Inferior lumbar triangle hernia with incarceration.

Lumbar hernia is a rare condition in which intra or extraperitoneal tissue protrudes through a defect in the posterolateral region of the flank. Incarceration is uncommon but represents a surgical emergency when present. A 54-year-old-male presented to the ED after sudden onset left flank pain after coughing. He was in significant distress secondary to pain and vomiting, and his physical exam revealed a tender mass in his left lateral lumbar region near the site of a previous stab wound. Bedside ultrasound revealed a fluid-filled structure, and CT scan demonstrated herniation of small bowel though the inferior lumbar triangle with associated small bowel obstruction. The patient underwent emergent surgical reduction with mesh repair and recovered uneventfully. Incarcerated lumbar hernia represents a rare diagnosis that may not be at the forefront of most practitioners' differential diagnoses. CT scan is useful to distinguish hernia from solid mass, abscess, or other pathology, while bedside ultrasound may prompt an attempt at immediate reduction. The presence of incarcerated bowel or obstruction warrants immediate surgical consultation.

The Ethics of Using the Recently Deceased to Instruct Residents in Cricothyrotomy.

Cricothyrotomy is a rare but crucial procedure in the armamentarium of the emergency physician. The infrequency with which it is performed has led to a reliance on models, simulators, and animals in resident education, but each of these methods has unique drawbacks. Using recently deceased patients as teaching tools has a long history in medicine, though controversy surrounds whether, how, and from whom consent ought to be obtained. Recent studies have shown that families expect to be asked for permission and often will grant it, even for invasive procedures such as cricothyrotomy. Obtaining consent maintains the integrity of the relationship among the physician, the deceased, the family, and the community and need not prohibit performing procedures on the newly dead for the purpose of resident education. Thus, a balanced approach to resident instruction that incorporates the use of the deceased in addition to other methods of instruction seems both prudent and feasible.

A survey of graduating emergency medicine residents' experience with cricothyrotomy.

INTRODUCTION: The Emergency Medicine (EM) Residency Review Committee stipulates that residents perform 3 cricothyrotomies in training but does not distinguish between those done on patients or via other training methods. This study was designed to determine how many cricothyrotomies residents have performed on living patients, the breadth and prevalence of alternative methods of instruction, and residents' degree of comfort with performing the procedure unassisted. METHODS: We utilized a web-based tool to survey EM residents nearing graduation and gathered data regarding the number of cricothyrotomies performed on living and deceased patients, animals, and models/simulators. Residents indicating experience with the procedure were asked additional questions as to the indication, supervision, and outcome of their most recent cricothyrotomy. We also collected data regarding experience with rescue airway devices, observation of cricothyrotomy, and comfort ("0-10" scale with "10" representing complete confidence) regarding the procedure. RESULTS: Of 296 residents surveyed, 22.0% performed a cricothyrotomy on a living patient, and 51.6% had witnessed at least one performed. Those who completed a single cricothyrotomy reported a significantly greater level of confidence, 6.3 (95% confidence interval [CI] 5.7-7.0), than those who did none, 4.4 (95% CI 4.1-4.7), p<<0.001. Most respondents, 68.1%, had used the recently deceased to practice the technique, and those who had done so more than once reported higher confidence, 5.5 (95% 5.1-5.9), than those who had never done so, 4.1 (95% CI 3.7-4.5), p<<0.001. Residents who practiced cricothyrotomy on both simulators and the recently deceased expressed more confidence, 5.4 (95% CI 5.0-5.8), than those who used only simulators, 4.0 (95% CI 3.6-4.5), p<<0.001. Neither utilization of models, simulators, or animals, nor observance of others' performance of the procedure independently affected reported confidence among residents. CONCLUSION: While prevalence of cricothyrotomy and reported comfort with the procedure remain low, performing the procedure on living or deceased patients increased residents' confidence in undertaking an unassisted cricothyrotomy upon graduation in the population surveyed. There is evidence to show that multiple methods of instruction may yield the highest benefit, but further study is needed.

Visual side effects of scopolamine/ dextroamphetamine among parabolic fliers.

INTRODUCTION: Scopolamine/dextroamphetamine has been used to combat motion sickness generated aboard research aircraft for decades. While it has shown to be effective, previous studies differ as to the presence of visual side effects secondary to scopolamine's anticholinergic properties. This study sought to quantify any such effects in order to determine if they are operationally significant. METHODS: Fliers in NASA's Reduced Gravity Program received a weight-based dose of scopolamine/ dextroamphetamine prior to boarding the aircraft. Measurements of pupil size, visual acuity, and accommodation were taken in identical conditions using subjects' dominant eyes prior to medication administration and again after landing. We enrolled 131 subjects ages 18-48. Pre- and postflight measurements of pupil size and acuity were available for 125 subjects. RESULTS: Average pupil size increased by 1.1 mm (95% CI 0.9-1.2). Only 1.6% of subjects experienced a change in visual acuity of greater than 10 ft. The average near-point accommodation changed from 8.61 to 7.84 diopters, a difference of -0.77 (-1.01 to -0.53) diopters or 1.34 cm (0.87-1.81). Increasing age also correlated significantly with worsening change in accommodation. DISCUSSION: This study found statistically significant changes in pupil size and near point accommodation that do not appear to be clinically important. No significant decrement in acuity was noted. While direct effects on in-flight performance could not be assessed, the use of scopolamine/dextroamphetamine among fliers aboard research aircraft does not appear to yield visual side effects sufficient to compromise later ground operations.