Impact of neighborhood disadvantage on posttrauma outcomes after sexual assault.

In the United States, 8,000,000 people seek emergency care for traumatic injury annually. Motor vehicle collisions (MVCs) and sexual assault are two common sources of trauma, with evidence that reduced neighborhood-level socioeconomic characteristics increase posttraumatic pain and stress after an MVC. We evaluated whether neighborhood disadvantage was also associated with physical and mental posttrauma outcomes after sexual assault in a sample of adult women (N = 656) who presented for emergency care at facilities in the United States following sexual assault and were followed for 1 year. Neighborhood characteristics were assessed via the Area Deprivation Index, and self-reported pain, anxiety, depression, and posttraumatic stress disorder (PTSD) symptoms were collected at 6 weeks posttrauma. Adjusted log-binomial regression models examined the association between each clinical outcome and neighborhood disadvantage. Women in more disadvantaged neighborhoods were more likely to be non-White and have lower annual incomes. At 6 weeks posttrauma, the prevalence of clinically significant pain, anxiety, and depressive symptoms more than doubled from baseline (41.7% vs. 18.8%, 62.4% vs. 23.9%, and 55.2% vs. 22.7%, respectively); 40.7% of women also reported PTSD symptoms. Black, Hispanic, and lower-income participants were more likely to report pre- and postassault pain, anxiety, and depression. After adjusting for race, ethnicity, and income, no significant association existed between neighborhood disadvantage and any outcome, ps = .197 - .859. Although neighborhood disadvantage was not associated with posttrauma outcomes, these findings highlight the need for continued research in diverse populations at high risk of adverse physical and mental health symptoms following sexual assault.

Implementation of dedicated social worker coaching for emergency medicine residents - Lessons learned.

Emergency medicine training is associated with high levels of stress and burnout, which were exacerbated by the COVID-19 pandemic. The pandemic further exposed a mismatch between trainees' mental health needs and timely support services; therefore, the objective of our innovation was to create an opportunity for residents to access a social worker who could provide consistent coaching. The residency leadership team partnered with our graduate medical education (GME) office to identify a clinical social worker and professionally-trained coach to lead sessions. The project was budgeted at an initial cost of $15,000 over 1 year. Residents participated in 49 group and 73 individual sessions. Post implementation in 2021, we compared this intervention to all other wellness initiatives. Resident response rate was 80.88% (n = 55/68) and median interquartile range (IQR) score of the initiative was 2 (1 = detrimental and 4 = beneficial) versus 3.79 (3.69-3.88) the median IQR of all wellness initiatives. A notable number, 22%, rated the program as detrimental, which could be related to summary comments regarding ability to attend sessions, lack of session structure, loss of personal/educational time, and capacity of the social worker to relate with them. Summary comments also revealed the innovation was useful, with individual sessions preferred to group sessions. Application of a social worker coaching program in an emergency medicine residency program appears to be a feasible novel intervention. Lessons learned after implementation include the importance of recruiting someone with emergency department/GME experience, orienting them to culture before implementation and framing coaching as an integrated residency resource.

Defining "county": A mixed-methods inquiry of county emergency medicine residency programs.

INTRODUCTION: There is no clear unified definition of "county programs" in emergency medicine (EM). Key residency directories are varied in designation, despite it being one of the most important match factors for applicants. The Council of Residency Directors EM County Program Community of Practice consists of residency program leadership from a unified collective of programs that identify as "county." This paper's framework was spurred from numerous group discussions to better understand unifying themes that define county programs. METHODOLOGY: This institutional review board-exempt work provides qualitative descriptive results via a mixed-methods inquiry utilizing survey data and quantitative data from programs that self-designate as county. UNIQUE TREATMENT ANALYSIS AND CRITIQUE: Most respondents work, identify, and trained at a county program. The majority defined county programs by commitment to care for the underserved, funding from the city or state, low-resourced, and urban setting. Major qualitative themes included mission, clinical environment, research, training, and applicant recommendations. Comparing the attributes of programs by self-described type of training environment, county programs are typically larger, older, in central metro areas, and more likely to be 4 years in duration and have higher patient volumes when compared to community or university programs. When comparing hospital-level attributes of primary training sites county programs are more likely to be owned and operated by local governments or governmental hospital districts and authorities and see more disproportionate-share hospital patients. IMPLICATIONS FOR EDUCATION AND TRAINING IN EM: To be considered a county program we recommend some or most of the following attributes be present: a shared mission to medically underserved and vulnerable patients, an urban location with city or county funding, an ED with high patient volumes, supportive of resident autonomy, and research expertise focusing on underserved populations.

Teaching emergency medicine residents health equity through simulation immersion.

OBJECTIVE: Our aim was to conduct a large, case-based diversity, equity, and inclusion (DEI) simulation exercise with a goal to improve the DEI pillars of cultural and structural awareness for residents. METHODS: Utilizing data resulting in poor health outcomes, the top eight themes were utilized, and via a modified Delphi approach, a diverse group of faculty developed representative cases. A mass simulation effort was organized with the assistance of our local simulation office. Twenty residents in groups of two to three rotated through all scenarios. Each resident group was allotted 15 min for each scenario. After each case, resident teams received feedback from standardized patients and a debrief together with the simulation directors. Pre- and postsimulation surveys were developed and distributed to residents. RESULTS: Twenty residents completed the simulation. Eighteen completed a pre- and postsimulation survey. Every resident rated the overall usefulness of this activity as a 5.0 on a scale of 1 to 5 with 5 being the highest score. All cases demonstrated an improvement in the residents perceived confidence on a 9-point Likert scale. All residents reported improved understanding of key concepts in health care disparities as related to race/ethnicity, homelessness, LGBTQIA, and their own biases. The largest improvement was seen in the overarching theme of "difficult conversations" with a presimulation survey mean of 3.9 and postsimulation survey mean of 6.5 (delta = +2.6, 95% confidence interval = 1.9 to 3.3, p < 0.01). CONCLUSIONS: Emergency medicine residency programs must fulfill their obligation to DEI efforts and national requirements while ensuring competency clinically. Mass simulation exercises are a way to incorporate this training. This preliminary data shows promise for a solution and can be easily duplicated. Diversity, health equity, inclusivity, and cultural humility can be effectively taught by an innovative mass simulation effort.

An Easily Assembled, Low-Cost Model for Lateral Canthotomy Education.

BACKGROUND: Lateral canthotomy is a vision-saving procedure. However, the low incidence of orbital compartment syndrome and the expense of simulators to practice this procedure can lead to low confidence and delays in the performance of the procedure by emergency physicians. DISCUSSION: We used a simple, inexpensive, easily assembled eye model for lateral canthotomy education at a residency program and a national conference obtaining feedback from simulation participants. Residents rated procedure laboratories that included the lateral canthotomy model as 4.9 to 5 (on a 5-point Likert scale, with 5 being the best score). National conference participants rated the model a 9 as a useful training model for practitioners on a 10-point Likert scale. CONCLUSION: This simple task trainer is practical, inexpensive, quickly assembled, and useful as a tool for practicing emergency medicine providers.

Perceived Care Quality Among Women Receiving Sexual Assault Nurse Examiner Care: Results From a 1-Week Postexamination Survey in a Large Multisite Prospective Study.

INTRODUCTION: This study examined the perspectives of female patients who had been sexually assaulted regarding the quality of care provided by sexual assault nurse examiners, including whether the patients' perspectives varied by their demographic characteristics and health status before the assault. METHODS: A total of 695 female patients who received care from sexual assault nurse examiners at 13 United States emergency care centers and community-based programs completed standardized surveys 1 week after receiving sexual assault nurse examiners' care for sexual assault. RESULTS: Most patients strongly agreed that the sexual assault nurse examiners provided high-quality care, including taking patients' needs/concerns seriously, not acting as though the assault was the patient's fault, showing care/compassion, explaining the sexual assault examination, and providing follow-up information. The perceptions did not vary by the patients' demographic characteristics or preassault health status. DISCUSSION: Female patients who had been sexually assaulted and who were evaluated at 13 widely geographically distributed sexual assault nurse examiners' programs consistently reported that the sexual assault nurse examiners provided high-quality, compassionate care.

Health care utilization by women sexual assault survivors after emergency care: Results of a multisite prospective study.

BACKGROUND: Approximately, 100,000 US women receive emergency care after sexual assault each year, but no large-scale study has examined the incidence of posttraumatic sequelae, receipt of health care, and frequency of assault disclosure to providers. The current study evaluated health outcomes and service utilization among women in the 6 weeks after sexual assault. METHODS: Women ≥18 years of age presenting for emergency care after sexual assault to twelve sites were approached. Among those willing to be contacted for the study (n = 1080), 706 were enrolled. Health outcomes, health care utilization, and assault disclosure were assessed via 6 week survey. RESULTS: Three quarters (76%) of women had posttraumatic stress, depression, or anxiety, and 65% had pain. Less than two in five reported seeing health care provider; receipt of care was not related to substantive differences in symptoms and was less likely among Hispanic women and women with a high school education or less. Nearly one in four who saw a primary care provider did not disclose their assault, often due to shame, embarrassment, or fear of being judged. CONCLUSION: Most women receiving emergency care after sexual assault experience substantial posttraumatic sequelae, but health care in the 6 weeks after assault is uncommon, unrelated to substantive differences in need, and limited in socially disadvantaged groups. Lack of disclosure to primary care providers was common among women who did receive care.

Argyria, an Unexpected Case of Skin Discoloration From Colloidal Silver Salt Ingestion.

BACKGROUND: Argyria is a rare condition characterized by gray/blue dislocation of the skin caused by chronic exposure to silver salts. CASE REPORT: We review the case of an 81-year-old man who presented to the emergency department after a motor vehicle accident, was incidentally found to have skin discoloration, and was ultimately diagnosed with argyria. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although most emergency physicians will not complete a toxicology fellowship, all emergency physicians are on the front line of toxicological presentations and should be able to recognize argyria and differentiate this condition from other causes of skin discoloration.

A Novel Approach to Neonatal Resuscitation Education for Senior Emergency Medicine Residents.

The majority of pediatric visits occur in general emergency departments. Caring for critically ill neonates is a low-frequency but high-stakes event for emergency physicians, which requires specialized knowledge and hands-on training. We describe a novel clinical rotation for emergency medicine (EM) residents that specifically augments skills in neonatal resuscitation through direct participation as a member of the neonatal resuscitation team. The neonatal resuscitation rotation evaluation median score of 4 (interquartile range [IQR] 3,4) was higher compared to all other off-service senior resident rotations combined (median 3, IQR 3,4) for the academic year 2018-2019. Ninety-two percent of residents evaluated the curriculum change as beneficial (median 4, IQR 4,4). The neonatal resuscitation rotation was rated more favorably than the pediatric intensive care rotation (median 4 IQR 3,4 vs median 3, IQR 2, 3) at a tertiary care children's hospital during the third year. Residency programs may want to consider implementing a directed neonatal resuscitation experience as part of a comprehensive pediatric curriculum for EM residents.

First reported case of thrombocytopenia from a Heterodon nasicus envenomation.

CONTEXT: The vast majority of the 2.5 million annual worldwide venomous snakebites are attributed to Viperidae or Elapidae envenomations. Of the nearly 2000 Colubridae species described, only a handful are known to cause medically significant envenomations. Considered medically insignificant, Heterodon nasicus (Western Hognose Snake) is a North American rear-fanged colubrid common in the legal pet trading industry. Previously reported cases of envenomations describe local pain, swelling, edema, and blistering. However, there are no reported cases of systemic or hematologic toxicity. CASE DETAILS: A 20-year-old female sustained a bite while feeding a captive H. nasicus causing local symptoms and thrombocytopenia. On day three after envenomation, the patient was seen in the emergency department for persistent pain, swelling, and blistering. At that time, she was found to have a platelet count of 90 × 109/L. Previous routine platelet counts ranged from 315 to 373 × 109/L during the prior two years. Local symptoms peaked on day seven post envenomation. Her local symptoms and thrombocytopenia improved on evaluation four months after envenomation. DISCUSSION: We report the first Heterodon nasicus envenomation causing both local toxicity and thrombocytopenia. Potential mechanisms based on H. nasicus venom composition are discussed in detail. Treatment is largely supportive. Bites by H. nascius should be evaluated by a toxicologist familiar with Colubridae species. This represents the first reported case of hematologic toxicity from envenomation by a North American colubrid snake.

Pediatric tea tree oil aspiration treated with surfactant in the emergency department.

Tea tree oil is an essential oil containing a mixture of aromatic hydrocarbons. We describe an 18-month-old male patient who ingested tea tree oil, developed central nervous system depression, respiratory distress, and received early emergency department treatment with surfactant. Early treatment of hydrocarbon pneumonitis with surfactant has not been previously described. Early administration of surfactant should be further evaluated for treatment of hydrocarbon aspiration.

Acetylcysteine for acetaminophen overdose in patients who weigh >100 kg.

N-Acetylcysteine (NAC) dosing for acetaminophen (APAP) overdose is weight based (150 mg/kg intravenous or 140-mg/kg oral loading dose) and, in the United States, the dosing protocol recommends using a maximum patient weight of 100 and 110 kg, respectively. Little clinical data describe the use of NAC for APAP poisoning in patients weighing >100 kg. The aim of this study was to describe the demographics, outcomes, and adverse event (AE) rates of patients weighing >100 kg treated with oral or IV NAC for APAP poisoning. Patients were identified from a multicenter retrospective NAC safety study for APAP overdose. We included patients with a recorded weight. Trained chart abstractors used a standardized form. Selected data included age, gender, weight, serum alanine transaminase, and aspartate transaminases, coingestants, NAC administration route, ingestion type, AEs, and outcome [hepatotoxicity (alanine transaminase > 1000 U/L), liver transplant, or death]. Descriptive statistics were used. Of 503 study patients, 37 (7.4%) had recorded weights >100 kg. The median (range) weight was 110 kg (101-160). The median (range) dosing for patients treated with oral NAC was 140 mg/kg (127-143 mg/kg) and 150 (108-168) mg/kg for IV NAC. Hepatotoxicity occurred in 12/36 (33.3%) patients. Death occurred in 4/36 (11.1%) patients. Thirteen NAC-related AEs occurred in 8 patients (1.6 per person). All AEs were related to NAC and were rated nonserious by the reviewer. Clinicians use an actual weight-based NAC dose rather than a maximum weight cutoff dose. Hepatotoxicity was common in our cohort. AEs were relatively common but not serious.

Sexual assault training in emergency medicine residencies: a survey of program directors.

INTRODUCTION: There is currently no standard forensic medicine training program for emergency medicine residents. In the advent of sexual assault nurse examiner (SANE) programs aimed at improving the quality of care for sexual assault victims, it is also unclear how these programs impact emergency medicine (EM) resident forensic medicine training. The purpose of this study was to gather information on EM residency programs' training in the care of sexual assault patients and determine what impact SANE programs may have on the experience of EM resident training from the perspective of residency program directors (PDs). METHODS: This was a cross-sectional survey. The study cohort was all residency PDs from approved EM residency training programs who completed a closed-response self-administered survey electronically. RESULTS: We sent surveys to 152 PDs, and 71 responded for an overall response rate of 47%. Twenty-two PDs (31%) reported that their residency does not require procedural competency for the sexual assault exam, and 29 (41%) reported their residents are required only to observe sexual assault exam completion to demonstrate competency. Residency PDs were asked how their programs established resident requirements for sexual assault exams. Thirty-seven PDs (52%) did not know how their sexual assault exam requirement was established. CONCLUSION: More than half of residency PDs did not know how their sexual assault guidelines were established, and few were based upon recommendations from the literature. There is no clear consensus as to how PDs view the effect of SANE programs on resident competency with the sexual assault exam. This study highlights both a need for increased awareness of EM resident sexual assault education nationally and also a possible need for a training curriculum defining guidelines for EM residents performing sexual assault exams.

Massive human ingestion of orpiment (arsenic trisulfide).

BACKGROUND: Because the toxicity of arsenic is well known, arsenic-containing compounds have frequently been ingested for suicidal purposes. We report a case of attempted suicide by massive ingestion of arsenic trisulfide, an arsenic mineral of low solubility, which resulted in minimal symptoms. CASE REPORT: An asymptomatic 57-year-old man presented to an Emergency Department 13h after his reported ingestion of approximately 84g of arsenic contained in a mineral specimen of orpiment (arsenic trisulfide) that had been crushed and mixed with an alcoholic beverage and food. His only symptom before presentation was nausea. Physical examination was unremarkable, and diagnostic tests included a normal electrolyte panel, a normal serum lactate, and a normal electrocardiogram. An abdominal radiograph revealed hyper-dense material scattered throughout the large intestine. As per the recommendations of the regional poison center, the patient was managed with whole bowel irrigation with a polyethylene glycol solution, maintenance intravenous hydration, and observation on a telemetry unit. Chelation was not performed. A spot urine specimen collected 12h after admission contained 1490µg of total arsenic per liter (background range<50µg per liter). The patient remained asymptomatic throughout his hospital course. Follow-up studies revealed a diminution in both intra-abdominal radiopacities and urine arsenic concentration. X-ray diffraction analysis of the specimen confirmed its identity as arsenic trisulfide. CONCLUSIONS: Our experience demonstrates that massive ingestion of a poorly soluble inorganic arsenic compound can be successfully managed with gastrointestinal decontamination alone without chelation, provided that the patient remains asymptomatic during close clinical monitoring.

Agranulocytosis and other consequences due to use of illicit cocaine contaminated with levamisole.

PURPOSE OF REVIEW: Most of the illicit cocaine consumed in the United States and elsewhere is contaminated with levamisole, a veterinary medication. Agranulocytosis caused by levamisole exposure through cocaine abuse was first described in 2009. Since then, levamisole has also been shown and is known to cause vascular and neurologic complications. In this review, we provide an overview of the medical consequences of exposure to levamisole from adulterated cocaine. RECENT FINDINGS: Within the past year, several new case series have deepened our understanding of the levamisole-agranulocytosis vasculopathy syndrome. The common nature of this exposure has been delineated, cocaine contaminated with levamisole. Significant controversy surrounds the role of granulocyte colony stimulating factor (GCSF) in levamisole-associated agranulocytosis. SUMMARY: More than three fourths of cocaine users in the United States are exposed to levamisole; a significant minority of these individuals will develop autoimmune-mediated neutropenia, cutaneous vascular complications, and/or leukoencephalopathy. Levamisole exposure should be considered in the differential diagnosis of patients who present with these conditions in the setting of cocaine abuse. Neutropenia appears to resolve rapidly with cessation of exposure, so that GCSF therapy and a work-up for other causes may not be needed in all patients.