Evaluation of Central Venous Access with Accelerated Seldinger Technique Versus Modified Seldinger Technique.

BACKGROUND: Central vein catheter (CVC) placement using the modified Seldinger technique is a common procedure in the emergency department, but can be time consuming due to the multiple pieces of equipment included in central line kits and the number of steps in the procedure. Preassembled devices combine a needle, guidewire, dilator, and sheath into one unit and potentially simplify the process and reduce time required for CVC placement using the accelerated Seldinger technique. OBJECTIVE: Our aim was to evaluate whether the use of combination central line devices and the accelerated Seldinger technique will reduce the time required to place a CVC and increase the ease of the procedure. METHODS: This two-arm randomized crossover study comparing the accelerated Seldinger technique to the modified Seldinger technique was performed in a simulation setting. Subjects were selected from among emergency physicians, emergency medicine residents, interns, physician assistants, and medical students. Subjects were timed using the modified and accelerated Seldinger techniques. Ease of use and satisfaction data were collected after both procedures. RESULTS: The use of the accelerated Seldinger technique with a combination CVC device was significantly faster compared to the modified Seldinger technique with a standard CVC kit. Procedure time was reduced by 35% (p = 0.001), and ease of use was increased by 7% (p = 0.046), without any increase in errors. CONCLUSIONS: In the simulated setting, the accelerated Seldinger technique using combination CVC devices is a faster and easier method for CVC placement compared to the modified Seldinger technique.

An Impaled Potential Unexploded Device in the Civilian Trauma Setting: A Case Report and Review of the Literature.

BACKGROUND: The management of patients with impaled unexploded devices is rare in the civilian setting. However, as the lines of the traditional battlefield are blurred by modern warfare and terrorist activity, emergency providers should be familiar with facility protocols, plans, and contact information of their local resources for unexploded devices. CASE REPORT: A 44-year-old male sustained a close-proximity blast injury to his lower extremities while manipulating a mortar-type firework. He presented to the regional trauma center with an open, comminuted distal femur fracture and radiographic evidence of a potential explosive device in his thigh. His management was coordinated with the local Explosive Ordinance Disposal and the fire department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Explosive devices pose a grave threat when encountered. Familiarization with protocols to manage these patients can mitigate disaster. Emergency providers should expect and be prepared to coordinate care for these patients.

Point of View Telemedicine at Point of Care.

Introduction The use of telemedicine by deployed healthcare providers to improve patient care has been increasing in recent foreign conflicts and humanitarian missions. These efforts have mostly been limited to email consultation with long response lag times. The United States Military has developed several modalities of telemedicine for use in austere environments, ranging from video conferencing, email, and store-and-forward technology. As of now, these efforts have required large pieces of equipment and many technical support personnel and have a delayed response time. Our study aimed to test the overall feasibility of use, the effects on time to intervention, and user confidence in a highly portable, real-time video set-up to aid in teleconsultations at the early stages of care for a simulated traumatic injury. Materials and methods Subjects or operators taking direct care of the simulated patient were junior emergency medicine (EM) residents or military trained medics. Video teleconsultation was completed by either senior EM residents in their final year of training or board-certified EM physicians. The subjects taking direct care of the simulated patient were blinded to whether their video device was actively sending images or not. All participants communicated verbally using hand-held radios. The total number of interventions and time to event analysis was completed and survey data were collected, assessing confidence levels on procedures performed and patient care.  Results We demonstrated the accessibility, ease of use, and overall practicality of this telemedicine platform. A trend was found towards decreased time to evacuation for patients with a live video feed. Alternatively, the data showed no significant difference in the addition of video as opposed to solely radio in terms of the number of interventions, time to interventions, or operator or teleconsultant confidence in the care delivered or procedures performed. Conclusions This study demonstrated the overall feasibility and ease of use of a highly portable telemedicine platform with live video capabilities. A trend was found toward earlier evacuation decisions when using the live video. Follow-up studies may consider examining more challenging simulations or prolonged field care utilization of this technology.

Heated Ultrasound Gel and Patient Satisfaction with Bedside Ultrasound Studies: The HUGS Trial.

INTRODUCTION: Our goal was to determine if heated gel for emergency department (ED) bedside ultrasonography improves patient satisfaction compared to room-temperature gel. METHODS: We randomized a convenience sample of ED patients determined by their treating physician to require a bedside ultrasound (US) study to either heated gel (102.0° F) or room-temperature gel (82.3° F). Investigators performed all US examinations. We informed all subjects that the study entailed investigation into various measures to improve patient satisfaction with ED US examinations but did not inform them of our specific focus on gel temperature. Investigators wore heat-resistant gloves while performing the examinations to blind themselves to the gel temperature. After completion of the US, subjects completed a survey including the primary outcome measure of patient satisfaction as measured on a 100-mm visual analogue scale (VAS). A secondary outcome was patient perceptions of sonographer professionalism measured by an ordinal scale (1-5). RESULTS: We enrolled 124 subjects; 120 completed all outcome measures. Of these, 59 underwent randomization to US studies with room-temperature gel and 61 underwent randomization to heated US gel. Patient 100-mm VAS satisfaction scores were 83.9 among patients undergoing studies with room-temperature gel versus 87.6 among subjects undergoing studies with heated gel (effect size 3.7, 95% confidence interval -1.3-8.6). There were similarly no differences between the two arms with regard to patient perceptions of sonographer professionalism. CONCLUSION: The use of heated ultrasound gel appears to have no material impact on the satisfaction of ED patients undergoing bedside ultrasound studies.

Integrating Point-of-Care Ultrasonography Into the Osteopathic Medical School Curriculum.

Point-of-care ultrasonography has been shown to have pervasive clinical and educational utility in medicine. The need to provide medical students with training in point-of-care ultrasonography has been recognized by an increasing number of osteopathic and allopathic medical schools. A 4-year integrated ultrasonography curriculum was implemented at Rocky Vista University College of Osteopathic Medicine in 2015. A review of the curriculum design, content, educational methods, and student feedback are described. Barriers to curriculum implementation and lessons learned, unique to integrating point-of-care ultrasonography into the osteopathic curriculum, are also discussed.