Western Journal of Emergency Medicine最新文献

Background: TikTok has rapidly become one of the most extensively downloaded and used social media platforms worldwide. Our focus on emergency medicine (EM)-related content on TikTok is to identify what specific video characteristics result in higher degrees of audience engagement, defined in this study as a total of video likes, comments, and shares.

Methods: Five second-year medical students using newly created TikTok accounts independently downloaded the first 100 videos to appear using the hashtag #emergencymedicine. The videos were reviewed for 52 variables. We performed a multiple linear regression analysis to examine the relationship between the variables and video engagement.

Results: Of the examined videos, 45.8% (222/484) were produced by physicians (MD or DO). Approximately half, 50.0% (242/484), had an educational component, while 55.4% (268/484) of videos were judged to have an entertainment component. Preliminary findings indicate that among TikTok videos featuring #emergencymedicine, a statistically significant positive correlation exists between video engagement and the presence of a healthcare identifier, (ie, individuals wearing white coats or scrubs). No significant correlation was observed between video engagement and video creators' self-identification as a healthcare professional, use of entertainment, or use of education. A notable negative correlation was identified between video engagement and the inclusion of music.

Conclusion: We identified qualities associated with negative and positive correlation with video engagement. For the 100 videos, only healthcare attire, such as wearing a white coat or scrubs, showed a significant positive correlation with engagement, while those with background music showed a negative correlation. Our study offers insight into how EM professionals can effectively use characteristics associated with higher engagement rates to relay information to a wider audience on TikTok.

Introduction: Medical device recalls are important to the practice of emergency medicine, as unsafe devices include many ubiquitous items in emergency care, such as vascular access devices, ventilators, infusion pumps, video laryngoscopes, pulse oximetry sensors, and implantable cardioverter defibrillators. Identification of dangerous medical devices as early as possible is necessary to minimize patient harms while avoiding false positives to prevent removal of safe devices from use. While the United States Food and Drug Administration (FDA) employs an adverse event reporting program (MedWatch) and database (MAUDE), other data sources and methods might have utility to identify potentially dangerous medical devices. Our objective was to evaluate the sensitivity, specificity, and accuracy of a machine learning (ML) algorithm using publicly available data to predict medical device recalls by the FDA.

Methods: We identified recalled medical devices (RMD) and non-recalled medical devices (NRMD) using the FDA's website and online database. We constructed an ML algorithm (random forest regressor) that automatically searched Google Trends and PubMed for the RMDs and NRMDs. The algorithm was trained using 400 randomly selected devices and then tested using 100 unique random devices. The algorithm output a continuous value (0-1) for recall probability for each device, which were rounded for dichotomous analysis. We determined sensitivity, specificity, and accuracy for each of three time periods prior to recall (T-3, 6, or 12 months), using FDA recall status as the reference standard. The study adhered to relevant items of the Standards for Reporting Diagnostic accuracy studies (STARD) guidelines.

Results: Using a rounding threshold of 0.5, sensitivities for T-3, T-6, and T-12 were 89% (95% confidence interval [CI] 69-97), 90% (95% CI 70-97), and 75% (95% CI 53-89). Specificity was 100% (95% CI 95-100) for all three time periods. Accuracy was 98% (95% CI 93-99) for T-3 and T-6, and 95% (95% CI 89-99) for T-12. Using tailored thresholds yielded similar results.

Conclusion: An ML algorithm accurately predicted medical device recall status by the FDA with lead times as great as 12 months. Future research could incorporate longer lead times and data sources including FDA reports and prospectively test the ability of ML algorithms to predict FDA recall.

Introduction: The choice of medications used in rapid sequence intubation (RSI) can result in the difference between an acceptable outcome and a lethal one. When executed properly, RSI is a lifesaving intervention. Nonetheless, RSI may result in fatal complications such as peri-intubation cardiac arrest. The risk of peri-intubation cardiac arrest reportedly increases in patients who are profoundly hypoxic or hypotensive prior to endotracheal intubation. Medication choice for RSI may either optimize or deoptimize hemodynamic parameters, thereby impacting patient outcomes. Therefore, our study aimed to examine the association of change in mean arterial pressure (MAP) with and without the use of a predetermined dose of 50 micrograms (μg) intravenous fentanyl as a pretreatment agent during RSI.

Methods: This prospective observational study included patients undergoing RSI at an academic emergency department (ED) over a three-year period between January 1, 2018-January 1, 2021. Average hemodynamic parameters were measured at the time of induction (prior to medication administration) and 10 minutes after induction. We categorized patients into fentanyl and non-fentanyl groups for analysis, and we compared data using chi-square and t-test as appropriate. Logistic regression analysis was conducted to account for potential confounding factors.

Results: A total of 278 patients were included in the analysis, of whom 160 received fentanyl and 118 did not. The majority of the patients underwent RSI by trainees 95.0% of the time. The first-pass success rate was 77.7% in our sample and did not differ significantly between the two groups (P = 0.84). Unadjusted analysis showed a larger decrease in hemodynamic parameters in the fentanyl group compared to the non-fentanyl group; systolic blood pressure decreased by 11.2% vs 1.6%, diastolic blood pressure decreased by 13.7% vs 3.8%, and MAP decreased by 12.7% vs 3.2%. After adjusting for potential confounders, fentanyl was 2.14 times more likely to lower MAP by 10%.

Conclusion: The use of 50 μg fentanyl for rapid sequence intubation in an ED is associated with higher odds of decreasing mean arterial pressure by at least 10% at 10 minutes from the time of induction. Therefore, it should be carefully dosed, and its use in clinical practice should be justified to avoid unnecessary complications.

Objective: Our goal was to assess emergency medical services (EMS) provider-perceived Alzheimer's disease and related dementias (ADRD) by patient sociodemographic characteristics and ZIP code tabulation areas (ZCTA) in the prehospital setting.

Methods: We conducted a retrospective descriptive analysis of EMS calls with patient contact for adults ≥ 65 years of age who were provided prehospital care between February 1, 2020 and January 31, 2022, using data from the San Francisco Department of Emergency Management and the 2021 American Community Survey. Logistic regression models assessed the associated between EMS provider-perceived ADRD and patient sociodemographic characteristics, including age, race/ethnicity, incident location, and ZCTA-level socioeconomic status.

Results: A total of 55,129 patient encounters were recorded, with EMS provider-perceived ADRD recorded in 4,112 (7.5%). Among cases with EMS provider-perceived ADRD, the most common primary impressions were mental disorders (17.1%), weakness (17.0%), injury (15.7%), and pain (13.1%). Increasing age was associated with higher odds of EMS provider-perceived ADRD among both sexes. Among females, EMS provider-perceived ADRD was higher among Hispanics (odds ratio [OR] 1.30, 95% confidence interval [CI] 1.11-1.52), Blacks (OR 1.20, 95% CI 1.03-1.40), Asians (OR 1.18, 95% CI 1.06-1.31), and Native Hawaiian and Pacific Islanders (OR 1.48, 95% CI 1.05-2.08]), while among males, only Asians (OR 87, 95% CI .76-.99) had lower odds, all compared to Whites. Females in low- and medium-income ZCTAs had lower odds of EMS provider-perceived ADRD relative to high-income ZCTAs, with no significant findings in males.

Conclusion: Our findings suggest a higher prevalence of EMS provider-perceived Alzheimer's disease and related dementias among minoritized and socioeconomically disadvantaged populations, including the oldest adults, and racial and ethnic minority communities. Future research and more precise data collection is needed to ensure equity for older adults who access emergency care in the prehospital setting.

Objective: This study determined if the caregivers of children in the emergency department (ED) have the same COVID-19 vaccination status as the child, the reasons they chose to not vaccinate the child, and self-identified barriers to vaccination to determine if the ED is appropriate for vaccination intervention.

Methods: A survey was administered to caregivers of pediatric ED patients at four Children's Hospitals in: Augusta, GA, Buffalo, NY, Madison, WI, and Sacramento, CA. Participants were asked about their and the child's demographics, vaccination status, and barriers to vaccination. We used descriptive statistics, Cohen's kappa, and logistic regression to analyze responses.

Results: 941 caregivers were considered for enrollment, and 800 consented to participation. Participants were 75% women with a mean age of 40.9 ± 8.9 years. 51% (409) of the pediatric ED patients were COVID-19 vaccinated, as were 74% (591) of the caregivers. There was variation across sites, but overall, 15% of caregivers of unvaccinated children wanted the child tobe vaccinated with the most common barriers to vaccination identified as safety data (25%), time availability (20%), and ability to obtain an appointment (13%). The most common reason for not wanting the child COVID-19 vaccinated was concern the vaccine didn't work or had too many side effects.

Conclusion: A small but clinically important group of pediatric ED patients are not COVID-19 vaccinated but their caregivers want them to be vaccinated, indicating that consideration should be given to offering vaccination in the ED. Reasons for avoiding COVID-19 vaccination were primarily concerns with efficacy and side effects.

Objectives: Management strategies for small bowel obstruction (SBO) vary from conservative approaches to surgical intervention. A known complication of surgery is the subsequent adhesions that can cause recurrent SBOs, longer hospital stays, and higher treatment costs. Our primary outcome was to identify independent risk factors that are associated with the decision for surgical intervention, and our secondary outcome was to describe characteristics of visits associated with complications.

Methods: This study was a single-center, retrospective chart review from a large, urban university hospital. We included adult patients admitted to the emergency department (ED) with the International Classification of Diseases, 10th Rev, codes for small bowel obstruction from June 1, 2017- May 30, 2019. Eligible covariates were demographics, radiological findings, clinical presentation, past medical history, and results of radiologic testing. We identified univariate associations of outcome and then performed a multivariate logistic regression to identify independent associations of each outcome. Finally, a backwards selection was used to determine the final model. We calculated odds ratios (OR) and 95% confidence intervals (CI) along with the area under the curve (AUC), as appropriate.

Results: A total of 530 patients met the study criteria; 148 (27.9%) underwent surgery of whom 35 (6.6%) had complications. We identified seven independent associations for the decision of surgery: abdominal distension (OR 0.27, 95% CI 0.10-0.62); gastrografin (OR 0.41, 95% CI 0.20-0.81); previous SBO (OR 0.42, 95% CI 0.26-0.66); higher Charlson Comorbidity Index score (OR 0.87, 95% CI 0.80-0.95); nasogastric decompression (OR 2.04, 95% CI 1.25-3.39), initial systolic blood pressure <100 mm Hg (OR 2.65, 95% CI 1.05-6.53); free fluid or volvulus/closed-loop obstruction on computed tomography (OR 7.95, 95% CI 4.25-15.39), with the AUC for the predictive model equaling 0.73.

Conclusion: We identified seven independent associations present in the ED associated with the decision for surgery. These associations are a step toward building better prediction models and improving decision-making in the ED, allowing for a more adequate treatment plan.

Background: This is a systematic review investigating the correlation between seizures identifiable on electroencephalogram (EEG), clinical excitatory movements (CEM), and ketamine administration for procedural sedation.

Methods: We searched MEDLINE, EMBASE, Cochrane CENTRAL, and Web of Science in April 2021. Search terms included variations for ketamine, myoclonus, seizures, status epilepticus, and electroencephalography. Two independent reviewers assessed papers based on eligibility criteria, which included human studies where EEG recordings were obtained during ketamine administration.

Results: Eight papers were eligible for inclusion with 141 subjects (24 children). Seven studies (133 subjects) reported epilepsy history; 70% (94/133) of these subjects had a pre-existing epilepsy diagnosis. No (0/39) subjects without epilepsy and 28% (26/94) of subjects with epilepsy had electrographic seizures after ketamine administration. In four studies where pediatric and adult subjects could be separated, children with epilepsy had electrographic seizures in 60% (3/5) of cases compared to 28% (6/33) of cases of adults with epilepsy. Of the subjects with epilepsy, 14% (10/74) had CEMs vs 5% (1/21) in subjects without epilepsy. Most CEMs (9/11) were temporally correlated with electrographic seizures.

Conclusions: Our findings indicate that in subjects with epilepsy, electrographic seizures were frequently seen with ketamine administration and were correlated with CEMs. No seizure activity after ketamine was seen in subjects without epilepsy. While the clinical significance of these findings needs further investigation, clinicians may want to consider patients' seizure history when providing counseling on the risks and benefits of ketamine sedation.

Background: Disastrous situations in the emergency department (ED) or community can overwhelm even the best-prepared teams due to their complexity and dynamic nature. In this paper we propose an integrated approach to disaster management, combining six theoretical and practical frameworks to enhance decision-making and operational effectiveness.

Discussion: The approach begins with "sensemaking," an instinctive process that helps leaders quickly gain situational awareness, a crucial foundation for the recognition-primed decision process (RPD). RPD enables swift, experience-based decisions without exhaustive analysis, aligning them with the appropriate domain in the Cynefin framework to guide subsequent interventions. In chaotic situations, rapid action is necessary, and the edge-of-chaos theory guides leaders to balance order and chaos for optimal adaptability. Complexity theory aids in managing the unpredictable elements of a crisis, highlighting the need for flexible responses. Finally, the Incident Command System ensures effective implementation by providing a standardized approach to command, control, and coordination. This cohesive strategy equips emergency physicians and incident commanders to manage both internal ED crises and broader community disasters effectively, with an emphasis on the importance of training in these frameworks to enhance the resilience of emergency medical services.

Conclusion: This multifaceted approach should improve disaster management by better preparing responders for the unpredictable nature of emergencies, enabling effective evaluation and management of complex scenarios, and leading to a more rapid restoration of order.

Introduction: Rural communities continue to face a shortage of emergency physicians despite the growing number of emergency medicine (EM) residencies. In rural areas, emergency physicians tend to be older, male, and White, and are less likely to have completed EM residency training or have board certification. There is also currently a higher rate of rural physicians leaving clinical practice than in urban emergency departments (ED). In this cross-sectional study we sought to identify the work environments of graduates of a rural EM residency program, and the strengths and weaknesses of such a program.

Methods: We conducted a survey among 29 graduates of a community-based EM program to evaluate the effectiveness of a residency program in training physicians who will work in rural areas. The survey assessed the graduates' perceptions of their level of preparedness, further training, and practice location after completing the program. Results are reported using descriptive statistics.

Results: Twenty respondents completed the survey (69%). Most of them identified as male (60%), White (70%), and non-Hispanic or -Latino (80%). Seventy-five percent of the graduates work in counties with fewer than 1,000,000 inhabitants, and 70% work in community hospitals and EDs caring for fewer than 100,000 patients/year. Four (20%) declared to work in critical access hospitals. Overall, respondents felt confident in their residency training.

Conclusion: A community-based EM training program may be an effective strategy for producing emergency physicians who go on to work in rural and smaller communities.

Introduction: Providing appropriate healthcare for transgender, intersexual and non-binary (TIN) individuals remains a significant challenge, as this group experiences higher rates of health inequalities, discrimination, and barriers to accessing care. Emergency physicians (EP) often lack formal training and knowledge about caring for TIN patients, while comparatively less evidence is available for other healthcare professionals, including emergency nurses (EN). Therefore, our goal in this study was to explore the experiences, knowledge, and attitudes as well as education/training needs of both ENs and EPs in Germany regarding the care of TIN patients.

Methods: In February 2023, we electronically surveyed EPs and ENs from emergency departments (ED) across Germany. The survey, developed through literature review and collaboration with experts and members of the TIN community, consisted of 15 closed-ended items divided into three sections: experiences and knowledge; attitudes; and education/training needs. We used standard descriptive statistics and tested for group differences using the chi-square test.

Results: Of the approximately 1,665 EPs and ENs contacted, 502 completed the survey and were eligible for further analysis (30% response rate). Of the respondents, 233 (46%) were EPs and 269 (54%) were ENs, with ENs being significantly younger and with fewer years in practice. More than half reported experience caring for TIN patients (71% of ENs vs 61% of EPs; P = 0.002), but there were significant gaps in medical and non-medical knowledge. Attitudes toward TIN patients were generally positive, but differences in communication approaches were noted, with ENs significantly more likely than EPs to limit their communication with TIN patients to what was necessary (25% of ENs vs 17% of EPs; P = 0.006). Most respondents (55% of ENs and 58% of EPs) had no training in the management of TIN patients, with only 8% of EPs and 17% of ENs having received such training during their medical/nursing school education (P = 0.01). Both groups agreed that there is an urgent need to increase awareness of emergency medical care for TIN patients among ED staff.

Conclusion: Both emergency physicians and nurses in Germany demonstrated deficits in knowledge of and clinical preparedness to care for patients in the ED who identify as transgender, intersexual and non-binary, indicating a clear need for enhanced education, training, and institutional support to improve emergency care for this vulnerable patient population.