Recent studies suggest that women with acute urethral syndrome or abdominal pain, presenting to emergency departments (EDs), have a high prevalence of Chlamydia trachomatis. Objectives: To estimate ...the prevalence of C. trachomatis in women presenting to an ED and to see whether those with dysuria or abdominal pain have a higher prevalence of C. trachomatis. Methods: The authors conducted a prospective cross‐sectional study of C. trachomatis in the urine of women aged 18 to 50 years who had a urinalysis performed at a university/county ED from February through May 1998. Urine specimens were labeled for the presence of symptoms and analyzed for C. trachomatis by ligase chain reaction (LCR). Polymerase chain reaction (PCR) testing of cervical swabs for C. trachomatis was done for usual clinical indications. Difference in proportions of positive LCR tests among patients was tested with Fisher's exact test. Agreement between PCR and LCR was measured using Cohen's kappa statistic. Results: Of 397 women whose urine was tested, 280 had symptoms of dysuria, abdominal pain, or both, and 117 had no symptoms. The overall prevalence of C. trachomatis by LCR was 3.8% (95% CI = 2.1% to 6.2%); and the combined PCR—LCR prevalence was 4.3% (95% CI = 2.5% to 6.8%). The presence of symptoms was not associated with a positive LCR test for C. trachomatis (p = 0.26, power = 0.8, alpha = 0.05, difference 3% vs. 12%). In the 172 patients who had both a PCR cervical swab and urine LCR, agreement was excellent (kappa = 0.67, 95% CI = 0.45 to 0.90). Conclusions: This ED had a surprisingly low prevalence of C. trachomatis. Women with symptoms were not more likely to test positive than those without.
A 27-year-old man developed respiratory arrest following intravenous administration of methylprednisolone sodium succinate. Skin tests were positive to methylprednisolone sodium succinate but not to ...methylprednisolone acetate. Severe anaphylactic reactions to intravenous corticosteroid medications can occur and can require epinephrine administration or endotracheal intubation. Skin tests and drug challenge should be done to establish the safety of a particular corticosteroid drug.
Study objective Sexual assault nurse examiner (SANE) programs have improved the quality of care for sexual assault victims. An adverse effect of these programs is reduced resident clinical exposure ...to victims of sexual assault. The objectives of this project are to determine the baseline level of resident competence in knowledge and management of sexual assault and to demonstrate the effectiveness of training in developing resident competence. Methods The study included 27 emergency medicine residents at an urban academic center with an active SANE program. The design included pretest, intervention, and retest at 6 months. The intervention included 8 hours of lecture, role play, and skills laboratories. Objectives were based on SANE standards. The 4 assessments were a written knowledge test, evidence collection on mannequin, standardized patient interviews, and a written emergency department note. Data were compared with paired t tests. Results Twenty-three (85%) residents completed the study. Preintervention, residents scored 56% on the written knowledge test, 63% on evidence collection, 71% on standardized patient interviews, and 66% on the written note. Residents showed significant postintervention improvements in written knowledge (improvement 24%; 95% confidence interval CI 20% to 27%) and evidence collection (improvement 18%; 95% CI 12% to 24%). Performance on standardized patient-based communication skills did not change after the intervention. Resident posttest scores were similar to those of SANE providers. Conclusion Emergency medicine residents training in an urban center with an active SANE program had limited knowledge and skills in the treatment of victims of sexual assault. Our multimodal educational intervention increased residents’ knowledge and evidence collection skills to levels equivalent to that of experienced providers in a SANE program.
There is considerable under-reporting of contaminated occupational needlestick and other sharp object injuries among emergency health care workers.
A convenience sample of emergency physicians, ...emergency nurses, and emergency medical technicians (EMTs).
A survey instrument eliciting demographic and work-related factors was developed and administered; survey items included age, sex, occupation, years in occupation, number of procedures performed per week, number of contaminated needlestick (and other "sharps") injuries recalled, and number of these injuries formally reported during the previous five years. Nonsegmented visual analog scales were used to assess eight attitudes possibly associated with nonreporting. Analysis was by analysis of variance and multiple linear regression with stepwise variable election.
Two hundred fifty-nine subjects recalled 643 contaminated exposures during the five-year study period, but only 228 (35%) were formally reported. One or more injuries occurred in 55% of EMTs compared with 72% of nurses and 80% of physicians (P less than .05). Physicians recalled a mean of 3.8 contaminated exposures, whereas nurses recalled 2.8 and EMTs recalled only 1.8 (P less than .05). Physicians formally reported a mean of 0.26 exposures, whereas EMTs reported 0.85 and nurses reported 1.25 (P less than .05). Physicians formally reported only one eighth of their injuries compared with EMTs and nurses, who each reported two thirds of these events (P less than .05). Perception of risk, occupation, years in occupation, and concern about excessive paperwork were the most powerful predictors of low reporting rate (P less than .05).
Work-related contaminated sharp object injuries are under-reported by emergency health care workers, especially emergency physicians.
Abstract We hypothesized that head computed tomography (CT) is an accurate screening tool for detecting nonnasal midfacial fractures in trauma patients. We retrospectively reviewed charts and ...official readings for all patients who underwent both head and facial CT scans for trauma at our trauma center between August 2002 and April 2003. The ability of head CT to diagnose nonnasal bone midfacial fractures was compared with that of facial CT using sensitivity, specificity, accuracy, as well as positive and negative predictive values. Agreement was measured with κ statistics. Ninety-five percent confidence intervals (CIs) were used to assess precision. Ninety-one patient records with head and facial CT scan reports were reviewed. Of the patients, 50 (55%) had nonnasal bone midfacial fractures. The sensitivity and specificity of head CT were 90% (95% CI = 79%-96%) and 95% (95% CI = 84%-99%), respectively; the positive and negative predictive values were 96% (95% CI = 86%-99%) and 89% (95% CI = 76%-95%), respectively. The rate of accuracy was 92%. The agreement was excellent ( κ = 0.85, 95% CI = 0.74-0.96). Head CT was sensitive and specific for identifying nonnasal bone midfacial fractures. An initial head CT alone may limit the need for a Waters view radiography or screening facial CT in detecting injuries.
Does a physician visual assessment change triage? Brillman, Judith C; Doezema, David; Tandberg, Dan ...
The American journal of emergency medicine,
1997, 1997-Jan, 1997-1-00, 19970101, Volume:
15, Issue:
1
Journal Article, Conference Proceeding
Peer reviewed
A prospective comparative trial was conducted to determine the effect of a physician's visual assessment of emergency patients on triage categorization and ability at triage to predict admission. The ...setting was a university, county, referral center and residency training site. Participants were a consecutive sample of emergency department patients presenting between the times of 0700 and 2300 hours for 5 weeks. All patients were assigned a triage category by an emergency nurse (RN) who saw the patient and by an emergency physician (EP) who had the option of performing a visual assessment. Triage categorization was compared for interobserver agreement (Kappa κ statistic) and by ability to predict admission (MacNemar's test). A total of 3,949 patients was entered. The patients that physicians visually assessed were triaged by nurses as more ill (
P < .001). For triage categories visualized by the EP compared with RN categorization, interobserver agreement was 59.8%, κ = .21. For triage categories not visualized by EP compared with RN categorization, interobserver agreement was 67.9%, κ = .45 (
P < .001). Sensitivity of EPs to predict admission is as follows: all RN triage, 41.3; not seen by EP, 54.9; seen by EP, 69.3. Specificity is as follows: all RN triage, 93.7; not seen by EP, 88.5, seen by EP, 83.9. When physician visual assessment was done, agreement between physicians and nurses decreased by more than half. Physicians who included visual assessment in patient triage were less likely to agree with RN categorization. A visual assessment by the physician improved the sensitivity for predicting admission with an only small cost in specificity.
To investigate the role of cranial magnetic resonance (MR) imaging in evaluating patients discharged from the emergency department after minor head injury.
A prospective blinded cohort study.
...University hospital ED.
Fifty-eight patients with minor head injury who were discharged from the ED with written head injury instructions. Patients admitted to the hospital were excluded.
Ultra-low-field cranial MR scans were performed on patients within 24 hours of discharge. Scans were read blindly by two radiologists.
Fisher's exact test was used to compare symptoms in patients with abnormal and normal MR scans. There was no significant difference in symptoms between patients with abnormal and those with normal scans (P greater than .10). The proportion of abnormal MR scans was analyzed using the binomial distribution. Six of the 58 patients (10.3%) had traumatic intracranial abnormalities (proportion, 0.103; SD, 0.04; 95% CI, 0.04-0.21). Three had cortical contusions, and three had small subdural hematomas. Two of the six patients with abnormal MR scans, both with small subdural hematomas, had normal computed tomography scans.
Ten percent of patients discharged from the ED after minor head injury had abnormal ultra-low-field cranial MR scans. Additional research is needed to establish the clinical importance of this unexpected observation.
There is a rapidly growing interest in emergency medicine (EM) and emergency out-of-hospital care throughout the world. In most countries, the specialty of EM is either nonexistent or in an early ...stage of development. Many countries have recognized the need for, and value of, establishing a quality emergency health care system and are striving to create the specialty. These systems do not have to be high tech and expense but can focus on providing appropriate emergency training to physicians and other health care workers. Rather than repeatedly "reinventing the wheel" with the start of each new emergency care system, the preexisting knowledge base of EM can be shared with these countries. Since the United States has an advanced emergency health care system and the longest history of recognizing EM as a distinct medical specialty, lessons learned in the United States may benefit other countries. In order to provide appropriate advice to countries in the early phase of emergency health care development, careful assessment of national resources, governmental structure, population demographics, culture, and health care needs is necessary. This paper lists specific recommendations for EM organizations and physicians seeking to assist the development of the specialty of EM internationally.
A worker was contaminated following a chemical explosion that splashed an HNO3 radioactive solution containing approximately 180 MBq (5 mCi) 192Ir onto the left side of his face. Initial efforts ...reduced the contamination at least fivefold. Removal of a patch of contaminated hair was necessary. Most of the contamination was fixed to the skin; only a small amount of contamination was absorbed.
Twelve patients with amebic liver abscess were admitted to a university hospital. Ten of these patients were admitted through the emergency department. Patients, especially men from third world ...countries, with fever, right upper quadrant pain, and leukocytosis are at high risk for this disease and should have the diagnosis confirmed with amebic serology and ultrasonography or computed tomography.
PDF
