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Wirachin Hoonpongsimanont,1 Maja Feldman,1 Nicholas Bove,1 Preet Kaur Sahota,1 Irene Velarde,1,2 Craig L Anderson,1 Warren Wiechmann1 1Department of Emergency Medicine, University of California, Irvine School of Medicine, Irvine, CA, USA; 2Touro University College of Osteopathic Medicine, Vallejo, CA, USA Purpose: Providing feedback to students in the emergency department during their emergency medicine clerkship can be challenging due to time constraints, the logistics of direct observation, and limitations of privacy. The authors aimed to evaluate the effectiveness of first-person video, captured via Google Glass™, to enhance feedback quality in medical student education. Material and methods: As a clerkship requirement, students asked patients and attending physicians to wear the Google Glass™ device to record patient encounters and patient presentations, respectively. Afterwards, students reviewed the recordings with faculty, who provided formative and summative feedback, during a private, one-on-one session. We introduced the intervention to 45, fourth-year medical students who completed their mandatory emergency medicine clerkships at a United States medical school during the 2015–2016 academic year.Results: Students assessed their performances before and after the review sessions using standardized medical school evaluation forms. We compared students’ self-assessment scores to faculty assessment scores in 14 categories using descriptive statistics and symmetric tests. The overall mean scores, for each of the 14 categories, ranged between 3 and 4 (out of 5) for the self-assessment forms. When evaluating the propensity of self-assessment scores toward the faculty assessment scores, we found no significant changes in all 14 categories. Although not statistically significant, one fifth of students changed perspectives of their clinical skills (history taking, performing physical exams, presenting cases, and developing differential diagnoses and plans) toward faculty assessments after reviewing the video recordings.Conclusion: First-person video recording still initiated the feedback process, allocated specific time and space for feedback, and possibly substituted for the direct observation procedure. Additional studies, with different outcomes and larger sample sizes, are needed to understand the effectiveness of first-person video in improving feedback quality. Keywords: clerkship, emergency medicine, feedback, medical student education, first-person video

Many studies have evaluated the effectiveness of alcohol screening and brief intervention (SBI) but most of them have reported substantial loss to follow-up without investigating the characteristics of those lost to follow-up. We examined the association between Alcohol Use Disorders Identification Test (AUDIT) scores, readiness-to-change scores and the demographic factors with lost to follow-up. This retrospective study compared demographic characteristics, AUDIT and readiness-to-change scores for 190 lost to follow-up patients to 221 completed follow-up patients who participated in SBI in the Emergency Department between June 2006 and May 2007. Comparing the association between baseline characteristics and completed follow-up rate, those 30–39, 40–49 and 50 years and older had 0.46 (95% CI 0.32–0.91), 0.49 (95% CI 0.29–0.90) and 0.58 (95%CI 0.22–0.79) lower odds of completing follow-up, respectively, in comparison to those 18–29 years of age. The loss to follow-up group reported more negative consequences of alcohol and binge drinking than the completed follow-up group (p = 0.04). Using logistic regression, patients who experienced more negative effects of alcohol had 0.87 lower odds of completing follow-up (95% CI 0.79–0.96). The patients lost to follow-up in this study were significantly different in age and alcohol drinking habits compared to those completed follow-ups. It is important to consider differential loss to follow-up in assessing the validity and generalizability of intervention studies. This could help in tailoring methods of approaching patients based on target population characteristics.

Background: Differences in productivity between off-service residents rotating in the emergency department (ED) and their emergency medicine (EM) resident counterparts have never been directly quantified. Objectives: We sought to quantify the difference between off-service residents rotating in the ED and their EM resident counterparts.We also sought to find whether shift cards could be used to increase the productivity of off-service residents rotating in the ED. Methods: This is a prospective cohort study conducted at an urban, tertiary, Level I trauma center.We implemented the use of shift cards for off-service residents during their EM rotation. Completion of the shift card involved recording patients seen and their dispositions, procedures done, and documenting a learned bedside teaching point from their shift that day. Productivity was measured in terms of patients seen per hour (PPH) and relative value units per hour (RVU/h). Results: Off-service residents showed a productivity of 0.529 PPH (95% confidence interval [CI] 0.493-0.566) and 1.40 RVU/h (95% CI 1.28-1.53) prior to implementation of shift cards. With the introduction of shift cards, productivity increased to 0.623 PPH (95% CI 0.584-0.663, p = 0.001) and 1.77 RVU/ h (95% CI 1.64-1.91, p = 0.001). In comparison, first year EM resident productivity was 0.970 PPH (95% CI 0.918- 1.02) and 3.01 RVU/h (95% CI 2.83-3.19). Conclusions: Shift cards can be used to foster motivation for off-service residents rotating in the ED, and is a simple and costeffective method to improve system-based practices and utilization of resources.

This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl. The patient later returned to the emergency department (ED) with severe dehydration from idiopathic central diabetes insipidus (DI). At her first visit, this previously healthy patient presented with mild dehydration, signs of acute gastroenteritis and normal urine output. Her brother had experienced similar symptoms a few days earlier. She tolerated an oral fluid challenge and was discharged from the ED with stable vital signs. Two days later, the patient returned with severe dehydration, resolving diarrhea and persistent vomiting. She was admitted to the pediatric intensive care unit. Magnetic resonance imaging illustrated an absent posterior pituitary enhancing signal, which demonstrated a loss of function in that region. There were no other abnormalities. The patient subsequently received desmopressin with improving clinical status and was discharged on the eighth hospital day. DI is a rare disease, but can be fatal if left undiagnosed. It should, therefore, be considered in the differential diagnosis of a dehydrated patient with an unexpectedly low urine specific gravity. [ABSTRACT FROM AUTHOR]

Introduction: Trauma patients who present to the emergency department (ED) intoxicated or with an alcohol use disorder (AUD) undergo more procedures and have an increased risk of developing complications. However, how AUD and blood alcohol concentration (BAC) impact a trauma patient's disposition from the ED remains inconclusive. In this study we aimed to identify the associations between positive BAC or an AUD with admission to the hospital, including the intensive care unit (ICU)., Methods: This was a retrospective study analyzing data from 2010-2018 at a university-based, Level I trauma ED. Included in the study were 4,699 adult trauma patients who completed the Alcohol Use Disorders Identification Test (AUDIT) and had blood alcohol content test results., Results: Positive BAC was associated with hospital admission and ICU admission after adjusting for injury severity score (ISS) (odds ratio 1.5 and 1.3, respectively). The AUDIT was only correlated with hospital and ICU admission in patients with ISS of 1 to 15. By increasing risk of AUD (low, moderate, high, and likely alcohol dependent) the proportion of ICU admissions rose from 29.3% to 37.3%, 40.0% and 42.0% (P <0.01). The results did not change significantly by adjustment for the age of patients., Conclusion: BAC is associated with increasing ED disposition to the hospital or ICU. Furthermore, self-reported alcohol use was associated with an increased risk of hospital or ICU admission in patients with minor or moderate injuries. Further studies to determine viable options to decrease admission rates in these patients are warranted.

Case Presentation: A 64-year-old man with a history of a 5.5-centimeter (cm) abdominal aortic aneurysm (AAA) presented to the emergency department (ED) complaining of severe back pain after climbing over a fence and falling a distance of eight feet. Prior to arrival, the prehospital paramedics reported that the patient did not have palpable pulses in either lower extremity. The initial physical examination in the ED was significant for absent dorsalis pedis pulses bilaterally as well as absent posterior tibialis pulses bilaterally and cold, insensate lower extremities. Point-of-care ultrasound identified an approximate 7-cm infrarenal AAA with a mural thrombus present. After receiving several computed tomography (CT) studies including CT head without contrast and CT angiography of the chest, abdomen and pelvis, the patient was diagnosed with acute thrombosis of AAA and associated thromboembolic occlusion of both his right and left distal iliac vessels causing bilateral acute limb ischemia. He immediately received unfractionated heparin and was admitted to the hospital for embolectomy and intra-arterial tissue plasminogen activator., Discussion: Acute thrombosis of AAA and subsequent thromboembolic events are a rare but significant complication that can occur in patients with a history of AAA. Thromboembolic events may occur spontaneously or in the setting of blunt abdominal trauma. Common presenting signs and symptoms include distal limb ischemia and absent femoral pulses. Timely management and recognition of this rare complication is vital as this condition can ultimately result in limb loss or death if not treated in a timely manner. Heparinization after confirmation of non-ruptured AAA as well as vascular surgery, and therapeutic and vascular interventional radiology consultations are key steps that should be taken to decrease patient morbidity and mortality.

Background: This study assessed the inconsistencies between self-reported alcohol consumption and blood alcohol content (BAC) in trauma patients. We aimed to identify the incidence of positive BAC in trauma patients who reported a zero score on the Alcohol Use Disorders Identification Test (AUDIT). We also sought to identify characteristics of individuals who were likely to negate alcohol use, yet yielded a positive BAC, to improve our ability to provide alcohol screening and healthcare to these at-risk alcohol consumers. Methods: We conducted a retrospective study from 2010 to 2018 at a university-based, level-one trauma emergency department. We identified 2581 adult trauma patients who reported a zero score on the AUDIT from the trauma registry. We collected BAC, age, gender, race, education level, mechanism of injury, language and injury severity score (ISS) from patient charts, and used descriptive analyses and multivariate logistic regression to analyze the data. Results: One hundred and thirty-one (5.08%) trauma patients who reported AUDIT of zero had a positive BAC. We found that being male (OR 1.53), assaulted or injured from a penetrating mechanism (OR 2.29) and having an ISS greater than 25 (OR 3.76) were independent positive predictors of trauma patients who reported an AUDIT of zero and had a positive BAC. Age (OR 0.99) was an independent negative predictor of trauma patients who reported an AUDIT of zero and had a positive BAC in this cohort. Conclusions: Inaccurate self-reporting of alcohol drinking behavior does exist in trauma patients. A composite of objective alcohol screening modalities, in addition to AUDIT, is needed to screen for alcohol use in this population. Healthcare providers should remain highly suspicious of alcohol-related injuries in individuals with the identified characteristics.

Background: Patients with an alcohol use disorder (AUD) have an increased risk of developing complications during their hospital stays; however, how AUD impacts the length of stay (LOS) and the utilization of hospital resources remains inconclusive., Aim: This study aimed to identify the associations between AUD, defined by self-reported alcohol consumption, blood alcohol content (BAC), and hospital LOS (HLOS) including intensive care unit (ICU) LOS in the trauma patient population., Study Design: We conducted a retrospective study analyzing data obtained from 2010 to 2018 at a university-based, level-one trauma emergency department. We identified 1689 adult trauma patients who completed the AUDs identification test (AUDIT) and were admitted to the hospital. We retrieved BAC, age, gender, LOS, and injury severity score (ISS) from the patient charts. The independent samples' median test was used to assess the association of HLOS and ICULOS with ISS, BAC levels, or AUDIT scores., Results: ISS was directly associated with higher HLOS ( P < 0.001) and ICULOS ( P < 0.001); however there was no statistically significant association between AUDIT scores and ICULOS ( P = 0.21) or HLOS ( P = 0.86). There was also no statistically significant association between BAC and HLOS ( P = 0.09) or ICULOS ( P = 0.07)., Conclusions: Our study found no associations between AUDIT, BAC, and both hospital and ICU LOS in trauma patients even though the literature supported an increased risk of medical complications in the AUD patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Emergencies, Trauma, and Shock.)

Background and Purpose: Clinical methods have incomplete diagnostic value for early diagnosis of acute stroke and large vessel occlusion (LVO). Electroencephalography is rapidly sensitive to brain ischemia. This study examined the diagnostic utility of electroencephalography for acute stroke/transient ischemic attack (TIA) and for LVO., Methods: Patients (n=100) with suspected acute stroke in an emergency department underwent clinical exam then electroencephalography using a dry-electrode system. Four models classified patients, first as acute stroke/TIA or not, then as acute stroke with LVO or not: (1) clinical data, (2) electroencephalography data, (3) clinical+electroencephalography data using logistic regression, and (4) clinical+electroencephalography data using a deep learning neural network. Each model used a training set of 60 randomly selected patients, then was validated in an independent cohort of 40 new patients., Results: Of 100 patients, 63 had a stroke (43 ischemic/7 hemorrhagic) or TIA (13). For classifying patients as stroke/TIA or not, the clinical data model had area under the curve=62.3, whereas clinical+electroencephalography using deep learning neural network model had area under the curve=87.8. Results were comparable for classifying patients as stroke with LVO or not., Conclusions: Adding electroencephalography data to clinical measures improves diagnosis of acute stroke/TIA and of acute stroke with LVO. Rapid acquisition of dry-lead electroencephalography is feasible in the emergency department and merits prehospital evaluation.

Background: Early diagnosis of stroke optimizes reperfusion therapies, but behavioral measures have incomplete accuracy. Electroencephalogram (EEG) has high sensitivity for immediately detecting brain ischemia. This pilot study aimed to evaluate feasibility and utility of EEG for identifying patients with a large acute ischemic stroke during Emergency Department (ED) evaluation, as these data might be useful in the prehospital setting., Methods: A 3-minute resting EEG was recorded using a dense-array (256-lead) system in patients with suspected acute stroke arriving at the ED of a US Comprehensive Stroke Center., Results: An EEG was recorded in 24 subjects, 14 with acute cerebral ischemia (including 5 with large acute ischemic stroke) and 10 without acute cerebral ischemia. Median time from stroke onset to EEG was 6.6 hours; and from ED arrival to EEG, 1.9 hours. Delta band power (P = .004) and the alpha/delta frequency band ratio (P = .0006) each significantly distinguished patients with large acute ischemic stroke (n = 5) from all other patients with suspected stroke (n = 19), with the best diagnostic utility coming from contralesional hemisphere signals. Larger infarct volume correlated with higher EEG power in the alpha/delta frequency band ratio within both the ipsilesional (r = -0.64, P = .013) and the contralesional (r = -0.78, P = .001) hemispheres., Conclusions: Within hours of stroke onset, EEG measures (1) identify patients with large acute ischemic stroke and (2) correlate with infarct volume. These results suggest that EEG measures of brain function may be useful to improve diagnosis of large acute ischemic stroke in the ED, findings that might be useful to pre-hospital applications., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Recent findings on emergency department (ED) patient experience surveys and concerns for the low response rates challenge the quality and reliability of the survey reports. We assessed the consistency of an ED patient experience survey report and identified the effects of patient demographics on ED patient experiences., Methods: We conducted a prospective, cross-sectional study at a university-based ED from July to December 2017. We obtained ED patient experience scores from an institutional version (IS) survey and the Press Ganey Associates-distributed survey (PGA). We compared top box scores from the two reports using frequency analysis and performed multivariable logistic regressions to identify associations between IS patient demographics and scores., Results: We obtained 289 PGA and 234 IS responses. The IS reported significant, higher top box scores in doctor-specific patient questions compared to PGA (all four P -values < 0.01). Female, Christian and White patients were more likely to give top box scores ( OR 3.07, OR 2.22 and OR 2.41, P -value < 0.05, respectively)., Conclusion: We found significant differences in ED patient experience scores between the IS and PGA surveys. We recommend that healthcare providers consider patient demographic variables when interpreting ED experience score reports. Multiple survey techniques and distribution methods may be adopted to best capture ED patient experiences., Competing Interests: Conflicts of interest: The authors declare no financial or other conflicts of interest.

Introduction: A multiple-mini interview (MMI) is a type of structured interview, which may assess many non-cognitive domains in residency applicants. There are few studies on MMI during the emergency medicine (EM) residency admissions process in the United States. We sought to determine the strengths, weaknesses, and acceptability of a pilot MMI for EM residency admissions., Methods: We piloted a five-station MMI with nine residency applicants. Following the MMI, we surveyed all participants, using 15 open- and closed-ended questions. Using grounded theory analysis, we coded the responses to the post-intervention survey to uncover the strengths and weaknesses of the MMI for EM residency admissions., Results: All nine students completed the survey. A positive theme that emerged from the survey was that the MMI was a positive, unexpected experience (all respondents, n=9). Candidates felt they were able to showcase unique talents, which would not be observed during a traditional interview (n=3). A negative theme that emerged from the survey was that the experience was intimidating (n=3). Candidates felt that the MMI left out important aspects of a typical interview day (n=3); such as, time for the candidate to become more familiar with the program., Conclusions: An MMI may be a positive experience for candidates, but may also induce more anxiety. The MMI may omit an important piece of the interview day: an opportunity for the applicants to familiarize themselves with the residency program.

Objectives: The primary objective of this study was to determine whether consensuses on the definition of emergency physician professionalism exist within and among four different generations. Our secondary objective was to describe the most important characteristic related to emergency physician professionalism that each generation values., Methods: We performed a cross-sectional survey study, using a card-sorting technique, at the emergency departments of two university-based medical centers in the United States. The study was conducted with 288 participants from February to November 2017. Participants included adult emergency department patients, emergency medicine supervising physicians, emergency medicine residents, emergency department nurses, and fourth- and second-year medical students who independently ranked 39 cards that represent qualities related to emergency physician professionalism. We used descriptive statistics, quantitative cultural consensuses and Spearman's correlation coefficients to analyze the data., Results: We found cultural consensuses on emergency physician professionalism in Millennials and Generation X overall, with respect for patients named the most important quality (eigenratio 5.94, negative competency 0%; eigenratio 3.87, negative competency 1.64%, respectively). There were consensuses on emergency physician professionalism in healthcare providers throughout all generations, but no consensuses were found across generations in the patient groups., Conclusions: While younger generations and healthcare providers had consensuses on emergency physician professionalism, we found that patients had no consensuses on this matter. Medical professionalism curricula should be designed with an understanding of each generation's values concerning professionalism. Future studies using qualitative methods across specialties, to assess definitions of medical professionalism in each generation, should be pursued.

Background: The 1995 Health Care Financing Administration (HCFA) guidelines stated that providers may only use the review of systems and past medical, family, social history in student documentation for billing purposes; therefore, many providers viewed the student documentation as an extraneous step and chose not to allow medical students to document patient visits. This workflow negatively affected medical student education in documentation skills. Although the negative impact on students' documentation skills is obvious, areas of deficits are unknown. Understanding the area of deficits will benefit future curriculums to prepare prospective resident physicians for proper documentation. We aimed to assess areas of deficits in documentation of fourth-year medical students according to HCFA billing guidelines., Methods: We conducted a prospective study of fourth-year medical students' simulated chart documentations at a United States medical school from May 2014 to May 2015. We evaluated students' simulated charts from an online learning tool using simulated cases for completeness according to HCFA guidelines and analyzed data using descriptive statistics., Results: We found that 98.9% (n = 90) of the charts were downcoded. Of these charts, 33.0% (n = 30) had incomplete history of present illness, 90.1% (n = 82) had incomplete review of systems, 73.6% (n = 67) had incomplete past medical, family, social history and 88.8% (n = 80) had incomplete physical exams., Conclusion: New curriculum should include billing guideline information and emphasize the completeness of charts according to acuity.

Background: The number of active opioid analgesic prescriptions has risen steadily, causing increases in nonmedical opioid use, addiction, and overdose. Insufficient focus on patient discharge instructions has contributed to lack of patient awareness regarding dangers of opioids. This study examines whether an educational Khan Academy-style animation discharge instruction on the dangers and safe usage of opioid analgesics elicits higher knowledge acquisition than current standard of care. Additionally, it measures the feasibility of implementing this video discharge instruction in the emergency department (ED)., Methods: Fifty-two English-speaking patients aged 18 years or older receiving an opioid prescription were enrolled in this study. Patients were randomized into 2 groups. The standard of care group received verbal instruction and an informational sheet, whereas the video animation group received a 6-minute video on proper usage of opioids in addition to standard of care. Video content was sourced from samhsa.gov and administered within the ED prior to discharge. Both groups received a 26-question test regarding the dangers and safe usage of opioids immediately after education. An unpaired t test compared knowledge acquisition between the 2 groups., Results: Fifty-four patients were approached, 52 patients enrolled; 27 in the standard group and 25 in the animation group. The standard of care group averaged 65% knowledge acquisition (16.8/26 correct), whereas the animation group averaged 82% acquisition (21.2/26 correct). The video animation significantly increased patient knowledge acquisition about opioid medications' risks and proper usage and disposal (P = .001)., Conclusion: It can be concluded that medical knowledge acquisition is improved in the video animation group compared with the current standard of care (P = .001). It can also be concluded that it is feasible to implement a novel media platform to educate patients receiving opioid analgesics in the ED (96.1%).

Objectives: Clinical research is often time-consuming and difficult to conduct in busy academic institutions. Previous studies have proposed methods to integrate undergraduate students as a means to increase research productivity. The authors aimed to describe the possibility to enhance emergency department research productivity at an academic emergency department in the United States, using undergraduate students in an Emergency Medicine Research Associates Program., Methods: The authors described the Emergency Medicine Research Associates Program curriculum and its implementation. We also conducted a retrospective study at a university-based emergency department from January 2005 to December 2014 to demonstrate the benefit of having an established Emergency Medicine Research Associates Program. The primary outcomes were number of Emergency Medicine Research Associates Program-related studies, number of enrolled patients, extramural/intramural funding, abstract presentations, and peer-reviewed publications. The authors analyzed the data using descriptive statistics., Results: Over the 10-year period, 110 Emergency Medicine Research Associates Program-assisted research studies were conducted, with research associates enrolling 46,219 patients. These studies yielded a total of 31 peer-reviewed publications and 77 abstract presentations (13 international, 27 national, 37 state/regional). The Emergency Medicine Research Associates Program-related studies were used as pilot studies to obtain US$1,751,036 in extramural grant funding and US$31,047 in intramural grant funding., Conclusion: The implementation of Emergency Medicine Research Associates Program can enhance emergency department clinical research productivity, and the inclusion of supplemental academic programs enhanced the undergraduate students' research experience., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Alcohol abuse is recognized as a significant contributor to injury. It is therefore essential that trauma centers implement screening and brief intervention (SBI) to identify patients who are problem drinkers. Although, the utility of SBI in identifying at-risk drinkers have been widely studied in level 1 trauma centers, few studies have been done in level 2 centers. This study evaluates the usefulness of SBI in identifying at-risk drinkers and to investigate the pattern of alcohol drinking among level 2 trauma patients., Methods: This is a retrospective study of a convenience sample of trauma patients participating in computerized alcohol screening, brief intervention, and referral to treatment (CASI) in an academic level 1 trauma center and a nearby suburban community hospital level 2 trauma center. CASI utilized Alcohol Use Disorders Identification Test (AUDIT) to screen patients. We compared the pattern of alcohol drinking, demographic factors, and readiness-to-change scores between those screened in a level 2 and 1 trauma center., Results: A total of 3,850 and 1,933 admitted trauma patients were screened in level 1 and 2 trauma centers respectively. There was no difference in mean age, gender, and language between the two centers. Of those screened, 10.2% of the level 1 and 14.4% of the level 2 trauma patients scored at-risk (AUDIT 8-19) (p < 0.005). Overall, 3.7% of the level 1 and 7.2% of the level 2 trauma patients had an AUDIT score consistent with dependency (AUDIT > =20) (p < 0.005). After adjusting for age, sex, education, and language, the odds of being a drinker at the level 2 center was two times of those at the level 1 center (p < 0.005). The odds of being an at-risk or dependent drinker at level 2 trauma center were 1.72 times of those at the level 1 center (p < 0.005)., Conclusions: Findings suggest that SBI is effective in identifying at-risk drinkers in level 2 trauma center. SBI was able to identify all drinkers, including at-risk and dependent drinkers at higher rates in level 2 versus level 1 trauma centers. Further studies to evaluate the effectiveness of SBI in altering drinking patterns among level 2 trauma patients are warranted.

We evaluated the effectiveness of text messaging versus email, as a delivery method to enhance knowledge retention of emergency medicine (EM) content in EM residents. We performed a multi-centered, prospective, randomized study consisting of postgraduate year (PGY) 1 to PGY 3 & 4 residents in three United States EM residency programs in 2014. Fifty eight residents were randomized into one delivery group: text message or email. Participants completed a 40 question pre- and post-intervention exam. Primary outcomes were the means of pre- and post-intervention exam score differences. Data were analyzed using descriptive statistics, paired t-test, and multiple linear regressions. No significant difference was found between the primary outcomes of the two groups (P=0.51). PGY 2 status had a significant negative effect (P=0.01) on predicted exam score difference. Neither delivery method enhanced resident knowledge retention. Further research on implementation of mobile technology in residency education is required., Competing Interests: No potential conflict of interest relevant to this article was reported.

Background: Previous studies of alcohol use have recognized several trends in consumption patterns among gender and age yet few have examined ethnic differences. This study examines the intra- and inter-ethnic differences in alcohol consumption among a population of patients seen in the emergency department., Methods: This is a cross-sectional study conducted in the emergency department in a large urban setting. Information on drinking behavior and ethnicity was collected using the Computerized Alcohol Screening and Brief Intervention (CASI) tool. We explored differences in drinking patterns using a multivariate multinomial logistic regression model., Results: We analyzed the drinking habits of 2,444 patients surveyed between November 2012 and May 2014. The results indicate that when compared to non-Hispanic whites, Asians have the lowest odds of drinking within normal limits or excessively, followed by other Latinos, and Mexicans. Age and gender consistently showed statistically significant associations with alcohol-use. The odds of drinking within normal limits or excessively are inversely associated with age and were lower among females. The predicted probabilities show a marked gender-specific difference in alcohol use both between and within ethnic/racial groups. They also highlight an age-related convergence in alcohol use between men and women within ethnic groups., Discussion: The results of this study show intra-racial/ethnic variability associated with sex and education. The highlighted differences within and between ethnic groups reinforce the need to use refined categories when examining alcohol use among minorities., Conclusion: The results of this study confirm some alcohol consumption trends among ethnic minorities observed in literature. It provides empirical evidence of the marked gender differences and highlights an age-related convergence for gender-specific alcohol use. Health-care personnel should be aware of these differences when screening and counseling.

Introduction: Emergency physicians are among the few specialists besides ophthalmologists who commonly perform ophthalmologic examinations using the slit lamp and other instruments. However, most medical schools in the United States do not require an ophthalmology rotation upon completion. Teaching procedural skills to medical students can be challenging due to limited resources and instructor availability. Our study assesses the effectiveness of a 40-minute hands-on teaching session on ophthalmologic examination for medical students using only two instructors and low-cost equipment., Methods: We performed an interventional study using a convenience sample of subjects. Pre- and post-workshop questionnaires on students' confidence in performing ophthalmologic examination were administered. We used a paired t-test and Wilcoxon rank test to analyze the data., Results: Of the 30 participants in the study, the mean age was 25 and the majority were first-year medical students. The students' confidence in performing every portion of the ophthalmologic exam increased significantly after the teaching session. We found that the average confidence level before the teaching session were below 2 on a 1-5 Likert scale (1 being the least confident). Confidence levels in using the slit lamp had the highest improvement among the skills taught (2.17 95% CI [1.84-2.49]). Students reported the least improvement in their confidence in assessing extraocular movements (0.73, 95% CI [0.30-1.71]) and examining pupillary function (0.73, 95% CI [0.42-1.04]). We observed the biggest difference in median confidence level in the use of the tonometer (4 with a p-value of <0.05)., Conclusion: A 40-minute structured hands-on training session can significantly improve students' confidence levels in ophthalmologic skills.

Background: Many suicidal and depressed patients are seen in emergency departments (EDs), whereas outpatient visits for depression remain high., Study Objective: The primary objective of the study is to determine a relationship between the incidence of suicidal and depressed patients presenting to EDs and the incidence of depressed patients presenting to outpatient clinics. The secondary objective is to analyze trends among suicidal patients., Methods: The National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey were screened to provide a sampling of ED and outpatient visits, respectively. Suicidal and depressed patients presenting to EDs were compared with depressed patients presenting to outpatient clinics. Subgroup analyses included age, sex, race/ethnicity, method of payment, regional variation, and urban verses rural distribution., Results: Emergency department visits for depression (1.16% of visits in 2002) and suicide attempts (0.51% of visits in 2002) remained stable over the years. Office visits for depression decreased from 3.14% of visits in 2002 to 2.65% of visits in 2008. Non-Latino whites had a higher percentage of ED visits for depression and suicide attempt and office visits for depression than other groups. The percentage of ED visits for suicide attempt resulting in hospital admission decreased by 2.06% per year., Conclusion: From 2002 to 2008, the percentage of outpatient visits for depression decreased, whereas ED visits for depression and suicide remained stable. When examined in the context of a decreasing prevalence of depression among adults, we conclude that an increasing percentage of the total patients with depression are being evaluated in the ED, vs outpatient clinics., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: The primary objective was to identify the most common reasons for intending to cut back on alcohol use, in emergency department (ED) and trauma patient populations. The secondary objective was to determine the association between reason to cut back on alcohol and education level., Methods: We conducted the study at a level one trauma center in California between 2008 and 2012. This was a retrospective analysis of data collected from computerized alcohol screening and intervention (CASI). We excluded patients who drank too little, and those whose scores were consistent with dependency (Alcohol Use Disorders Identification Test [AUDIT]>19). The CASI database includes the patient's age, gender, language, education level, an AUDIT score (1-40 scale), a readiness to change score (1-10), and the option to choose any of 10 "reasons to cut back" on their alcohol consumption., Results: From 10,537 patients, 1,202 met criteria for the study (848 ED, 354 trauma). Overall, the most common reasons cited for cutting back on alcohol were "To avoid health problems" (68.5%), "To avoid getting a DUI" (43.6%), "It could save me money" (42.0%), and "To avoid situations where I could get hurt" (41.0%). Trauma patients cited the following reasons significantly more than ED patients: "To avoid situations where I could get hurt" (46.3% versus 38.8%, respectively), "So I can be in control of my behavior" (40.7% versus 32.2%), and "My partner or spouse wants me to stop" (20.1% versus 15.0%). Additionally, those patients who cited "To avoid health problems" reported 1.2 points higher than average (p<0.001) on the 10-point readiness to change scale. Those who have completed some college or an associate degree cited "To avoid health problems" less often than high school graduates (odds ratio [OR] 0.45), while they cited "To avoid situations where I could get hurt" (OR 2.5) and "To avoid being in a car crash caused by alcohol use" (OR 3.8) more often than high school graduates., Conclusion: Health, injury, finances, and legal issues remain top concerns for patients, while trauma patients specifically had proportionately more concerns with situations where they could get hurt.

Introduction: The World Health Organization estimates that one million people die by suicide every year. Few studies have looked at factors associated with disposition in patients with chief complaints of depression, suicidal ideation (SI) and suicidal attempts (SA) who present to the emergency department (ED). Our objective was to assess individual determinants associated with ED disposition of patients in depressed patients presenting to the ED., Methods: We conducted a retrospective study using the National Hospital Ambulatory Medical Care Survey from 2006 to 2008. We used logistic regression to identify factors associated with discharge, in SI, SA and depression patients. Independent variables included socio-demographic information, vital signs, mode of arrival, insurance status, place of residence and concomitant psychiatric diagnosis., Results: Of the 93,030 subjects, 2,314 met the inclusion criteria (1,362 depression, 353 SI and 599 SA). Patients who arrived by ambulance were less likely to be discharged (odds ratio [OR] 0.63, 95% confidence interval [CI] 0.43-0.92). Hispanic patients and patients age 15 to 29 were likely to be discharged (OR 1.61, 95% CI 1.16-2.24 and OR 1.55, 95% CI 1.15-2.10 respectively). Insurance status and housing status were not significantly associated patient was being discharge from EDs., Conclusion: The Hispanic population had higher discharge rates, but the reasons are yet to be explored. Patients with SA and SI are discharged less frequently than those with depression, regardless of insurance type or housing status.

Chest pain is a common presenting symptom in the emergency department. After ruling out emergent causes, emergency physicians need to identify and manage less commonly encountered conditions. Pulmonary sequestration (PS) is a rare congenital condition involving pulmonary parenchyma. In PS, a portion of non-functional lung tissue receives systemic blood supply from an anomalous artery. While most individuals with PS present in early life with symptoms of difficulty feeding, cyanosis, and dyspnea, some present later with recurrent pneumonia, hemoptysis, or productive cough. In this report, we present a case of PS in an adult with acute onset pleuritic chest pain.

Background: The impact of alcohol use has been widely studied and is considered a public health issue. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends Screening and Brief Intervention and Referral Treatment (SBIRT), but the actual practice in the Emergency Department (ED) is constrained due to limited provider time and financial resources., Objectives: To assess the effectiveness of alcohol screening using Computerized Alcohol Screening and brief Intervention (CASI) compared to alcohol screening by triage nurse during Medical Screening Examination (MSE) in the ED., Methods: Retrospective review of CASI/MSE database from January 2008 through December 2009, collected in the tertiary, Level I Trauma ED was performed. Inclusion criteria included age ≥18 years, and completion of both the MSE and CASI. We analyzed the database by comparing age, gender, primary language (English, Spanish), and Alcohol Use Disorders Identification Test scores using McNemar's test., Results: Data were available for 5835 patients. CASI showed a significant increase in detection of at-risk drinking over MSE across all ages, gender, and primary language (p < 0.05). MSE found 2.5% at-risk drinkers and CASI found 11.5% at-risk drinkers (odds ratio [OR] 8.88, 95% confidence interval [CI] 6.89-11.61). Similar results were found in 18- to 20-year-old patients. MSE identified 1.8% at-risk drinkers and CASI reported 15.94% (OR 19.33, 95% CI 6.30-96.47)., Conclusion: CASI increased detection of at-risk alcohol drinkers compared with MSE across all ages, gender, and primary language. CASI is a promising innovative method for alcohol screening in the ED for the adult population, including under-aged drinkers., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Injuries and fatalities in adult drivers 18-65 years of age have decreased in recent years due to safer vehicles, enhanced medical policies, and implementation of injury prevention policies. However, adult drivers over 65 years of age are continuing to suffer from motor vehicle collision-related injuries and fatalities at a more constant rate. A number of physiological factors contribute to the deterioration in visual acuity, slower reaction speeds, and decreased awareness in older drivers. The objective of this study was to examine injury severity and fatality rates in older drivers compared to their younger counterparts in Orange County, California., Methods: This study used the Statewide Integrated Traffic Record System data for Orange County for the years 1998-2007. Drivers were categorized into 4 age groups: 25-64, 65-74, 75-84, and older than 85 years of age. Injury severity was assessed by the investigating officer., Results: Of the 197,814 drivers involved in motor vehicle collisions, 178,481 (90.2%) were in the 25-64 age group; 11,397 (5.8%) were 65-74; 6,592 (3.3%) were 75-84; and 1,344 drivers (0.7%) were over 85. Those aged 25-64 had the lowest fatality rate per 100,000 people, 2.5, whereas those 75-84 had the highest fatality rate, 4.9. The percent of crashes involving a left turn increased with age, and the percent that were stopped in the road decreases with age. Change in injury collision involvement ratio in the 3 younger age groups decreased by 26% to 32%, but decreased by 18% among drivers aged 85 years and older., Conclusion: The decrease in collision fatalities was greater in the 25-64-year-old group compared to the older adult population. This disparity highlights the need for further injury prevention efforts for older drivers.

Objective: The objective of this study was to assess drinking patterns of Spanish-speaking patients using a bilingual computerized alcohol screening and brief intervention (CASI) tablet computer equipped with the Alcohol Use Disorders Identification Test (AUDIT)., Methods: This retrospective study was conducted in a tertiary university hospital emergency department (ED) between 2006 and 2010. Data from 1816 Spanish-speaking ED patients were analyzed using descriptive statistics, the chi-square test for independence, and the Kruskal-Wallis rank sum test for comparisons using quantitative variables., Results: Overall, 15% of Spanish-speaking patients were at-risk drinkers, and 5% had an AUDIT score consistent with alcohol dependency (≥20). A higher percentage of Spanish-speaking males than females were at-risk drinkers or likely dependent. Spanish-speaking males exhibited higher frequency of drinking days per week and higher number of drinks per day compared with females. Among older patients, nondrinking behavior increased and at-risk drinkers decreased. The majority of males and females were ready to change their behavior after the CASI intervention; 61% and 69%, respectively, scored 8-10., Conclusions: This study indicated that CASI was an effective tool for detecting at-risk and likely dependent drinking behavior in Spanish-speaking ED patients. The majority of patients were ready to change their drinking behavior. More alcohol screening and brief intervention tools should be tested and become readily accessible for Spanish-speaking patients.