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ABSTRACT Nicotine is a major alkaloid in tobacco plants and an addictive component of tobacco products. Some bacteria grow on tobacco plants and have evolved the ability to metabolize nicotine. As part of our microbiology teaching lab, we used minimal media with nicotine as the sole carbon source to isolate nicotine-degrading bacteria from tobacco leaves and commercial tobacco products. Students then identified these bacteria using 16S rRNA sequencing and biochemical assays and assessed their ability to catabolize nicotine using UV spectroscopy. Students were able to isolate and identify 14 distinct genera that can metabolize nicotine. This modification of the commonly used unknown project gave students firsthand experience using selective media, and students got the opportunity to work with largely uncharacterized microbes with a real-world connection to public health, which increased student engagement. Students had the opportunity to think critically about why nicotine-degrading microorganisms associate with tobacco plants, why there are different bacteria that use the same specialized metabolism, and how these organisms are isolated from other bacteria using selective media.

Nicotine is a major alkaloid in tobacco plants and an addictive component of tobacco products. Some bacteria grow on tobacco plants and have evolved the ability to metabolize nicotine. As part of our microbiology teaching lab, we used minimal media with nicotine as the sole carbon source to isolate nicotine-degrading bacteria from tobacco leaves and commercial tobacco products. Students then identified these bacteria using 16S rRNA sequencing and biochemical assays and assessed their ability to catabolize nicotine using UV spectroscopy. Students were able to isolate and identify 14 distinct genera that can metabolize nicotine. This modification of the commonly used unknown project gave students firsthand experience using selective media, and students got the opportunity to work with largely uncharacterized microbes with a real-world connection to public health, which increased student engagement. Students had the opportunity to think critically about why nicotine-degrading microorganisms associate with tobacco plants, why there are different bacteria that use the same specialized metabolism, and how these organisms are isolated from other bacteria using selective media., Competing Interests: The authors declare no conflict of interest.

Objective: Cardiac arrest leads to an array of metabolic disturbances. We aimed to investigate the association between prehospital blood glucose levels (BGLs) and rates of return of spontaneous circulation (ROSC) in non-traumatic out-of-hospital cardiac arrests (OHCAs)., Methods: A retrospective analysis of adult non-traumatic OHCAs within Kalamazoo County, MI, from January 2018 to May 2020 using the Michigan Emergency Medical Services Information System database was performed. Demographic data, Utstein variables, and BGLs (hypoglycemia < 70 mg/dL, euglycemia 70-120 mg/dL, and hyperglycemia >120 mg/dL) were abstracted. Chi-square and Wilcoxon rank sum tests were used to evaluate the relationship between BGL and ROSC., Results: In total, 314 patients met the inclusion criteria. The mean age was 62.9 years. ROSC was achieved in 147 (46.8%) patients. Fifty (15.9%), 75 (23.9%), and 189 (60.2%) patients were hypoglycemic, euglycemic, and hyperglycemic, respectively. An association was found between the glycemic group and ROSC (P < .0001), with an estimated odds of ROSC being 77% lower (95% confidence interval, 46%-90%) for hypoglycemic than euglycemic or hyperglycemic patients. The point difference between median ROSC-yes BGL (median [interquartile range] = 160 mg/dL [110-225 mg/dL]) was 33 mg/dL (95% CI, 13-51 mg/dL) greater than the ROSC-no group (median [interquartile range] = 127 mg/dL [75-190 mg/dL], P = .001)., Conclusion: Non-traumatic OHCA patients achieving ROSC had a significantly higher prehospital BGL than the ROSC-no group. Further study is warranted to investigate the role intra-arrest BGL may have as a prognostic marker for ROSC., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest or financial ties to disclose. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., (Copyright © 2023 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)

Context: EMS providers frequently encounter patients in end-of-life situations. These situations can become ethically challenging depending on the nature of the event, availability of advance directives, and overall understanding of the situation by the patient and caregivers. This is particularly true for patients who are enrolled in Hospice, a specific form of end-of-life care available to patients with a terminal illness and expected lifespan of less than six months., Objectives: This study aimed to survey the state of Michigan's EMS providers regarding encounters with hospice patients to better understand challenges caring for this population and to identify any need for additional education., Methods: An anonymous electronic survey was distributed via agency medical directors and a statewide listserv to all licensed EMS providers. Responses were collected via RedCap. Descriptive statistics were calculated., Results: A total of 706 responses were received. Most responses were from paramedics (55%) or EMTs (34%). 96% indicated having at least one encounter with a hospice patient and 66% had greater than 10 encounters. Only 24% had received formal education on the care of hospice patients. A high percentage (86%) indicated interest in additional training in this area. Challenges identified among providers were inaccessible advance directives (72%), pressure from family for more aggressive treatment (61%), and difficulty contacting hospice personnel (48%)., Conclusion: Educational gaps may be narrowed with additional end-of-life specific curricular components, with EMS providers expressing a strong desire for such training., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective Several studies have examined the impact of mechanical cardiopulmonary resuscitation (CPR) devices among multi-jurisdictional emergency medical services (EMS) systems; however, the variability across such systems can inject bias and confounding variables. We focused our investigation on the effect of introducing the Lund University Cardiac Assist System 2 (LUCAS-2) into a single basic life support (BLS) fire department first response jurisdiction served by a single private advanced life support (ALS) agency, hypothesizing that the implementation of the device would increase prehospital return of spontaneous circulation (ROSC) rates as compared with manual CPR.  Methods A retrospective observational analysis of adult non-traumatic prehospital cardiac arrest ALS agency records was conducted. Descriptive statistics were computed, and logistic regression was used to assess the impact of CPR method, response time, age, gender, CPR initiator, witnessed status, automated external defibrillator (AED) initiator, and presence of an initial shockable rhythm on ROSC rates. A Chi-square analysis was used to compare ROSC rates among compression modalities both before and after the implementation of LUCAS-2 on July 1, 2011.  Results From an initial dataset of 857 cardiac arrest records, only 264 (74 pre-LUCAS period, 190 LUCAS-2 period) met inclusion criteria for the primary objective. The ROSC rates were 29.7% (22/74) and 29.5% (56/190), respectively, for manual-only and LUCAS-assisted CPR (p=0.9673). Logistic regression revealed a significant association between ROSC and two of the independent variables: arrest witnessed (OR 3.104; 95% CI 1.896-5.081; p<0.0001) and initial rhythm shockable (OR 2.785; 95% CI 1.492-5.199; p<0.0013).  Conclusions Analyses support the null hypothesis that there is no difference in prehospital ROSC rates among adult non-traumatic cardiac arrest patients when comparing mechanical-assisted and manual-only CPR. These results are consistent with other larger multi-jurisdictional mechanical CPR studies. Systems with limited personnel might consider augmenting their resuscitations with a mechanical CPR device, although cost and system design should be factored into the decision. Secondary analysis of independent variables suggests that prehospital cardiac arrest patients with a witnessed arrest or an initial rhythm that is shockable have a higher likelihood of attaining ROSC. The power of our primary objective was limited by the sample size. Additionally, we were not able to adequately assess the quality of CPR among the two comparison groups with a lack of consistent end-tidal carbon dioxide (EtCO2) data. ., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Mastenbrook et al.)

Background Rapid sequence intubation (RSI) is a multistep process that emergency physicians commonly perform. Unfortunately, there is little published in the graduate medical education literature regarding the use of checklists for RSI education. Methods We developed a pre-intubation checklist for RSI preparation and evaluated emergency medicine residents' use of it. We developed the checklist using a three-round modified Delphi process among a group of emergency medicine faculty physicians within our institution. Over a three-year period, residents were randomized into two groups: a "checklist group" and a "without-checklist group." Residents were then evaluated for RSI critical step completion in a simulated critically ill patient by two independent study investigators. Inter-rater reliability kappa scores were calculated. Following completion of the scenario, residents in both groups were asked to complete an anonymous survey. Both groups had access to the checklist at the time of the survey. The survey was used to determine if they found the checklist helpful. Odds ratios with p-values, at an alpha of 0.05 for significance, were computed for checklist items comparing the checklist and without-checklist groups. Data analysis was performed using SAS software (SAS, Cary, NC v 9.4). This study was approved by the authors' Institutional Review Board. Results Each assessment was completed by two investigators. Inter-rater reliability was substantial (κ=0.79). Residents having access to the checklist were more likely to verbalize a critical step with a p-value of < 0.0001 and an odds ratio of 2.17 (95% CI: 1.48, 3.19). The checklist group normalized vital signs prior to intubation in 25/28 (89%, 95% CI: 72.81, 96.29) versus only 6/29 (21%, 95% CI: 9.85, 38.39) with a p-value of <0.0001 in the without-checklist group. The checklist group evaluated for difficult laryngoscopy 26/28 (93%, 95% CI: 77.36, 98.02) versus only 21/29 (72%, CI 95% 54.28, 85.30) with p=0.0223 in the without-checklist group. All of the surveyed residents indicated that the checklist would be helpful for future use in the ED. Conclusion This RSI checklist improved adherence to preparatory steps of RSI. Utilizing a checklist increased evaluation for a difficult airway and normalizing vital signs. Residents found the checklist helpful for ED use., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Pazderka et al.)

Objectives: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted., Methods: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence., Results: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30)., Conclusion: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2021, Mastenbrook et al.)

Smoke inhalation is the most common cause of acute cyanide poisoning in the developed world. Hydroxocobalamin is an antidote for cyanide poisoning. There is little published about human intraosseous antidote administration. We present a case of intraosseous hydroxocobalamin administration in an adult smoke inhalation victim, found in cardiac arrest inside her burning manufactured home. Return of spontaneous circulation was achieved after 20 min of cardiopulmonary resuscitation. Five grams of hydroxocobalamin were subsequently given intraosseously. On hospital arrival, patient was found to have a respiratory-metabolic acidosis. She had red-coloured urine without haematuria, a known sequela of hydroxocobalamin administration. Patient's neurological status deteriorated, and she died 4 days after admission. This case highlights that intraosseously administered hydroxocobalamin seems to adequately flow into the marrow cavity and enter the circulatory system despite the non-compressible glass antidote vial. This appears to be only the second reported human case of intraosseous hydroxocobalamin administration., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: There are several complications associated with automated mechanical CPR (AM-CPR), including tension pneumothoraces. The incidence of these complications and the risk factors for their development remain poorly characterized. Tension hemopneumothorax is a previously unreported complication of AM-CPR. The authors present a case of a suspected tension hemopneumothorax that developed during the use of an automated mechanical CPR device. Case Description: A 67 year-old woman with a history of COPD and CABG was observed by an off-duty firefighter to be slumped behind the wheel of an ice cream truck that drifted off the road at a low rate of speed and was stopped by a wooden fence, resulting in only minor paint scratches. The patient was found to be in cardiac arrest with a shockable rhythm. No signs of trauma were noted, and equal bilateral breath sounds were present with BVM ventilation. After 13 minutes of manual CPR, fire department personnel applied their Defibtech LifeLine ARM mechanical CPR device to the patient. During resuscitation, the device had to be repositioned twice due to rightward piston migration off of the sternum. Seven minutes after AM-CPR application, the patient had absent right-sided breath sounds and ventilations were more difficult. Needle decompression was performed with an audible release of air. A chest tube was placed by an EMS physician and roughly 400 mL of blood were immediately returned. At the next 2-minute pulse check, ROSC was noted, and the patient was transported to the hospital. She had an ischemic EKG and elevated troponin. Chest CT showed emphysematous lungs, bilateral rib fractures, and a small right-sided pneumothorax. Despite aggressive measures, the patient's condition gradually worsened, and she died 48 hours after presentation. Discussion/Conclusion: Migration of AM-CPR device pistons may contribute to the development of iatrogenic injuries such as hemopneumothoraces. Patients with underlying lung disease may be at a higher risk of developing pneumothoraces or hemopneumothoraces during the course of AM-CPR. Awareness of these potential complications may aid first responders by improving vigilance of piston location and by providing quicker recognition of iatrogenic injuries that need immediate attention to improve the opportunity for ROSC.

Background: Neurologic complications of varicella zoster virus (VZV) reactivation can be associated with considerable mortality and morbidity. Aseptic meningitis associated with VZV infection is rare, occurring in 0.5% of immunocompetent individuals. One third of VZV-related neurologic disease occurs without the classic herpes zoster exanthema, making early recognition more difficult., Case Report: A 60-year-old man presented to the emergency department with chest pain and impaired memory that he attributed to a transient ischemic attack as suggested by an urgent care facility 1 day earlier. He suffered a seizure while in the emergency department and was admitted to the intensive care unit. A computed tomography scan of his head and a magnetic resonance imaging scan were both negative for acute findings. An abnormal electroencephalogram consistent with an encephalopathy together with his new-onset seizure triggered a lumbar puncture that was positive for VZV. He was placed on acyclovir and was discharged from the hospital 5 days after admission. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The typical presentation of a VZV central nervous system infection occurs with a sudden onset of fever, headache, nuchal rigidity, and focal neurologic signs. Our patient's recent impaired memory and subsequent seizure were likely manifestations of the developing VZV meningoencephalitis, while his chest pain may have correlated with subsequent development of a vesicular rash. Seizures are encountered in 11% of patients with VZV central nervous system infection, and VZV has recently been associated with cerebral vasculopathy. Awareness of alternative presentations for herpes zoster and meningitis is important in cases without classic symptoms to enable diagnosis and prevent delays in treatment., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: The number of mass casualty incidents (MCIs) has been steadily increasing. High-priority MCI patient outcomes are highly dependent on rapid identification, treatment, and transport. Although there are several methods used to mark patients for rapid extraction, most current methods utilize low-profile tags, with no gold standard. This study examines if the use of a vertical cue, a triage flag, to identify high priority MCI patients results in faster extraction times than those with a wrist triage tag alone., Methods: A prospective randomized crossover study was conducted with medical students trained in basic disaster life support, who completed 2 extraction simulations. Two fields were each arranged with 32 randomly placed, pretriaged manikins (10 red, 17 yellow, 5 black). The manikins were marked with either triage tags alone or with triage tags and flags. The total time elapsed for participants to report all high-priority manikin triage tag numbers was recorded., Results: Eighty-two participants completed both simulations. The average completion time for the "tags-only" simulation was 94.5 seconds (±16.4 seconds) compared to 70.7 seconds (±13.2 seconds) for the flags and tags simulation. This corresponds to an average decrease of 23.8 seconds ( P  < 0.0001), or a 25.2% reduction in time., Conclusion: Using a vertical cue decreased the time required to identify high-priority patients. This suggests that a rapidly deployable and visually apparent triage marker may allow faster identification and extraction of patients across a field of victims with varying injury severities than a flat horizontal triage tag, thereby potentially improving patient outcomes., Competing Interests: The authors report no conflicts of interest, financial or otherwise., (© 2020 The Authors. JACEP Open published by Wiley Periodicals LLC on behalf of the American College of Emergency Physicians.)

Background: Endotracheal intubation (ETI) is used to effectively manage a patient's airway. Failure of ETI may lead to ineffective ventilation or oxygenation, potentially causing organ damage and eventually death. Approximately 8% of ETIs are difficult and 1% are unsuccessful. Tools and techniques to successfully obtain airway access are essential., Case Report: A patient with chronic obstructive pulmonary disease presented to the emergency department in acute respiratory distress. Noninvasive positive pressure ventilation was unsuccessful in improving the patient's tidal volume and work of breathing. The patient was unable to be intubated by conventional techniques because of a mass obstructing the view of her vocal cords. A cricothyrotomy was considered, but not initially performed because of her distorted anatomy. After multiple intubation attempts from several different physicians, the patient was successfully intubated with the aid of a suction Yankauer, which was used to move the mass peripherally and further served as a conduit through which a bougie was passed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The risk for complications rises with each intubation attempt. While there are a variety of tools and aids that can be used to assist in difficult intubations, rapid airway access is essential, and common tools do not always work. We hope that knowledge of this novel, yet simple and effective technique will help physicians successfully intubate patients with distorted oropharyngeal anatomy who cannot be intubated using conventional methods., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Herpes zoster (zoster) also commonly known as "shingles," occurs following re-activation of the varicella zoster virus. It contributes a large cost burden to the U.S. health care system, with an estimated 1 million cases costing $1 billion annually. The current gold standard treatment is acyclovir, which limits viral replication. However, acyclovir has been reported to cause neurotoxicity in patients with acute or chronic kidney disease., Case Report: This case presents an occurrence of acyclovir-induced toxic encephalopathy in a patient with normal renal function. A 63-year-old male presented to the emergency department with ataxia, tremors, fluctuating aphasia, confusion, agitation, and fatigue. Results of imaging, lumbar puncture, and laboratory studies directed clinicians toward acyclovir toxicity, despite a normal creatinine level. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians will likely be the first point of contact in the health care system following the onset of acyclovir toxicity. With an increasing incidence of zoster disease, such atypical toxic manifestations may increase. Early recognition is important to avoid permanent neurologic compromise., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine if a common air medical curriculum exists among Accreditation Council for Graduate Medical Education (ACGME) emergency medicine (EM) residencies., Methods: Institutional review board exemption was obtained. A cross-sectional survey study design was used. All ACGME-approved EM residencies as of February 2013 were identified, and the program directors were e-mailed a 3-question survey. Descriptive statistics were calculated for each response, and a response bias analysis was completed., Results: All 160 ACGME EM residencies were contacted by e-mail. One hundred six (66%) programs responded. Sixty-nine (65%) of the respondents offered an air medical experience. Only 25 of the 69 (36%) stated that they had a formal air medical curriculum, and 15 programs provided a copy of their curriculum. Protocol education was present in 80% of programs. Safety training was present in 60% of the programs. Financial education was present in 7% of programs. There was no statistically significant difference between responders and nonresponders except for residency class size., Conclusion: After 30 years of published articles and position statements calling for standardized air medical resident crew member training, there is still no standardized training program among emergency medicine residencies., (Copyright © 2015 Air Medical Journal Associates. Published by Elsevier Inc. All rights reserved.)