Western Journal of Emergency Medicine最新文献

Introduction: Applying to emergency medicine (EM) residency programs is costly. In the past several years, the EM residency application process has undergone multiple changes in recommendations regarding away rotations and interview format, primarily but not solely driven by COVID-19 restrictions. To date, little is known about the financial impact of these changes on EM applicants. This study assesses recent trends and changes in the costs of the EM residency application.

Methods: We analyzed EM applicant survey data from the Texas STAR (Seeking Transparency in Application to Residency) database from 2019-2024. Application cycles were grouped into three time periods: pre-pandemic (2019-2020), pandemic (2021-2022), and post-pandemic (2023-2024). Applicants' self-reported data for application fees, away rotation costs, interview costs, and total expenses were analyzed. We conducted Kruskal-Wallis testing to evaluate differences in expense-related variables across the three time periods. We performed post-hoc analysis using the Dunn test if significant differences were detected.

Results: This study included 3,495 EM applicants, which represents 8.4% of the total 41,497 Texas STAR survey respondents from 2019-2024. Average per-applicant total costs were $5,412, $2,076, and $3,156 in the pre-, during-, and post-pandemic application cycles. Self-reported total applicant expenses decreased between the pre- and pandemic period and increased from the pandemic and post-pandemic period (P < .01). Applicants had the lowest overall costs in 2021. Away rotation, second look, application costs, interview travel and lodging, and virtual interview costs all reached their lowest levels during the pandemic period (P < .01). In the post-pandemic period, travel and lodging costs were higher than pre- and during pandemic levels, while interview costs remained lower due to the continued use of virtual interviews (P < .01). Applicants from the Western Region of the US saw the highest total costs compared to the Northeast, which saw the lowest.

Conclusion: The total expenses reported by medical students applying to EM residency programs were significantly reduced during the pandemic, compared to other years. Some expenses, notably away rotation and second look and application costs, have risen post-pandemic. To help reduce the financial burden of the EM residency process, the continued use of virtual interviews is an opportunity for cost savings.

Introduction: Recent evidence suggests that survival to hospital discharge in patients with out-of-hospital cardiac arrest (OHCA) is similar among patients receiving a single dose epinephrine protocol compared to a multi-dose epinephrine protocol. However, it is unknown whether survival to hospital rates differ for single dose vs. multi-dose epinephrine within sex and race subgroups. Our objective in this study was to determine whether survival to hospital discharge rates varied for single dose vs. multi-dose epinephine protocols among men, women, White, and non-White patients.

Methods: We conducted a pre-post Single Dose Epinephrine Implementation Study from November 1,2016 - October 29, 2019 at five North Carolina emergency medical services (EMS) systems, involving patients ≥ 18 years old with non-traumatic OHCA. Data on race, sex, and the primary outcome of survival to hospital discharge were determined from the Cardiac Arrest Registry to Enhance Survival and from EMS records. We performed intention-to-treat analysis. We compared survival to hospital discharge rates between single dose vs multi-dose epinephrine protocols within sex and race subgroups using generalized estimating equations with a logit link to account for clustering among EMS agencies and to adjust for age, witnessed arrest, automated external defibrillator availability, EMS response interval, the presence of a shockable rhythm, receiving bystander cardiopulmonary resuscitation, and sex or race. In the model, we evaluated interactions between epinephrine protocol and race and sex.

Results: Of the 1,690 patients included, (899 multi-dose, 791 single dose), 38.7% (657/1,690) were female and 74.7% (1,262/1,690) were White. Survival to hospital discharge occurred in 13.6% (122/899) of patients in the multi-dose group and 15.4% (122/791) in the single dose epinephrine group (OR 1.19, 95%CI 0.89-1.59). Single dose epinephrine was associated with increased survival to hospital discharge rates in White patients (adjusted odds ratio [aOR] 1.17, 95% confidence interval [CI] 1.05-1.30). However, the rates were similar for single dose vs. multi-dose epinephrine among men (aOR 1.03, 95% CI 0.93-1.14), women (aOR 1.23, 95% CI 0.97-1.56), and non-White patients (aOR 1.08, 95% CI 0.78-1.51). Interactions between epinephrine protocol and subgroups were not significant.

Conclusion: Rates of survival to hospital discharge were similar in the single dose and multi-dose epinephrine strategies regardless of sex. Single dose epinephrine was associated with increased survival to hospital discharge among White patients but not in non-White patients, which may be due to unmeasured confounding or inadequate power.

Introduction: Although ultrasound is readily available to emergency physicians and known to be very accurate for diagnosing rotator cuff tears, it is rarely used for this purpose. Our goal in this study was to develop and preliminarily assess the accuracy of a simplified shoulder ultrasound protocol (the "supra-short" protocol), designed to be used by emergency physicians for diagnosis of supraspinatus tears.

Methods: We performed a pilot diagnostic accuracy study in which we assessed the accuracy of the supra-short protocol as performed by minimally trained emergency physicians for identifying supraspinatus tears in volunteers. As a criterion standard, a sports medicine physician also performed a complete shoulder ultrasound on each volunteer. We determined the test characteristics of the supra-short protocol for supraspinatus tears, as well as the median time to complete a scan and the percentage of images deemed adequate by expert review.

Results: Nine emergency physicians performed a total of 40 bilateral supra-short scans on six volunteers (two of whom were known to have shoulder pathology and four of whom had normal shoulders). Of the 80 shoulders scanned, there were 18 cases in which complete ultrasound performed by the sports medicine physician revealed a supraspinatus tear; 12 (66.7%) of those were identified by the novice sonographers using the supra-short protocol. Overall, the sensitivity of the supra-short protocol was 66.7% (95% CI 29.9-92.5%) and the specificity was 87.1% (95% CI 70.2-96.4%). The median time to completion of each shoulder was 133 seconds (interquartile range 88-182). Upon expert image review, 80.0% of the images were deemed adequate.

Conclusion: After minimal training, emergency physicians were able to quickly perform the supra-short US protocol but were only able to identify supraspinatus tears with moderate accuracy, suggesting the need for more extensive training before clinical use.

Introduction: Ambulances are often left to idle, which may contribute to maintenance costs, environmental harm, and resource inefficiencies. Engine idling affects the health of first responders due to the consequences of exhaust. Our study objective was to gain understanding of current emergency medical services (EMS) policies and perspectives on ambulance engine idling.

Methods: We designed an anonymous, 48-question survey that was distributed to all levels of EMS clinicians. There were 684 total survey responses from 11 states. We excluded those that only included demographics, yielding 507 responses. The response rate was 10.8%. The questions surveyed demographics, service characteristics, and current policies and perspectives on idling. We used multiple question types, including some that asked participants to rate their level of concern on a five-point Likert scale. "Strongly disagree" was coded as 1, and "strongly agree" was coded as 5. "Neither agree or disagree" was considered a neutral response and was coded as 3. Additionally, we conducted a thematic analysis on data derived from the free-text responses to identify themes.

Results: Few (12%) respondents reported written policies on idling. The biggest concerns regarding idling involved the following (reported as median (IQR, 25^th and 75^th percentiles): patient comfort (4, IQR 4-5); EMS clinician comfort (4, IQR 4-5), and medication compromise (4, IQR 4-5). There was a neutral level of concern regarding equipment failure (3, IQR 3-4) and response delays (3, IQR 3-5). There was a less than neutral level of concern regarding engine failure (2, IQR 2-4); vehicle theft (2, IQR 2-4), air quality (2, IQR 2-3); increased fuel usage (2, IQR 2-3); and carbon emissions (2, IQR 2-3). Six themes emerged: fear of harming patient; safety; effects on air quality; habits and indifference; cost of idling; and frustration.

Conclusion: Emergency medical services clinicians mainly hesitate to turn off their engines out of concern for patient/personnel harm and potential equipment failure. The theme of frustration, noted in free-text responses, describes EMS clinicians' feelings of suspicion and concern for an ulterior motive behind the study, which highlights the need for a collaborative effort at addressing this collective issue.

Introduction: The coronavirus disease 2019 (COVID-19) pandemic significantly altered emergency department (ED) utilization patterns. This study quantifies the statistics at a Level I trauma center in Southern California from 14 months before to nine months after the start of the pandemic (January 2019-December 2020). We hypothesized that during the COVID-19 pandemic, changes in ED use patterns impacted patient acuity, as measured by admission rate, mortality rate, ED volume, Emergency Severity Index (ESI), and female:male ratio, even when controlling for COVID-19 cases.

Methods: In this study we examined 97,793 ED visits from January 2019-December 2020 at the University of California, Irvine Medical Center in Orange, CA, via an administrative database comprised of anonymized datapoints from the electronic health record. We included all months from January 2019-December 2020 to account for potential secular trends by calendar month. Primary outcome measures were hospital admission rate and all-causes mortality rate among non-COVID-19 patients who presented to the ED. Secondary outcome measures included the mean number of ED visits per month, mean ESI, and female:male ratio among non-COVID-19 patients. Statistical analyses were performed.

Results: We found an increase in the mortality rate per ED visit of 0.8859% before the pandemic to 1.2706% (P < .001) during the pandemic. After excluding COVID-19 cases, the mortality rate per ED visit remained elevated at 1.1746% (P < .001), a relative increase of 32.6%. Hospital admission rate increased from 26.0% before the pandemic to 32.3% during the pandemic (P < .001). The mean number of ED visits per month decreased from 4,271.2 ± 193.1 before the pandemic to 3,558.7 ± 437.1 per month during the pandemic (P < .001), a relative decrease of 16.7% when excluding COVID-19 cases. The mean ESI of non-COVID-19 related cases during the pandemic decreased from 2.85 pre-pandemic to 2.84 during the pandemic (P = .03). The female:male ratio decreased from 1.003 pre-pandemic to 0.885 during the pandemic (P < .001).

Conclusion: This study reveals a decrease in patient volume with an increase in mortality and admission rate, demonstrating an association between shifts in ED utilization patterns and increased patient acuity during the pandemic. Understanding patients' emergency care-seeking behavior during this period is essential for preparing for future large-scale public health crises and optimizing ED resource allocation and mobilization based on lessons learned from COVID-19. Overall, these findings highlight the need for further research into the development of strategies to address changes in care-seeking behavior during access-limiting scenarios.

Introduction: Heatwaves are becoming more frequent and severe globally. Heat is associated with increases in emergency department (ED) volumes and higher morbidity for a range of chronic conditions. We describe how temperature impacts ED arrivals at different acuity levels.

Methods: We obtained time-series records for daily ED arrivals stratified by Emergency Severity Index (ESI) from 2010 - 2019 from hospital records. Wet-bulb temperature was the exposure of interest; analysis was controlled for precipitation, snow, wind speed, day of week, and federal holidays. We fitted a Poisson model for each ESI category and estimated the association between temperature and ED arrival acuity with a distributed lag non-linear model with three days of lag to account for delayed health effects of temperature.

Results: We analyzed data for 3,652 days totaling 556,663 arrivals between 2010 - 2019. At lag 0, lower temperatures were associated with a reduced relative risk of arrival to the ED for ESI 2, ESI 3, and total arrivals. At higher temperatures, ESI 2 and ESI 3 showed an increased relative risk of arrival (wet-bulb exposure of 25°C at 0-day lag: ESI 2 RR = 1.06 [1.02-1.10]; ESI 3 RR = 1.04 [1.01-1.07]). While not statistically significant, ESI 1 exhibited a subtle increase in arrivals at the highest temperatures while ESI 4 & 5 displayed a subtle decrease in relative risk of arrivals under these conditions.

Conclusion: Extremes of temperature, particularly heat, appear to affect ED arrivals differently across different acuity levels. Medium- to higher-acuity presentations appear to be more responsive to heat, with a statistically significant increase in ED presentations on days with the highest heat burden. The highest acuity presentations became numerically but not statistically more frequent on days with the highest heat burden, while the lowest acuity presentations decreased numerically but not statistically in these conditions.

Introduction: Over 20% of the United States population speaks a language other than English, and many use the emergency department (ED) to access healthcare. However, there remains concern that patients preferring languages other than English are under-represented in clinical research. Thus, our goal was to assess the proportion of ED studies that excluded patients for recruitment due to language.

Methods: We conducted a narrative review using seven search engines for 2018-2023. We included studies if they mentioned language of participants and prospectively enrolled patients in an ED or prehospital setting. We excluded studies if they only included patients <18 years and/or were conducted exclusively outside the US. Two independent reviewers reviewed studies. Analyses included descriptive statistics.

Results: Of the 10,513 studies we identified, 281 were eligible for review; 163 (58%) excluded non-English language preferred (NELP) patients. Among the 107 interventional studies, 69% excluded NELP patients. Of the 135 studies focused on health equity/social emergency medicine, 47% excluded NELP patients.

Conclusion: We found 163 (58%) studies conducted in the ED that mention language and excluded NELP patients. Additional work is needed to encourage and support inclusive study designs.

Introduction: Hip fractures are a common reason for presentation to the emergency department (ED) and are associated with significant morbidity. Nerve blocks have emerged as a safe and effective tool to treat pain associated with hip fractures. In this study, we aimed to measure the frequency with which nerve blocks were performed for ED patients with hip fractures. Our secondary aims were to study the demographic and clinical characteristics of patients who received and did not receive a nerve block.

Methods: We performed a retrospective study at a single-center, urban, academic, Level I trauma center. We measured the frequency with which patients received a nerve block. We measured other demographics (age, ethnicity, insurance) and clinical data (comorbidities, Emergency Severity Index, National Emergency Department Overcrowding Scale, and hip fracture type). Lastly, we measured the types of nerve block performed, who performed the nerve block, and any associated complications.

Results: Overall, 17% (36/209) of the studied patients and 14% (36/257) of all patients with an acute hip fracture received a nerve block. Patients who were cared for by ultrasound (US) fellowship-trained physicians were more likely to receive a nerve block compared to patients cared for by non-US fellowship-trained physicians (20/35 vs 16/174; P-value < .001).

Conclusions: Nerve blocks were performed for a minority of patients presenting with an acute hip fracture. Patients who are cared for by ultrasound fellowship-trained physicians may be more likely to receive a nerve block than patients cared for by non-ultrasound fellowship-trained physicians in the emergency department.

Introduction: Out-of-hospital cardiac arrest remains a leading cause of death and significantly impacts global health outcomes. International guidelines emphasize the importance of high-quality CPR (cardiopulmonary resuscitation).

Objectives: Our goal was to compare CPR efficiency using the criteria recommended by international guidelines between two out-of-hospital cardiac arrest intervention scenarios: CPR at the incident site; and CPR during patient transport to the hospital by emergency medical services.

Methods: In each of the two scenarios, five full two-minute cycles of cardiac compression were applied to a manikin according to international guidelines. The CPR quality parameters were chest compression rate, chest compression depth recorded by the manikin, and investigator-evaluated correct hand placement on the manikin.

Results: We analyzed data from 240 CPR cycles provided by 24 healthcare professionals. The mean chest compression rate was higher (120.5±10.9/minutes vs 125.3±14.7/min, P = .001) and the mean chest compression depth was shallower (43.9±6.6 millimeters [mm] vs 37.9±7.2 mm, P = .001) in the on-the-move group. The two groups' appropriate hand placement rates were similar (92.1±5.4% vs 92.2±4.5%, P = .48) CONCLUSION: In this study, the moving ambulance simulation demonstrated that chest compressions were administered at a rate exceeding recommended guidelines and at a shallower depth than recommended, while the frequency of correct hand placement remained comparable. If the patient requires transportation from the scene of the incident, the healthcare team must be aware of the potential adverse effects on the chest compression quality.

Introduction: Pharmacogenomic-assisted prescribing of medications uses individual genetic information to identify drug-gene interactions. We aimed to assess potential pharmacogenomic drug-gene interactions in geriatric emergency department (ED) patients who sustained a fall.

Methods: This was a prospective study involving 25 older adult ED patients with fall-related injury. Data collected included current medications, demographics, and mechanism of injury. All patients provided a DNA sample, which underwent pharmacogenomic testing by an accredited genetics lab, Each patient's medications were reviewed against their pharmacogenomic report and categorized as Green (continue to use), Yellow (use with caution) or Red (stop use) based on their genetic information and published interactions by the Clinical Pharmacogenetics Implementation Consortium, Dutch Pharmacogenetics Working Group, and US Food and Drug Administration-approved drug label information. The main study outcome was pharmacogenomic drug-gene interactions.

Results: Of the 25 patients enrolled (median age, 81 years, IQR 76-85), 68% were female. Patients were taking a median of eight medications (IQR 5-11). The most common types were antihypertensives, statins, anticoagulants, and anti-platelet medications. Significant drug-gene interactions (Yellow or Red) were identified in 14/25 patients (56%; 95% CI 35-76%). Further, 6/25 (24%; 95% CI 9-45%) had one or more potentially serious (Red) interactions identified.

Conclusion: We found that in geriatric ED patients with a fall-related injury, most had a significant pharmacogenomic drug-gene interaction. DNA testing identifies these interactions and can assist with pharmacogenomic-guided medication prescribing, which may decrease adverse drug events and improve clinical outcomes.