest pain who underwent Bravo device placement several days prior.

Volvulus Irritating the Myocardium: A Case Report.

Gastric volvulus is a rare condition that may present with various symptoms and may occur as an acute or chronic condition. Signs and symptoms may include nausea, vomiting, abdominal pain, and chest pain. It is imperative to recognize acute gastric volvulus in a timely fashion, since a delay in diagnosis may result in foregut obstruction and increased risk of strangulation, if not recognized and treated promptly. Additionally, secondary complications that are equally life-threatening, such as cardiac arrhythmias, can occur. For this very reason, it is important to highlight gastric volvulus as a possibility when developing a differential diagnosis in patients complaining of abdominal pain. This case report describes a 73-year-old female with no past cardiac risk factors, who presented to the emergency department (ED) with symptoms of supraventricular tachycardia (SVT), intermittent diarrhea, and nausea per emergency medical services (EMS). Upon EMS arrival at the patient's home, her heart rate was 210 beats per minute (bpm). Despite her condition appearing to result from a cardiac condition, imaging studies found a large hiatal hernia through which the stomach had displaced. The patient's stomach had distended, forming a volvulus and placing pressure on thoracic organs. This case highlights a rare but potentially life-threatening cardiac arrhythmia associated with gastric volvulus.

Brugada syndrome in the setting of hypothermia.

Hypothermia is a common diagnosis in the Emergency Department. It can cause a multitude of symptoms and complications if not treated promptly. The following case report discusses Brugada pattern on an electrocardiogram in a patient with hypothermia and diabetic ketoacidosis. There was resolution of the Brugada pattern on the electrocardiogram after the patient was warmed to 35.3 °C.

Central neurogenic hyperventilation secondary to suspected metastatic renal cell carcinoma.

Central neurogenic hyperventilation (CNH) is a neurogenic disorder rarely described within Emergency Medicine literature. CNH is a primary cause of hyperventilation, most commonly due to primary central nervous system neoplasms. Patient presentation varies based on the underlying cause, and may present with a sole chief complaint of dyspnea. We present a case of an adult male with a history of deep vein thrombosis, anticoagulated on apixaban, and extensively metastatic renal cell carcinoma who presented with a two-week history of dyspnea. Evaluation in the emergency department showed a primary respiratory alkalosis with a compensatory metabolic acidosis. Diagnostic work-up failed to reveal a cardiac, pulmonary, metabolic, or toxic cause. During the emergency department course, the patient became dysarthric and altered, at which point, computed tomography scan of the head revealed a pontine hemorrhage. The hemorrhage was stabilized with prothrombin complex concentrate, but the patient's dyspnea and mental status deteriorated throughout the course of his hospitalization. While the cause of the patient's hemorrhage was not elucidated, given the patient's widely metastatic disease, it was presumed to be secondary to metastasis. Our case highlights both a unique cause of a rare disorder of hyperventilation, and a diagnostic challenge to the emergency medicine provider. It is important to consider central causes of hyperventilation in patients with dyspnea and neurologic symptoms.

Appropriate Evaluation of Psychiatric Patients Highlighted by Creutzfeldt-Jakob Disease: A Case Report.

INTRODUCTION: Determination of medical stability for patients presenting with psychiatric complaints is common for emergency clinicians. A thorough history and physical examination is important. CASE REPORT: A 53-year-old male presented to the emergency department (ED) with depression, suicidal ideation, and decline in activities of daily living over six months. While his initial neurologic examination was non-focal, subsequent re-evaluations demonstrated significant changes, and he was ultimately diagnosed with Creutzfeldt-Jakob disease. CONCLUSION: This case demonstrates how a detailed history of the present illness could have led to a more accurate and timely medical disposition from the ED.

Standardized Direct Observation Assessment Tool: Using a Training Video.

BACKGROUND: We developed a DVD training tool to educate physicians evaluating emergency residents on accurate Standardized Direct Observation Assessment Tool (SDOT) application. OBJECTIVE: Our goal was to assess whether this training video improved attendings' and senior residents' SDOT use. METHODS: Participants voluntarily completed SDOT evaluations based on a scripted "test" video. A DVD with "positive" and "negative" scenarios of proper SDOT use was viewed. It included education on appropriate recording of 26 behaviors. The test scenario was viewed again and follow-up SDOTs submitted. Performances by attendings and residents on the pre- and post-test SDOTs were compared. RESULTS: Twenty-six attendings and 26 senior residents participated. Prior SDOT experience was noted for 8 attendings and 11 residents. For 20 anchors, participants recorded observed behaviors with statistically significant difference on one each of the pretest (no. 20; p = 0.034) and post-test (no. 14; p = 0.041) SDOTs. On global competency assessments, pretest medical knowledge (p = 0.016) differed significantly between groups. The training intervention changed one anchor (no. 5; p = 0.035) and one global assessment (systems-based practice; p = 0.031) more negatively for residents. Recording SDOTs with exact agreement occurred 48.73% for attendings pretest and 54.41% post-test; resident scores were 45.86% and 49.55%, respectively. DVD exposure slightly raised attending scores (p = 0.289) and significantly lowered resident scores (p = 0.046). CONCLUSIONS: Exposure to an independently developed SDOT training video tended to raise attending scores, though without significance, while at the same time lowered senior resident scores statistically significantly. Emergency attendings' and senior residents' SDOT scoring rarely differed with significance; about half of anchor behaviors were recorded with exact agreement. This suggests senior residents, with appropriate education, may participate in SDOT assessment.

Correlation Between United States Medical Licensing Examination and Comprehensive Osteopathic Medical Licensing Examination Scores for Applicants to a Dually Approved Emergency Medicine Residency.

BACKGROUND: It is important for emergency medicine (EM) residency programs to be able to correlate the United States (US) Medical Licensing Examination (USMLE) and Comprehensive Osteopathic Medical Licensing Examination (COMLEX) scores of applicants. OBJECTIVE: We sought to determine the correlation between USMLE and COMLEX scores for EM residency applicants. METHODS: Retrospectively, from 2006 through 2013, USMLE and COMLEX examination scores for applicants to our 4-year, 56-member, dually approved EM residency were analyzed. Using the COMLEX score as the outcome variable and USMLE score as the predictor, multiple linear regression models, stratified by test step, were created. RESULTS: There were 556 students representing 25 discrete medical schools included. Pair 1 consisted of applicants submitting COMLEX Level-1 and USMLE Step-1 scores (n = 486). Pair 2 were those with COMLEX Level-2 and USMLE Step-2 scores (n = 356). For Pair 1, mean, standard deviation, and median scores on the COMLEX were 551, 69, and 548, respectively; for the USMLE, scores were 216, 16, and 217, respectively. Results for Pair 2 on COMLEX were 566, 80, and 562, respectively; USMLE results were 228, 18, and 229, respectively. A strong correlation was observed for Pair 1 (r = 0.78; p < 0.001). A 1-point increase in USMLE Step-1 is associated with a 3.55-point increase in the COMLEX Level-1 score (ß = 3.55; 95% confidence interval [CI] 3.30-3.80; p < 0.001). A similar strong correlation was observed for Pair 2 (r = 0.72; p < 0.001), where a 1-point increase in USMLE Step-2 is associated with a 3.29-point increase in the COMLEX Level-2 score (ß = 3.29; 95% CI 2.96-3.62; p < 0.001). CONCLUSIONS: A strong positive correlation between Steps 1 and 2 of the USMLE and COMLEX was found.

Comparison of airway intubation devices when using a biohazard suit: a feasibility study.

OBJECTIVES: We set out to compare emergency medicine residents' intubating times and success rates for direct laryngoscopy (DL), GlideScope-assisted intubation (GS), and the Supraglottic Airway Laryngopharyngeal Tube (SALT) airway with and without biohazard gear. METHODS: Each resident passed through 2 sets of 3 testing stations (DL, GS, SALT) in succession, intubating Laerdal mannequin heads with the 3 modalities after randomization to start with or without biohazard gear. RESULTS: Thirty-seven residents participated, and 27 were male (73%); 14 (37.8%) had prior experience intubating in biohazard suits. There was a statistically significant difference in those who had prior intubation experience between DL (37, 100%), GS (32, 86.5%), and SALT (12, 32.4%) (P < .001) and in median time to intubation (48 seconds, no suit; 57 seconds, with suits) (P = .03). There was no statistically significant difference between the overall times to intubate for the 3 devices. First-pass success was highest for DL (91.2%, no suit; 83.7%, suit) followed by GS (89%, no suit; 78.3%, suit) and SALT (51%, no suit; 67.6%, suit). CONCLUSION: A minority of participants had prior experience intubating in biohazard suits. Use of biohazard suits extends time to successful intubation. There was no difference in time to intubation for the 3 devices, but first-pass success was highest for DL (with or without biohazard gear).

Gender differences in perceptions and self-reported driving behaviors among teenagers.

BACKGROUND: The Centers for Disease Control reports that motor vehicle crashes (MVCs) are the leading cause of injury and death among U.S. teenagers, and disproportionately affect males. Among preventable causes of MVCs involving teenage drivers, distracted driving continues to be a serious public health problem. OBJECTIVES: To describe gender differences in teenage drivers' self-perceptions of safe driving behaviors, and self-reported risk behaviors and distractions while driving. METHODS: We prospectively surveyed teenage drivers from four high schools in Pennsylvania and New Jersey. Gender comparisons were made between self-reported perceptions and self-reported driving behaviors. Descriptive statistics and chi-squared testing were used in data analyses; significance was set at p < 0.05. RESULTS: Seven hundred fifty-six high school teenage drivers completed surveys. Males (52%) and females (48%) were equally distributed; 32% of males reported that they were extremely safe drivers, whereas only 18% of females reported that they were extremely safe drivers (p < 0.001). Significantly more females (91%) compared to males (77%) reported always wearing their seatbelts (p < 0.001). Female drivers were more likely than male drivers to self-report that they always make their passengers wear a seat belt (76% vs. 63%, p < 0.001). A higher proportion of males reported using their cell phones while driving, compared to females (68% vs. 56%, p = 0.004), and 42% of males reported texting while driving, compared to 34% of females (p = 0.037). CONCLUSION: Teenage male drivers perceive themselves to be safe drivers, but report engaging in more distracted driving and risky behaviors compared to females. These results suggest that there is an opportunity for gender-specific educational and injury prevention programs for teen drivers.

Sex- and gender-specific research priorities in cardiovascular resuscitation: proceedings from the 2014 Academic Emergency Medicine Consensus Conference Cardiovascular Resuscitation Research Workgroup.

Significant sex and gender differences in both physiology and psychology are readily acknowledged between men and women; however, data are lacking regarding differences in their responses to injury and treatment and in their ultimate recovery and survival. These variations remain particularly poorly defined within the field of cardiovascular resuscitation. A better understanding of the interaction between these important factors may soon allow us to dramatically improve outcomes in disease processes that currently carry a dismal prognosis, such as sudden cardiac arrest. As part of the 2014 Academic Emergency Medicine consensus conference "Gender-Specific Research in Emergency Medicine: Investigate, Understand, and Translate How Gender Affects Patient Outcomes," our group sought to identify key research questions and knowledge gaps pertaining to both sex and gender in cardiac resuscitation that could be answered in the near future to inform our understanding of these important issues. We combined a monthly teleconference meeting of interdisciplinary stakeholders from largely academic institutions with a focused interest in cardiovascular outcomes research, an extensive review of the existing literature, and an open breakout session discussion on the recommendations at the consensus conference to establish a prioritization of the knowledge gaps and relevant research questions in this area. We identified six priority research areas: 1) out-of-hospital cardiac arrest epidemiology and outcome, 2) customized resuscitation drugs, 3) treatment role for sex steroids, 4) targeted temperature management and hypothermia, 5) withdrawal of care after cardiac arrest, and 6) cardiopulmonary resuscitation training and implementation. We believe that exploring these key topics and identifying relevant questions may directly lead to improved understanding of sex- and gender-specific issues seen in cardiac resuscitation and ultimately improved patient outcomes.

Unique obstacle race injuries at an extreme sports event: a case series.

Obstacle course endurance events are becoming more common. Appropriate preparedness for the volume and unique types of injury patterns, as well as the effect on public health these events may cause, has yet to be reported in emergency literature. We describe 5 patients who presented with diverse injuries to illustrate the variety of injuries sustained in this competitive event. In particular, 4 of the patients had a history of contact with electrical discharge, an obstacle distinctive to the Tough Mudder experience.

Training mothers in infant cardiopulmonary resuscitation with an instructional DVD and manikin.

CONTEXT: Classes in infant cardiopulmonary resuscitation (CPR) can be time consuming and costly. OBJECTIVE: To determine whether mothers in an obstetric unit could learn infant CPR by using a 22-minute instructional kit and to assess the value and confidence they gained by learning CPR. DESIGN: Quasi-experimental study with enrollment between January and December 2008. SETTING: Obstetric unit in Lehigh Valley Hospital, a suburban teaching hospital in Allentown, Pennsylvania. PARTICIPANTS: Mothers at least 18 years old who had given birth within the previous 24 hours. INTERVENTION: The experimental group included mothers without prior CPR training who watched a 22-minute instructional DVD and practiced on a manikin. The control group included mothers with prior conventional CPR training. MAIN OUTCOME MEASURES: In both groups, knowledge and proficiency were assessed with written and practical examinations developed by certified CPR instructors. Participant surveys were conducted at 3 times: immediately before dissemination of course materials, within 24 hours after the mother agreed to participate in the study, and 6 months after initial evaluation. RESULTS: A total of 126 mothers were enrolled in the study: 79 in the experimental group, 25 in the control group, and 22 who withdrew from the study. Written and practical examinations were used to determine proficiency, and composite scores were generated, with a maximum composite score of 12. The composite scores were statistically significantly higher in the experimental group than in the control group, with median scores of 10 and 7, respectively (P<.001). Twenty-two mothers (21%) had been previously offered CPR training. In the experimental group, 76 mothers (96%) felt more confident as caregivers after learning CPR. Before training in both groups, 84 mothers (81%) stated that learning CPR was extremely important, compared with 100 mothers (96%) after training (P=.001). CONCLUSION: Use of an instructional kit is an effective method of teaching CPR to new mothers. Mothers reported that learning CPR is extremely important and that it increases their confidence as caregivers.

Cardiopulmonary resuscitation prescription program: a pilot randomized comparator trial.

BACKGROUND: The American Heart Association wants to increase the number of citizens who know how to perform cardiopulmonary resuscitation (CPR). It is unknown whether giving patients a prescription (Rx) to learn CPR is effective. We sought to determine if patients with, or at risk for, heart disease and their families were more likely to follow prescriptive advice to buy a CPR Anytime™ kit (American Heart Association, Dallas, TX) or to take a CPR class. METHODS: This was a prospective randomized pilot study of a convenience sample of 162 patients who presented to one of three recruiting sites: a suburban community emergency department (ED), an office-based primary care (IM), or cardiology (CD) setting. After consent was obtained, CPR-naïve participants aged>44 years were randomized to one of two study arms. One group received a Rx for a CPR Anytime™ self-learning kit, consisting of a CPR mannequin and a 22-minute DVD. The comparator group was prescribed a CPR class. RESULTS: At the IM office, 7/29 (24%), at the CD office 3/25 (12%), and at the ED 2/23 (9%) patients purchased the CPR kit. Across both investigational arms, 4 were lost to follow-up, yielding approximately 15% (12/77) who followed Rx advice to purchase the CPR kit and 0% (0/79) who took a CPR class. Cumulatively, a participant was significantly more likely to purchase a kit than to take a class (p=0.0004). CONCLUSION: Patients can be motivated to purchase CPR Anytime™ kits but not to take a CPR class from prescribed advice.

Cognitive versus technical debriefing after simulation training.

BACKGROUND: Recent literature describes "cognitive dispositions to respond" (CDRs) that may lead physicians to err in their clinical reasoning. OBJECTIVES: To assess learner perception of high-fidelity mannequin-based simulation and debriefing to improve understanding of CDRs. METHODS: Emergency medicine (EM) residents were exposed to two simulations designed to bring out the CDR concept known as "vertical line failure." Residents were then block-randomized to a technical/knowledge debriefing covering the medical subject matter or a CDR debriefing covering vertical line failure. They then completed a written survey and were interviewed by an ethnographer. Four investigators blinded to group assignment reviewed the interview transcripts and coded the comments. The comments were qualitatively analyzed and those upon which three out of four raters agreed were quantified. A random sample of 84 comments was assessed for interrater reliability using a kappa statistic. RESULTS: Sixty-two residents from two EM residencies participated. Survey results were compared by technical (group A, n = 32) or cognitive (group B, n = 30) debriefing. There were 255 group A and 176 group B comments quantified. The kappa statistic for coding the interview comments was 0.42. The CDR debriefing group made more, and qualitatively richer, comments regarding CDR concepts. The technical debriefing group made more comments on the medical subjects of cases. Both groups showed an appreciation for the risk of diagnostic error. CONCLUSIONS: Survey data indicate that technical debriefing was better received than cognitive debriefing. The authors theorize that an understanding of CDRs can be facilitated through simulation training based on the analysis of interview comments.

Using simulation to instruct emergency medicine residents in cognitive forcing strategies.

PURPOSE: Recent literature defines certain cognitive errors that emergency physicians will likely encounter. The authors have utilized simulation and debriefing to teach the concepts of metacognition and error avoidance. METHOD: The authors conducted a qualitative study of an educational intervention at Lehigh Valley Hospital during academic year 2002-03. Fifteen emergency medicine residents--eight from postgraduate year three (PGY3) and seven from postgraduate year two (PGY2)--experienced a difficult simulator lab scenario designed to lead them into a cognitive error trap. The debriefing was a PowerPoint with audio format CD-ROM with a didactic on succinylcholine (15 minutes) and cognitive forcing strategies (30 minutes). After debriefing, residents were interviewed by an ethnographer with an 11-question (15-minute) interview and completed an eight-question written survey. RESULTS: The residents ranked this experience second only to direct patient care for educational effectiveness. Survey results (Likert scale, 1 = disagree completely to 5 = agree completely) included "Improved my ability to use succinylcholine" (mean = 4.73), "Improved my ability to diagnose and treat hyperkalemia" (mean = 4.6), and "Cognitive forcing strategies is a useful educational effort" (mean = 4.33). The major interview themes that evolved were that the simulation lab was a positive experience; succinylcholine knowledge was gained; mistakes caused reflection/motivation; the lab was stressful; attending feedback was desired; the lab was realistic; and cognitive forcing strategies were discussed. When asked what they learned, more of the PGY3s commented on cognitive strategies or heuristic techniques (six out of eight), whereas the PGY2s commented on knowledge gained about succinylcholine (five out of seven) and only one PGY2 mentioned cognitive strategies. CONCLUSION: Pilot data suggest that metacognitive strategies can be taught to residents, though they may be better understood by upper-level residents.