Overcoming barriers to promotion for women and underrepresented in medicine faculty in academic emergency medicine.

Equity in the promotion of women and underrepresented minorities (URiM) is essential for the advancement of academic emergency medicine and the specialty as a whole. Forward-thinking healthcare organizations can best position themselves to optimally care for an increasingly diverse patient population and mentor trainees by championing increased diversity in senior faculty ranks, leadership, and governance roles. This article explores several potential solutions to addressing inequities that hinder the advancement of women and URiM faculty. It is intended to complement the recently approved American College of Emergency Physicians (ACEP) policy statement aimed at overcoming barriers to promotion of women and URiM faculty in academic emergency medicine. This policy statement was jointly released and supported by the Society for Academic Emergency Medicine (SAEM), American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM).

Evaluating infant positioning for lumbar puncture using sonographic measurements.

OBJECTIVES: Hypoxia has been observed when infants undergo lumbar puncture in a tight flexed lateral recumbent position. This study used sonographic measurements of lumbar interspinous spaces to investigate the anatomic necessity and advantage derived from this tight flexed positioning in infants. METHODS: This was a brief, prospective, observational study of a convenience sample of patients. Twenty-one healthy infants under 1 month of age were scanned in two positions: prone in a spine-neutral position and lateral recumbent with their knees bent into their chest and their neck flexed. In each position, a 5- to 10-MHz linear array transducer was used to scan midline along the lumbar spinous processes in the sagittal plane. The distances between the spinous processes were measured near the ligamentum flavum using the ultrasound machine's calipers. Pulse oximetry was monitored on all infants during flexed positioning. RESULTS: In the spine-neutral position, all studied interspinous spaces were much wider than a 22-gauge spinal needle (diameter 0.072 cm). The mean (±SD) interspinous spaces for L3-4, L4-5, and L5-S1 in a spine-neutral position were 0.42 (±0.07), 0.37 (±0.06), and 0.36 (±0.11) cm, respectively. Flexing the infants increased the mean lumbar interspinous spaces at L3-4, L4-5, and L5-S1 by 31, 51, and 44%, respectively. CONCLUSIONS: This study verified that tight, lateral flexed positioning substantially enhances the space between the lumbar spinous processes and that a spine-neutral position also allows for a large enough anatomic interspinous space to perform lumbar puncture. However, further clinical research is required to establish the feasibility of lumbar puncture in a spine-neutral position.

Success of ultrasound-guided peripheral intravenous access with skin marking.

OBJECTIVES: The most effective technique for ultrasound-guided peripheral intravenous access (USGPIVA) is unknown. In the traditional short-axis technique (locate, align, puncture [LAP]), the target vessel is aligned in short axis with the center of the transducer. The needle is then directed toward the target under real-time ultrasound (US) guidance. Locate, align, mark, puncture (LAMP) requires the extra step of marking the skin at two points over the path of the vein and proceeding with direct visualization as in LAP. The difference in success between these two techniques was compared among variably experienced emergency physician and emergency nurse operators. METHODS: Subjects in an urban academic emergency department (ED) were randomized to obtain intravenous (IV) access using either LAP or LAMP after two failed blind attempts. Primary outcomes were success of the procedure and time to complete the procedure in variably experienced operators. RESULTS: A total of 101 patients were enrolled. There was no difference in success between LAP and LAMP, even among the least experienced operators. Of successful attempts, LAMP took longer than LAP (median 4 minutes, interquartile range [IQR] 4-10.5 vs. median 2.9 minutes, IQR 1.6-7; p = 0.004). Only the most experienced operators were associated with higher levels of success (first attempt odds ratio [OR] 6.64; 95% confidence interval [CI] = 2 to 22). Overall success with up to two attempts was 73%. Complications included a 2.8% arterial puncture rate and 12% infiltration rate. CONCLUSIONS: LAMP did not improve success of USGPIVA in variably experienced operators. Experience was associated with higher rates of success for USGPIVA.

Pediatric hemoptysis with pulmonary hemorrhage and respiratory failure.

Hemoptysis is a rare complaint in the pediatric population. It is most commonly of infectious etiology and is rarely life threatening. However, there are rare life-threatening causes of pediatric hemoptysis, which should be included in the differential diagnoses of children presenting to the emergency department (ED) with this complaint. This study aims to present a case of pediatric hemoptysis, briefly discuss the differential diagnosis, and present a review of the causes, manifestations, and treatment for hemoptysis secondary to diffuse alveolar hemorrhage (DAH).

Effect of hip abduction and external rotation on femoral vein exposure for possible cannulation.

Femoral vein access is often required during resuscitation efforts and when other routes of intravenous access are difficult. This study evaluated by ultrasound the effect of abduction/external rotation of the hip on venous accessibility. This was a prospective repeated measurement study. The common femoral veins of 25 volunteers were scanned transversely inferior to the inguinal ligament with the leg straight and in external rotation/abduction. The diameter of the vein and percent accessible (not posterior to the femoral artery) were determined. Data were analyzed using repeated measures analysis of variance. The mean percentage of the femoral vein accessible with the leg in external rotation/abduction was greater than with the leg straight (82.6 +/- 20.3 vs. 70.4 +/- 26.3, respectively); p < 0.03. External rotation/abduction of the hip may improve the success rate of femoral vein cannulation by increasing the percentage of the femoral vein accessible.

Pilot study to evaluate the accuracy of ultrasonography in confirming endotracheal tube placement.

STUDY OBJECTIVE: Visualization of the vocal cords and end-tidal capnography are the usual standards in confirming endotracheal tube placement. Vocal cord visualization is, however, not always possible, and capnography is not 100% reliable and requires ventilation of the lungs to confirm placement. The goal of this study is to determine the accuracy of ultrasonography for detecting endotracheal tube placement into the trachea and esophagus in real time. METHODS: This was a prospective, randomized, controlled study. Eligible patients were adults undergoing elective surgery requiring intubation. Exclusion criteria were a history of difficult intubation, abnormal airway anatomy, aspiration risk factors, and esophageal disease. Thirty-three patients were enrolled. After induction of anesthesia and neuromuscular blockade, the anesthesiologist placed the endotracheal tube in the trachea and esophagus in random order with direct laryngoscopy. During the intubations, a high-frequency, linear transducer was placed transversely on the neck at the suprasternal notch. Two emergency physicians, blinded to the order and performance of the intubations, independently recorded the location of the endotracheal tube according to the real-time ultrasonographic image. A 2-by-2 table was used to calculate sensitivity and specificity of the emergency physicians' ability to detect placement of the endotracheal tube. RESULTS: For each physician, the sensitivity for identifying the first intubation as tracheal was 100% (95% confidence interval [CI] 77% to 100%) with a specificity of 100% (95% CI 82% to 100%). One endotracheal tube was unintentionally placed twice in the esophagus, but both tube placements were identified as esophageal by the emergency physicians. CONCLUSION: In this pilot study, 2 emergency physicians experienced in ultrasonography accurately detected placement of endotracheal tubes during intubation with ultrasonography in select patients in the controlled environment of the operating room. Future studies should examine the use of ultrasonography to visualize endotracheal tube placement in real time by emergency physicians with less ultrasonographic training; use of the technique in the emergency department on a wider range of patients, including patients with difficult airways; and assessment of the utility of ultrasonography in confirmation of endotracheal tube position in already intubated patients.

Sonographic assessment of the epiglottis.

OBJECTIVES: The ideal diagnostic test for the diagnosis of epiglottitis would be simple, rapid, noninvasive, and highly accurate, performed at the bedside, and would not use ionizing radiation. The purpose of this study was to assess the utility of ultrasound to image the epiglottis and to determine the range of normal epiglottis diameter for men and women. METHODS: This was a prospective study of a convenience sample of 100 subjects between the ages of 18 and 50 years who had no known acute or chronic laryngeal diseases or surgeries. The anterior neck of each subject was scanned in both the long and short axis with a 5-10 MHz linear transducer. Sonographically, the epiglottis appeared as a curvilinear, hypoechoic structure with an echogenic pre-epiglottic space. The sonographic appearance of the epiglottis and the pre-epiglottic space were recorded and anteroposterior measurements of the epiglottis just distal to the hyoid bone were made. Comparisons between men and women were performed with use of a Student's t-test. Pearson's correlation analysis was performed to evaluate the relationship between subject height and epiglottic size. RESULTS: The epiglottis was visualized in all 100 subjects including 62 women and 38 men. The average patient age was 35.2 +/- 8.1 years. The epiglottic thickness was 2.39 +/- 0.15 mm. This was greater in men (2.49 +/- 0.13 mm) than in women (2.34 +/- 0.13 mm) (p < 0.001). There was moderate correlation between height and epiglottic thickness (R = 0.48). However, when this was analyzed separately for men and women, there was no significant correlation between epiglottic thickness and height. CONCLUSIONS: Bedside ultrasonography is easy to perform and can accurately evaluate the epiglottis. Further analysis should include patients with known epiglottic disease to assess the utility of this technique to detect pathologic enlargement.