Journal of acute medicine最新文献

Background: Enhancing geriatric emergency care is important for the global aging society; however, the current state of collaboration between the government and healthcare professional organizations and its effect on this issue remain unclear. Therefore, this study was conducted for clarification.

Methods: The Taiwan Health Promotion Administration and the Taiwan Society of Emergency Medicine (TSEM) cooperated to lead 13 emergency departments (EDs) in implementing geriatric EDs based on the model of acute care for elders between January 1, 2021 and November 30, 2021. Experts from the Taiwan Association of Gerontology and Geriatrics and the Taiwan Association of Critical Care Nurses were also invited to set up a Taiwan Geriatric Emergency Department Guide (TGED) and individual goals for each ED. Education, benchmarking, regular joint and individual meetings, communication, and discussion were then performed via communication software, and intensive follow-up was conducted using a monthly checklist.

Results: Despite the impact of COVID-19, 10 of the 13 EDs accomplished the overall goals (76.9%). According to the TGED, the achievement rates for the seven domains were as follows: interdisciplinary team (100%), education (92.3%), equipment and supplies (100%), environment (92.3%), care protocol (100%), quality indicator (100%), and monitor indicator (92.3%). A practice guide and an education guide for the subsequent promotion of geriatric EDs were also established based on the experiences and results from the 13 EDs.

Conclusions: A new model for collaboration between the government and healthcare professional organizations was successfully implemented in Taiwan and thus could serve as an important reference for enhancing geriatric emergency care in the future.

Tension pneumothorax (TP) and diaphragmatic hernia (DH) might present with similar symptoms, increasing the probability of missing an underlying diaphragmatic hernia in cases of coexistence. There are a few case reports of DH with tension viscerothorax or fecopneumothorax, but all those had a delayed presentation. However, there is no case report on TP and DH presenting together immediately after trauma. We present a case of coexistence of TP and DH immediately after blunt chest trauma, where ultrasound helped in the identification and management of this life-threatening condition.

Cardiac arrest is a common condition with low survival rates. Point-of-care ultrasound (POCUS) has been increasingly integrated in cardiac arrest care to enhance diagnostic accuracy and guide interventions. POCUS can be divided into cardiac and non-cardiac applications. Cardiac applications include assessment of cardiac tamponade, pulmonary embolism, ventricular fibrillation, and chest compression quality. Non-cardiac applications include endotracheal tube confirmation, pneumothorax assessment, and evaluation of aortic and intra-abdominal pathology. POCUS can also be used to identify the presence or absence of a pulse more rapidly and accurately than manual palpation. Prognostic utility is highest in traumatic arrests, but more limited in non-traumatic arrests. In appropriately trained individuals, POCUS is a valuable component of cardiac arrest care.

Background: Emergency department (ED) overcrowding has become a widespread global problem, with multi-factorial causes spanning input, throughput, and output domains. In Taiwan, the unique context of universal health coverage and a severe nursing shortage further complicates the situation. The Lunar New Year holiday period is associated with increased ED demand, yet the extent, causes, and responses to post-holiday overcrowding remain unclear.

Methods: We conducted a descriptive observational survey targeting ED directors from all certified emergency care hospitals in Taiwan one week after the 2024 Lunar New Year holiday (February 8 to 14). The questionnaire compared operational status with the same period in previous years, assessing patient volume, bed availability, staffing, perceived causes of overcrowding, and implemented countermeasures. Data from 59 responding hospitals were analyzed using Chi-square, ANOVA/Kruskal-Wallis tests, and logistic regression to identify factors associated with unusual operational status and prolonged waiting for beds.

Results: Of the 59 hospitals (18 medical centers, 20 regional hospitals, 21 district hospitals), 41 (69.5%) reported abnormal post-holiday ED operations, including severe overcrowding, hospitalization difficulties, and increased bed full notifications. In multivariate analysis, prolonged waiting for beds was the only factor significantly associated with severe operational anomalies (odds ratio [OR] = 11.31, p = 0.019). Factors contributing to prolonged waiting included decreased ED nurse staffing (OR = 5.40, p = 0.021), closure of general ward beds (OR = 3.26, p = 0.032), and closure of ICU beds (OR = 6.27, p = 0.025). A one-nurse decrease increased the odds of waiting for beds by 25% ( p = 0.008), and a 1% ward bed closure increased the odds by 7.1% ( p = 0.012). Although 35 hospitals implemented countermeasures such as opening extra beds or restricting transfers, only 14.3% reported significant improvement.

Conclusion: Reduced nursing staff and closure of general wards and ICU beds were strongly associated with prolonged waiting for beds and ED overcrowding after the Lunar New Year holiday. Current hospital-level measures have limited and temporary effects. A comprehensive approach integrating ED process optimization, hospital-wide management strategies, and community-level interventions is needed to improve bed allocation efficiency, strengthen nursing workforce sustainability, and alleviate overcrowding in Taiwan's EDs.

Background: Point-of-care ultrasound (POCUS) is increasingly recognized as a vital skill in various medical specialties. Its integration into postgraduate medical training enhances diagnostic accuracy and clinical decision-making. Despite its growing importance, the implementation of a structured POCUS curriculum in postgraduate medical education remains challenging.

Methods: A pilot study was conducted at the National Cheng-Kung University Hospital to evaluate the introduction of a POCUS curriculum tailored to postgraduate-year physicians. The curriculum included basic and advanced courses with hands-on training sessions held during weekends across 2020. Participants' pre-course and post-course proficiency were assessed through questionnaires and skill evaluations.

Results: The study included 116 physicians, revealing a broad spectrum of prior ultrasound training and varied frequency of clinical ultrasound use. The structured curriculum significantly improved participants' POCUS skills, particularly in cardiac ultrasound, in which most participants achieved high proficiency levels. The program was successful in addressing the existing gap in ultrasound education and practice among postgraduates.

Conclusion: Integration of a structured POCUS curriculum within postgraduate medical education significantly enhances the ultrasound proficiency of physicians. Continuous and comprehensive training programs, supported by adequate resources and expert instruction, are crucial for the widespread adoption and effective use of POCUS in clinical settings.

Snake envenomation is a neglected tropical disease with two million snake bites reported each year (WHO). Much less common is snake venom ophthalmia secondary to eye exposure from spitting snakes. This paper reports an unusual case of systemic envenomation via the ocular route of a 14-year old male from the Philippines. A mixture of snake blood and venom came in contact with the patient's left eye causing severe pain and blurring of vision, shortly followed by generalized body weakness and ptosis. Copious irrigation with normal saline was done at the emergency room, and Purified Cobra Antivenin (PCAV) was administered. Symptoms of systemic envenomation abated following PCAV administration. Ofloxacin ophthalmic drops and eye lubrication were prescribed for seven days to minimize complications, and the patient was discharged well after three days of hospitalization. Although difficult to ascertain, signs and symptoms pointed to systemic envenomation, and this could be the first case of an unconventional venom route to date. This paper opens possibilities and serves as precedent for future research - ocular envenomation, snake venom, and blood components, and symptomatic management.

In critically ill patients, there is complexity and dynamicity of the disease as well as absence of specific template to cover all aspects of the diagnosis. Improving accuracy in the diagnosis documentation is not only an important aspect in the communication among clinicians, other healthcare providers and administrators for better patient's clinical management; their financial aspects and quality metrics; but might also influence the future research depending on these documentations. This brief report highlights a systematic approach for updated daily as well as final diagnosis in critically ill patients.

Background: Non-emergency medicine (EM)-trained physicians comprise a notable proportion of the emergency medicine workforce in Taiwan and many other countries. The possible performance differences at the emergency department (ED) between EM-trained and non-EM-trained physicians have not been evaluated before.

Methods: This retrospective observational study was conducted between August 2018 and July 2020 at a regional hospital in Taiwan. We compared the two physician groups for quality-of-care outcomes, including waiting time, rate of failing to visit patients within the required time, length of ED stay, admission rate, intensive care unit admission rate, unscheduled return visit, return of spontaneous circulation rate in out-of-hospital cardiac arrest patients, in-hospital cardiac arrest incidence, referral rate, and computed tomography (CT) scan utilization.

Results: A total of 37,013 ED visits were included. When compared to the non-EM-trained physicians, patients managed by the seven EM-trained physicians had shorter waiting time (6.1 min vs. 9.2 min, p < 0.001), shorter ED stay (146.5 min vs. 176.1 min, p < 0.001), lower rate of failing to visit patients within the required time (0.8% vs. 1.1%, p = 0.010), lower unscheduled return visit rate (4.9% vs. 5.4%, p = 0.043), and lower CT scan utilization (0.16 [times/patient/visit] vs. 0.18 [times/patient/visit], p < 0.001).

Conclusion: The EM-trained and non-EM-trained physicians' performance at a regional hospital ED differed. Our findings could be used as a reference for healthcare policy-makers and hospital management.

Background: The observational study examines the evolution of emergency medicine residency programs in Taiwan, comparing key program attributes between 2003 and 2021. To identify significant changes in emergency medicine resident program structure, educational resources, and operational aspects.

Methods: According to the previous study carried out in 2003, we conducted a comprehensive analysis of 22 specified items across four domains: contact information, training content, faculty and research, and patient care and benefits, comparing key program attributes between 2003 and 2021. Chi-Square test used for the categorical variables statistical analysis.

Results: The proportion of programs detailing faculty descriptions increased markedly from 63% in 2003 to 95% in 2021, while the mention of residency director roles rose from 4% to 32% in the same period. Conversely, the detailed enumeration of faculty numbers and elective course features saw a decline. Furthermore, the study identified stable areas, such as benefits other than salary and patient numbers, suggesting established standards or external limitations.

Conclusions: The substantial improvements in program structure and educational resources highlight ongoing efforts to enhance training quality and adapt to the changing healthcare landscape. This study contributes valuable insights into the progression of emergency medicine residency.

Hyperkalemia is an acute life-threatening metabolic imbalance that is commonly seen in emergency departments. The primary cause is renal disease, but it also results from increased potassium intake in the diet, severe volume contraction, some medications, and other metabolic disturbances. Signs and symptoms suggestive of hyperkalemia must be recognized early so that life-saving interventions can be initiated. Rapid acquisition of an electrocardiogram (ECG) is important for making an early diagnosis because it can provide clues to the diagnosis long before laboratory results become available. Acute care providers are trained in the progression of alterations on the ECG tracings that occur as serum potassium levels rise. The earliest signs of mild hyperkalemia (5.5-6.5 mmol/L) are tall, narrow-based T waves, best seen in the precordial leads. As the potassium level becomes moderately elevated (6.5-8.0 mmol/L), the PR and QRS intervals become progressively longer, and the P waves might be lost. Severe hyperkalemia (> 8.0 mmol/L) often produces fascicular and intraventricular blocks and an eventual "sine wave" appearance which leads to ventricular fibrillation or asystole if immediate treatment is not provided. Hyperkalemia also often produces bradycardic rhythms along the progression of ECG findings, but this manifestation is not well-known or commonly taught. As a result, life-threatening hyperkalemia may be easily missed until laboratory results reveal the diagnosis. Additionally, standard treatments for bradydysrhythmias, such as atropine and electrical pacing, are often ineffective in treating this life-threatening cause of bradycardia. With early recognition of bradyarrhythmia caused by hyperkalemia, however, the proper treatment can be expedited and clinical decline can be averted.