Search

Background Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies. Methods We conducted a prospective, observational study of such a decision instrument at 21 centers across the United States. The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury. We examined the performance of the decision instrument in 34,069 patients who underwent radiography of the cervical spine after blunt trauma. Results The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury (sensitivity, 99.0 ... more...

This is the first comprehensive clinical reference on cancer emergencies. It is edited and written by world-renowned experts in emergency medicine and oncology and covers the diagnosis and management of the full range of emergencies caused directly by cancer or by its treatment. It shows how the entire spectrum of clinical medicine is brought to bear in the care of cancer patients in the unique setting of the emergency department (ED), from health promotion and prevention, to treatment and palliative care. Recognizing the multiple, overlapping contexts in which emergency care of cancer patients occurs, the book addresses clinically crucial interdisciplinary topics such as the ethics of ED cancer care, the interface with palliative social work, substance abuse, and more. Finally, perspective on care system and social forces that shape ED cancer care, such as cancer care disparities and care models, and on how ED cancer care is delivered outside of the United States, frame the book as a whole. Against the backdrop of rising numbers of cancer patients and survivors as the United States population ages and a forecast shortage of oncologists, this book is designed to serve as the authoritative, single-source clinical reference on cancer emergencies. The intended audience includes emergency physicians, oncologists, internists, family physicians, emergency nurses, nurse practitioners, physician assistants, policy makers as well as pre- and postgraduate trainees. more...

PURPOSE: To assess knowledge, attitudes, and formal instruction related to injury control among fourth-year medical students. Injury is the leading cause of death among Americans aged 1 to 44 years. METHOD: The authors conducted a cross-sectional survey of fourth-year students at six U.S. medical schools, four of which maintain federally funded injury prevention research centers. Main outcome measures included injury-related knowledge scores, three attitude measures, and self-reported exposures to injury prevention education. RESULTS: Six hundred and thirty-five fourth-year medical students (73% of those eligible) participated. The responding students were, on average, unable to correctly answer half of the questions testing injury-related knowledge. They rated medical problems more important and more preventable than injury problems, and they felt more comfortable asking their patients about risk factors for medical problems. These findings may be explained, in part, by the students' reported minimal exposure to injury control education in medical school. The students encountered the topic more frequently on rotations in pediatrics (84%), family medicine (73%), and preventive medicine (66%) than on rotations in emergency medicine (47%), internal medicine (41%), or obstetrics and gynecology (34%). Injury control was encountered least often on rotations in psychiatry (23%) and surgery (14%). CONCLUSIONS: These findings suggest that injury control is given limited coverage in the curricula of U.S. medical schools. As a result, students have little understanding of the principles and benefits of injury control. more...

Emergency physicians (EPs) are faced with significant challenges regarding pain management, while preventing abuse of prescription opioids. Prescription monitoring programs (PMPs) are increasingly used to help allay the abuse of controlled substances. The objective of this study was to determine EPs' intention to use the Texas PMP within the framework of the Technology Acceptance Model. A cross-sectional, 24-item survey instrument was developed and distributed to EPs attending an emergency medicine conference. PMP nonusers reported a positive intention to use the PMP in the future, with attitude (β = 0.61, p < 0.01) as the only statistically significant predictor of intention. PMP users reported a positive intention to use the PMP, with perceived usefulness (β = 0.62, p < 0.01) as the only statistically significant predictor of intention for PMP users. This exploratory study provides a basis for understanding EPs' intention to use a PMP. The use of PMPs by EPs may lead to a decrease in prescription opioid abuse and improve patient safety related to opioid prescribing in the emergency department setting. more...

Objective: To determine the minimum clinically important difference in physician–assigned visual analog scale (VAS) pain scores. Methods: Physicians attending emergency medicine didactic conferences were enrolled in this descriptive study. The subjects sequentially reviewed 11 written scenarios describing patients in moderate to severe pain. The subjects rated their perceptions of each patient's pain on a 100–mm VAS, then contrasted this pain with that of the previous patient scenario. For these contrasts, the subjects chose one of five responses: “much less,” “a little less,” “about the same,” “a little more,” or “much more” pain. The minimum clinically important difference was defined as the difference between scores for scenario pairs in which one patient's pain was rated “a little less” or “a little more” severe. Results: There were 230 comparisons by 23 health professionals. Of these, 64 were judged “a little less,” and 56 “a little more,” painful. These 120 comparisons, with their pain score differences, were used to determine the minimum clinically important difference. Pain judged to be “a little less” or “a little more” severe was associated with a mean difference in VAS scores of 18 mm (95% CI 16–20 mm), corresponding to a decrement of 23% (95% CI 20–26%) from the more painful scenario. Conclusions: Pain research outcomes involving a more...

In this issue of Annals, Rupp and Delaney1 have done an excellent job of naming the barriers to adequate care of emergency department (ED) patients in pain. Although they paint a somewhat bleak picture for emergency medicine, our specialty is not alone in undertreating pain. Studies have documented oligoanalgesia, the undertreatment of pain, in a variety of patient groups, including medical and surgical inpatients, nursing home residents, cancer patients, and others.2-4 These barriers are common to all medical specialties (inadequate education, lack of institutional commitment) but many are more salient to the emergency medicine community (time demands, lack of patient-physician continuity, diagnostic uncertainty).5 Deficiencies in pain treatment have prompted a number of initiatives to improve the quality of pain management, including practice guidelines from what is now the Agency for Healthcare Research and Quality, quality improvements guidelines from the American Pain Society, and beginning in 2001, revised pain standards from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).6-8 Despite the pessimism that colors this discussion, it is apparent that analgesic practices are evolving rapidly. The latest ED data from the National Hospital Ambulatory Medical Care Survey reveal that, from 1997 through 2001, there has been an impressive 18% increase in analgesic use in US EDs (from 47.2 to 56.2 mentions per 100 visits), with marked increases in both nonsteroidal anti-inflammatory agents and opioid analgesics.9 We do not know the reasons for this increase; however, a number of factors may be at work. These influences include policy and regulatory initiatives, institutional quality improvement programs, pharmaceutical marketing campaigns, educational efforts, and new knowledge from basic and clinical research, among others. This topography of influence is important to understand if we are to move from passive observers to active instigators of change. With regard to policy, this is an active time in the area of pain management. In 2001, the US Congress declared this the “decade of pain control and research,” and JCAHO issued revised standards mandating pain assessment in our EDs. More recently, Congressman Mike Rogers (R-MI) introduced the National Pain Care Policy Act of 2003 (H.R. 1863), another step in the federal recognition of pain as an important health care issue. This bill would create a National Center for Pain and Palliative Care Research at the National Institutes of Health and provide additional funds for pain research and education. In addition, it would create a White House Conference on Pain Care to identify key barriers to high-quality pain management practices and establish a clearinghouse at the Agency for Healthcare Research and Quality to collect and disseminate protocols and evidence-based practices regarding pain to clinicians and the general public. The impact of these policy and regulatory initiatives is difficult to quantify. The revised JCAHO standards have generated some grumblings from emergency physicians about imposed regulations and, in preliminary data from our research efforts, they seem to have prompted increased documentation of pain intensity, although perhaps little else. This documentation reveals that, in general, our patients present with extremely high levels of pain. In one published study, fully half of all patients presenting to the ED with pain experienced pain of severe intensity (8 to 10 on a 10point numeric rating scale), with median overall scores of 8.10 Despite the intention to promote pain intensity as an outcome measure with which to judge the quality of our efforts, our ongoing research finds that pain intensity is measured only once in most EDs, at the time of patient arrival, without additional measures that might reflect the impact of our therapies. This docP A I N M A N A G E M E N T / E D I T O R I A L more...

The objective of this study was to determine the feasibility of protocol-driven human recombinant hyaluronidase (rHuPH20)-enhanced subcutaneous (SC) hydration and opioid administration in adults presenting to the emergency department (ED) with sickle cell disease acute pain episodes (SCDAPE). Adults with SCDAPE were given 150 U of rHuPH20 and normal saline subcutaneously. Opioids were administered SC every 15 minutes for 4 hours until numerical rating scale (NRS) pain intensity scores fell to5, or Ramsay Sedation Scores were4. Pain intensity and pain relief were recorded hourly. Total morphine equivalents and fluid volume, total pain relief (TOTPAR), patient- and physician-perceived global efficacy, patient-perceived global SC needle discomfort, physician-rated ease of needle placement, and adverse effects were noted. Ten patients (6 males, 4 females), mean age 32.9 years (23-56 years) completed the trial. Mean pain intensity scores fell 25% (from 9.2 to 6.9) from baseline and mean 4-hour TOTPAR score was 4 (maximum: 16). A mean total of 119 mg (70-170 mg) morphine equivalents and 846 mL (200-1650 mL) normal saline were administered. Mean patient and physician global perceived efficacy ratings were 3.4 and 4.2 (of 5). Patient global discomfort of SC needle presence was 2.7 (of 10), and ease of needle placement was physician rated at 4 (of 4; easiest). Patients experienced mild swelling and stinging at the SC site, and no infusion required discontinuation. The authors conclude that rHuPH20-enhanced subcutaneous hydration and opioid administration appear feasible from this pilot study. These results need confirmation in a controlled clinical trial. more...

Study objective: Chest pain and myocardial infarction following the use of cocaine have been well documented. We assessed the prevalence of cocaine use in patients who presented to the emergency department with chest pain of possibly ischemic origin. Design: During times of research assistant availability, consecutive adults with the chief complaint of chest pain unexplained by trauma or radiographic abnormality were questioned about cocaine use in the preceding week. Urine was tested for the presence of cocaine or cocaine metabolites with a highly accurate bedside urine test kit (specificity, 100%; sensitivity 98%). Anonymous unlinked data-collection methods were used. Therefore we could not determine whether the patients who used cocaine had sustained myocardial infarctions. Setting: One suburban and three urban EDs. Results: We enrolled 359 patients with a mean age of 51 years, 8% of whom sustained myocardial infarctions. Sixty patients (17%) had cocaine or cocaine metabolites in urine. The likelihood of testing positive for cocaine varied by age group: 18 to 30 years, 29%; 31 to 40 years, 48%; 41 to 50 years, 18%; 51 to 60 years, 3%; 61 years or older, 0% ( P Conclusion: Many ED patients with chest pain have recently used cocaine. Because the recent use of cocaine is not uncommon in patients with chest pain up to 60 years old, such patients should be questioned about cocaine use. When treatment or disposition may be altered, consideration should be given to objective assessment of cocaine use because patient self-report does not appear reliable. [Hollander JE, Todd KH, Green G, Heilpern KL, Karras DJ, Singer AJ, Brogan GX, Funk JP, Strahan JB: Chest pain associated with cocaine: An assessment of prevalence in suburban and urban emergency departments. Ann Emerg Med December 1995;26:671-676.] more...

Background Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. Case report We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. Discussion We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. Conclusion The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting. more...

Background Hip fractures are a painful condition commonly encountered in the emergency department (ED). Older adults in pain often receive suboptimal doses of analgesics, particularly in crowded EDs. Nerve blocks have been utilized by anesthesiologists to help control pain from hip fractures postoperatively. The use of nerve stimulator with ultrasonographic guidance has increased the safety of this procedure. Objectives We instituted a pilot study to assess the ability of Emergency Medicine (EM) resident physicians to effectively perform this procedure after a didactic and demonstration session. Methods First-year EM residents from three urban training programs underwent a 1-h didactic and hands-on training session on the femoral nerve block (FNB) procedure. A written pretest was used to assess baseline knowledge; it was administered again (with test items randomized) at 1 and 3 months post training session. A critical actions checklist (direct observation of procedure steps via simulated patient encounter) was used to assess the residents after the training session and again at 3 months. Results A total of 38 EM residents were initially evaluated. Thirty-three successfully completed 1-month and 3-month written test evaluations; 30 completed all written and direct observation evaluations. The mean written pretest scores were 66% (SD 9); post-test 92% (SD 5), 1-month 74% (SD 8), and 3-month 75% (SD 9). After initial training, 37 of 38 (97%) residents demonstrated competency (completing ≥ 15 of 19 critical actions) in the FNB procedure determined via direct observation. At 3 months, 25 of 30 residents (83%) continued to retain 85% of their initial critical action skills, and 3 of 30 (10%) saw an improvement in their proficiency. Conclusion A 1-h training and demonstration module yielded high competency rates in residents performing critical actions related to the FNB; these skills were well maintained at 3 months. An ongoing study will attempt to correlate this competency with procedures performed on patients. more...

Ultrasound guidance is associated with improved efficiency and success of peripheral nerve blockade and a decreased incidence of vascular puncture, making these interventions safer. Patients with peripheral nerve blocks report decreased pain and increased satisfaction scores. We present the development of a mobile ultrasound-guided block service that allows for the safe and efficient placement of nerve blocks and perineural catheters at the nontraditional location of the patient's bedside and in the emergency department. more...