J Emerg Med
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Cardiac tamponade from necrotizing descending mediastinitis is a rare but life-threatening complication of cervicofacial infections. ⋯ A 49-year-old woman presented in shock with pleuretic chest pain at a small community clinic. She was transferred to our emergency department where cardiac tamponade was diagnosed and drained. Her initial complete blood count and chest radiography suggested a neoplastic process. She, however, was diagnosed with descending necrotizing mediastinitis due to group A Streptococcus. She underwent surgical drainage and recovered uneventfully. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Descending necrotizing mediastinitis can present with cardiac tamponade and a leukemoid reaction mimicking a neoplastic process. Recognizing this entity allows initiation of potentially life-saving treatments.
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Jaundiced infants are uncommon in most emergency departments (EDs). Biliary rupture remains one of the more rare and less described causes of this condition. ⋯ A 5-month-old male presented to our ED with scleral icterus, increasing abdominal distention, and increased irritability. A bedside ultrasound revealed a moderate amount of ascites and further imaging suggested he had a rupture of his common bile duct. Surgical exploration confirmed this and revealed the presence of choledocholithiasis, which was the likely cause of the rupture. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Biliary rupture remains a rare but serious condition in very young patients. Emergency physicians should consider bedside ultrasound as an adjunct in undifferentiated abdominal distention or jaundice in this patient population.
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Prior studies of admitted geriatric syncope patients suggest that diagnostic tests affect management < 5% of the time; whether this is true among all emergency department (ED) patients with syncope remains unclear. ⋯ Although routine testing is prevalent in ED patients with syncope, the diagnostic yield is relatively low. Nevertheless, some testing, particularly echocardiography, may yield critical findings. Current efforts to reduce the cost of medical care by eliminating nondiagnostic medical testing and increasing emphasis on practicing evidence-based medicine argue for more discriminate testing when evaluating syncope.
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Observational Study
Can Emergency Medical Services Use Turnaround Time as a Proxy for Measuring Ambulance Offload Time?
"Offload delay" occurs when the transfer of care from paramedics to the emergency department (ED) is prolonged. Accurately measuring the delivery interval or "offload" is important, because it represents the time patients are waiting for definitive care. Because recording this interval presents a significant challenge, most emergency medical services systems only measure the complete at-hospital time or "turnaround interval," and most offload delay research and policy is based on this proxy. ⋯ The results show that the correlation between the delivery and turnaround intervals is good. However, there remains much to be learned about the at-hospital time intervals and how to use these data to make decisions that will improve resource utilization and patient care. Efforts to establish a method to accurately record the delivery interval and to understand the at-hospital portion of the ambulance response are necessary.
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As the specialty of emergency medicine (EM) continues to spread around the world, a growing number of academic emergency physicians have become involved in global EM development, research, and teaching. While academic departments have always found this work laudable, they have only recently begun to accept global EM as a rigorous academic pursuit in its own right. ⋯ Reflecting a growing interest in global health, more of today's EM faculty members are ascending the academic ranks as global EM specialists. Whether attempting to climb the academic ladder as a clinician-educator or clinician-researcher, advanced planning and the firm support of one's academic chair is crucial to the success of the promotion process. Given the relative youth of the subspecialty of global EM, however, it will take time for the pathways to academic promotion to become well delineated.