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Objectives: Physicians with training in anesthesiology, emergency medicine, internal medicine, neurology, and surgery may gain board certification in critical care medicine upon completion of fellowship training. These clinicians often only spend a portion of their work effort in the ICU. Other work efforts that benefit an ICU infrastructure, but do not provide billing opportunities, include education, research, and administrative duties. For employed or contracted physicians, there is no singular definition of what constitutes an intensive care full-time equivalent (FTE). Nevertheless, hospitals often consider FTEs in assessing hiring needs, salary, and eligibility for benefits., Data Sources: Review of existing literature, expert opinion., Study Selection: Not applicable., Data Extraction: Not applicable., Data Synthesis: Not applicable., Conclusions: Understanding how an FTE is calculated, and the fraction of an FTE to be assigned to a particular cost center, is therefore important for intensivists of different specialties, as many employment models assign salary and benefits to a base specialty department and not necessarily the ICU., Competing Interests: Dr. Nurok serves as an advisor to Avant-garde Health, and he receives stock options for this role. Dr. Nunnally is a member of the Board of Regents of the American College of Critical Care Medicine. As such, he serves as an honorary member of the Society of Critical Care Medicine Council. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)

Background: Physical restraints are used in the emergency department (ED) for agitated patients to prevent self-harm and protect staff. Prior studies identified associations between sociodemographic factors and ED physical restraints use., Objectives: The primary objective was to compare characteristics of ED patients receiving physical restraints for violent and nonviolent indications vs. patients who were not restrained. The secondary objective was to compare rates of restraint use among ED providers., Methods: This was a single-center cross-sectional study of adult ED patients from March 2019 to February 2021. Factors compared across groups were age over 50 years, gender, race, ethnicity, insurance, housing, primary language, Emergency Severity Index, time of arrival, mode of arrival, chief complaint, and medical admission. Odds ratios were reported. Rates of emergency physician restraint orders were compared using the chi-square test., Results: Restraints were used in 1228 (0.9%) visits. Younger age, male gender, "unknown" ethnicity, self-pay or "other" nonprivate insurance, homelessness, arrival by first responders, and medical hospitalization were associated with increased odds of restraint. Black patients had lower odds of any restraint than White patients (odds ratio 0.93; 95% confidence interval 0.79-1.09) and higher odds of violent restraint than White patients, although not significant (odds ratio 1.55; 95% confidence interval 0.95-2.54). ED providers had significant differences in total and violent restraint use (p-values < 0.0001 and 0.0003, respectively)., Conclusion: At this institution, certain sociodemographic characteristics were associated with receiving both types of physical restraint. Emergency physicians also differed in restraint-ordering practice. Further investigation is needed to understand the influence of implicit bias on ED restraint use., Competing Interests: Declaration of Competing Interest Drs. Stillman, Geiderman, Torbati, and Mr. Mirocha report no potential conflicts of interest pertaining to this manuscript., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: eCPR, the modality of extracorporeal membrane oxygenation (ECMO) applied in the setting of cardiac arrest, has emerged as a novel therapy which may improve outcomes in select patients with out-of-hospital cardiac arrest (OHCA). To date, implementation has been mainly limited to single academic centres. Our objective is to describe the feasibility and challenges with implementation of a regional protocol for eCPR., Methods: The Los Angeles County Emergency Medical Services (EMS) Agency implemented a regional eCPR protocol in July 2020, which included coordination across multiple EMS provider agencies and hospitals to route patients with refractory ventricular fibrillation (rVF) OHCA to eCPR-capable centres (ECCs). Data were entered on consecutive patients with rVF with suspected cardiac aetiology into a centralized database including time intervals, field and in-hospital care, survival and neurologic outcome., Results: From July 27, 2020 through July 31, 2022, 35 patients (median age 57 years, 6 (17%) female) were routed to ECCs, of whom 11 (31%) received eCPR and 3 (27%) treated with eCPR survived, all of whom had a full neurologic recovery. Challenges encountered during implementation included cost to EMS provider agencies for training, implementation, and purchase of automatic chest compression devices, maintenance of system awareness, hospital administrative support for staffing and equipment for the ECMO program, and interdepartmental coordination at ECCs., Conclusion: We describe the successful implementation of a regional eCPR program with ongoing patient enrolment and data collection. These preliminary findings can serve as a model for other EMS systems who seek to implement regional eCPR programs., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Prehospital ECG-based cardiac catheterization laboratory (CCL) activation for ST-segment-elevation myocardial infarction reduces door-to-balloon times, but CCL cancellations (CCL X ) remain a challenging problem. We examined the reasons for CCL X , clinical characteristics, and outcomes of patients presenting as ST-segment-elevation myocardial infarction activations who receive emergent coronary angiography (EA) compared with CCL X ., Methods and Results: We reviewed all consecutive CCL activations between January 1, 2012, and December 31, 2014 (n=1332). Data were analyzed comparing 2 groups stratified as EA (n=466) versus CCL X (n=866; 65%). Reasons for CCL X included bundle branch block (21%), poor-quality prehospital ECG (18%), non-ST-segment-elevation myocardial infarction ST changes (18%), repolarization abnormality (13%), and arrhythmia (8%). A multivariate logistic regression model using age, peak troponin, and initial ECG findings had a high discriminatory value for determining EA versus CCL X (C statistic, 0.985). CCL X subjects were older and more likely to be women, have prior coronary artery bypass grafting, or a paced rhythm ( P<0.0001 for all). All-cause mortality did not differ between groups at 1 year or during the study period (mean follow-up, 2.186±1.167 years; 15.8% EA versus 16.2% CCL X ; P=0.9377). Cardiac death was higher in the EA group (11.8% versus 3.0%; P<0.0001). After adjusting for clinical variables associated with survival, CCL X was associated with an increased risk for all-cause mortality during the study period (hazard ratio, 1.82; 95% CI, 1.28-2.59; P=0.0009)., Conclusions: In this study, prehospital ECG without overreading or transmission lead to frequent CCL X . CCL X subjects differ with regard to age, sex, risk factors, and comorbidities. However, CCL X patients represent a high-risk population, with frequently positive cardiac enzymes and similar short- and long-term mortality compared with EA. Further studies are needed to determine how quality improvement initiatives can lower the rates of CCL X and influence clinical outcomes.

Patients in the emergency department frequently voice refusals of care or are unable or unwilling to consent to care. While general principles surrounding consent and refusal can be articulated in theory, it is often far more complicated in the real setting. Further, it is impossible to contemplate in advance every possible situation that might arise. In order to properly care for patients, the emergency physician has an obligation to understand ethical principles and the reasoning process one must go through to resolve an ethical dilemma. Emergency physicians face such complex decisions on a routine basis. Ethical reasoning skills are obviously a core competence in emergency medicine, even if easy answers are elusive. Two cases are presented that illustrate this complexity, and routes to resolution are discussed.

Objective: To characterize the reasons for and effects of diversions of advanced life support (ALS) ambulances in a large urban area with a high concentration of receiving hospitals., Methods: A retrospective study was performed in a large urban region during a consecutive three-month period. Diversion was defined as the ALS transport of a patient to an emergency department (ED) other than the designated primary receiving facility. Case-matched concurrent cohorts of patients who were and were not diverted were studied to establish emergency medical services (EMS) time intervals, including total prehospital interval (TPI), on-scene interval (OSI), and patient transfer interval (PTI); age; gender; Glasgow Coma Score (GCS); ALS interventions; and insurance status. The reasons for diversion and the chief complaints of diverted patients were also studied., Results: During the study period, 2,534 ALS runs occurred, of which 147 (5.8%) were diverted. Twenty-four (16.3%) diversions had incomplete run times, leaving 123 (83.7%) for analysis. The most common chief complaints of diverted patients were shortness of breath (SOB), chest pain (CP), and altered mental status (AMS). The most common reason for diversion was special consideration (SC), defined as a diversion requested by a patient, family member, law enforcement officer, or private medical doctor. Diverted ambulances had significant increases in TPI, 36.4 [95% confidence interval (95% CI) 35.1-37.7] vs. 33.4 [95% CI 32.13-34.7], and PTI, 10.3 [95% CI 9.4-11.2] vs. 7.9 [95% CI 7.2-8.6], compared with nondiverted ambulances. Further analysis demonstrated that SC diversions accounted for all of the increases in TPI (p<0.001) and PTI (p<0.001) when compared with other types of diversions and nondiverted transports., Conclusion: "Special consideration" was the most common reason for diversion in this study. Special consideration diversions increased TPI and PTI, causing delays in arrival to the ED and decreased ALS ambulance availability.

Unlabelled: Distracting painful injuries (DPIs) may mask symptoms of spinal injury in blunt trauma victims and form an important element in a decision instrument used to identify individuals who require cervical spine radiography., Objective: To identify the types and frequencies of injuries that actually act as DPIs among blunt trauma patients undergoing cervical spinal radiography., Methods: This was a prospective observational study of consecutive blunt trauma victims presenting to an urban Level 1 regional trauma center between April 1, 1998, and September 30, 1998. Prior to cervical spinal radiography, treating physicians evaluated each patient to determine whether a DPI was present or absent and, if present, what type of injury was sustained. Injuries were categorized as fractures, soft-tissue injuries and lacerations, burns, visceral injuries, crush injuries, or other injuries., Results: Data were collected for 778 patients, between 1 month and 98 years old, of whom 264 (34%) were considered to have DPIs. Physicians were unable to determine the DPI status in 47 (6%) additional cases. Fractures accounted for a majority of DPIs (154, or 58%), 42 (16%) were soft-tissue injuries or lacerations, and 86 (34%) were due to a variety of other entities, including visceral, crush, burn, or other miscellaneous injuries. Among the 37 (5%) patients with an acute cervical spinal injury, 20 (54%) had a DPI, including three (8%) who had DPI as the only indication for cervical radiography., Conclusions: A significant number of blunt trauma patients are believed by clinicians to have DPIs that can possibly mask the presence of cervical spinal injury. Fractures and trauma to soft tissues are the most common types of DPI.

In this review, the physiologic and pharmacologic effects of tricyclic antidepressants are discussed as they apply to an overdose situation. Systemic arterial hypotension is a frequent occurrence in major overdoses. Occasionally conventional resuscitative measures such as crystalloid or colloid infusion are inadequate and vasoactive agents must be employed in an attempt to normalize blood pressure. The use of these agents is discussed in terms of their physiologic and pharmacologic actions in the management of refractory hypotension induced by tricyclics.

The Cardiotrak is a small, lightweight device originally developed for use by pacemaker patients to transmit their electrocardiograms (ECGs) by telephone to their doctor or to a hospital. The Cardiotrak seemed well suited for use by paramedics and was field tested on 76 patients. In 69 patients, clear ECGs were transmitted with ease; in the remaining seven, only minor, correctable problems were noted. The Cardiotrak appears to have advantages over other devices used to transmit ECGs to base station hospitals from paramedics.

Emergency physicians frequently encounter patients who have been or may have been exposed to viral hepatitis, and are often in a position to offer immunoprophylaxis. Needlestick exposure among hospital employees is endemic in any large hospital. Currently treatment of clinical hepatitis is only symptomatic; rational immunoprophylaxis is the only method available to influence the course of the disease. The basic types of viral hepatitis are reviewed, as are transmission of the disease, serologic tests, high risk groups, and immunoprophylactic agents. Treatment plans are outlined for different types of exposure, and an algorithm is included for management of needlestick exposure.

Fracture of the penis is an unusual injury which has been reported fewer than 70 times. The injury results from a sudden bending of the erect penis. Such a force ruptures the tunica albuginea, usually unilaterally, resulting in local bleeding and immediate deturgescence of the penis; the urethra may also be torn. Treatment has not been standardized, and is aimed at restoring normal function and preventing late sequelae. The physician also should be aware of possible psychiatric complications. We present a case diagnosed in our emergency department and treated surgically with good results.

Two patients with injuries to the ankle sustained by rotational trauma complained only of pain in the ankle. Careful examination revealed tenderness over the proximal fibula. Subsequent radiographic studies revealed high helical fracture of the fibula, as originally described by Maisonneuve. The Maisonneuve fracture is produced by diastasis - a separation of bones resulting from rupture of ligaments around the ankle. According to classification of fibula injuries by mechanism of injury, the Maisonneuve fracture is due to external rotation of the foot relative to the tibia but it is not clear whether the foot is in pronation or supination or moves during injury.

The incidence of serious ventricular arrhythmias following acute myocardial infarction is highest during the first few hours after injury, and thereafter declines. Several investigations into the prophylactic use of lidocaine to prevent the development of arrhythmias have shown that lidocaine, given in therapeutic doses, is effective in preventing ventricular fibrillation and in reducing early mortality. Lidocaine was found to be effective when given either by the intravenous or by the intramuscular routes. The recommended dosage is 100 mg given as an intravenous bolus followed by 2 to 4 mg/min as an infusion, which should be given by infusion pump. Another recommendation is to use two 100 mg boluses 20 minutes apart, along with the same infusion. We recommend that lidocaine be started as soon as possible in all patients suspected of having suffered acute myocardial infarction.