The western journal of emergency medicine
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Non-contrast computed tomography (CT) is widely regarded as the gold standard for diagnosis of urolithiasis in emergency department (ED) patients. However, it is costly, time-consuming and exposes patients to significant doses of ionizing radiation. Hydronephrosis on bedside ultrasound is a sign of a ureteral stone, and has a reported sensitivity of 72-83% for identification of unilateral hydronephrosis when compared to CT. The purpose of this study was to evaluate trends in sensitivity related to stone size and number. ⋯ In a population with CT-proven urolithiasis, ED bedside ultrasonography had similar overall sensitivity to previous reports but showed better sensitivity with increasing stone size and number. We identified 100% of patients with stones ≥6 mm that would benefit from medical expulsive therapy by either the presence of hematuria or abnormal ultrasound findings.
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Board scores are an important aspect of an emergency medicine (EM) residency application. Residency directors use these standardized tests to objectively evaluate an applicant's potential and help decide whether to interview a candidate. While allopathic (MD) students take the United States Medical Licensing Examination (USMLE), osteopathic (DO) students take the Comprehensive Osteopathic Medical Licensing Examination (COMLEX). It is difficult to compare these scores. Previous literature proposed an equation to predict USMLE based on COMLEX. Recent analyses suggested this may no longer be accurate. DO students applying to allopathic programs frequently ask whether they should take USMLE to overcome this potential disadvantage. The objective of the study is to compare the likelihood to match of DO applicants who reported USMLE to those who did not, and to clarify how important program directors consider it is whether or not an osteopathic applicant reported a USMLE score. ⋯ DO students who reported USMLE were more likely to match. DO students applying to allopathic EM programs should consider taking USMLE to improve their chances of a successful match.
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Multicenter Study
Predictors of unattempted central venous catheterization in septic patients eligible for early goal-directed therapy.
Central venous catheterization (CVC) can be an important component of the management of patients with severe sepsis and septic shock. CVC, however, is a time- and resource-intensive procedure associated with serious complications. The effects of the absence of shock or the presence of relative contraindications on undertaking central line placement in septic emergency department (ED) patients eligible for early goal-directed therapy (EGDT) have not been well described. We sought to determine the association of relative normotension (sustained systolic blood pressure >90 mmHg independent of or in response to an initial crystalloid resuscitation of 20 mL/kg), obesity (body mass index [BMI] ≥30), moderate thrombocytopenia (platelet count <50,000 per μL), and coagulopathy (international normalized ratio ≥2.0) with unattempted CVC in EGDT-eligible patients. ⋯ Septic patients eligible for EGDT with relative normotension and those with moderate thrombocytopenia were less likely to undergo attempted CVC at any site. Those with coagulopathy were also less likely to undergo attempted thoracic central line placement. Knowledge of the decision-making calculus at play for physicians considering central venous catheterization in this population can help inform physician education and performance improvement programs.
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Mental health patients boarding for long hours, even days, in United States emergency departments (EDs) awaiting transfer for psychiatric services has become a considerable and widespread problem. Past studies have shown average boarding times ranging from 6.8 hours to 34 hours. Most proposed solutions to this issue have focused solely on increasing available inpatient psychiatric hospital beds, rather than considering alternative emergency care designs that could provide prompt access to treatment and might reduce the need for many hospitalizations. One suggested option has been the "regional dedicated emergency psychiatric facility," which serves to evaluate and treat all mental health patients for a given area, and can accept direct transfers from other EDs. This study sought to assess the effects of a regional dedicated emergency psychiatric facility design known at the "Alameda Model" on boarding times and hospitalization rates for psychiatric patients in area EDs. ⋯ The results of this study indicate that the Alameda Model of transferring patients from general hospital EDs to a regional psychiatric emergency service reduced the length of boarding times for patients awaiting psychiatric care by over 80% versus comparable state ED averages. Additionally, the psychiatric emergency service can provide assessment and treatment that may stabilize over 75% of the crisis mental health population at this level of care, thus dramatically alleviating the demand for inpatient psychiatric beds. The improved, timely access to care, along with the savings from reduced boarding times and hospitalization costs, may well justify the costs of a regional psychiatric emergency service in appropriate systems.
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Eligible residents during their fourth postgraduate year (PGY-4) of emergency medicine (EM) residency training who seek specialty board certification in emergency medicine may take the American Osteopathic Board of Emergency Medicine (AOBEM) Part 1 Board Certifying Examination (AOBEM Part 1). All residents enrolled in an osteopathic EM residency training program are required to take the EM Resident In-service Examination (RISE) annually. Our aim was to correlate resident performance on the RISE with performance on the AOBEM Part 1. The study group consisted of osteopathic EM residents in their PGY-4 year of training who took both examinations during that same year. ⋯ We have shown there is a strong correlation between a resident's percentile score on the RISE during their PGY-4 year of residency training and first-time success on the AOBEM Part 1 taken during the same year. This information may be useful for osteopathic EM residents as an indicator as to how well prepared they are for the AOBEM Part 1 Board Certifying Examination.