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The high-profile deaths of Eric Garner and George Floyd have led to legislative actions banning the use of neck restraints by law enforcement officers. The debates behind these policy changes are i...

Objectives Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. Methods From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT) scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared to the adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a >50% stenosis without another OHCA cause. Results SDCT scans occurred within 1.9 ± 1.0 h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentially identifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n = 6); pneumothorax or thoracic organ laceration (n = 8); and mediastinal, pericardial, or vascular hemorrhage (n = 3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatments resulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. Conclusions This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

The police must on occasion use physical force and weapons in order to apprehend and control subjects and fulfil the police function. It is inevitable that some of these interactions will result in injuries to both subjects and officers, with a range of both tangible and intangible harms and costs. It is therefore important to study injuries related to the use of force with an eye toward identifying opportunities to minimize injury and reduce the harms and costs. Injuries to both subjects and officers were examined in a sample of more than 10,000 use of force incidents drawn from 81 agencies located in 8 states. In addition to describing injury rates across a broad spectrum of situational and agency characteristics, we present multilevel logistic regression models predicting subject and officer injury. Among key findings, we report that the likelihood of injury for both subjects and officers is lower when force incidents end quickly and with the minimal necessary superior level of force relative to subject resistance, and higher for both subjects and officers when subjects flee. At the agency level, we find that the likelihood of injury varies by agency size and type. Finally, we explored possible higher-level variation and found that agencies in the sample from Midwestern states (primarily Wisconsin) have substantially lower injury rates that appear to be associated with their less frequent use of weapons and greater reliance on low-level physical force tactics, as compared to agencies in the sample from Western and other states.

To test the diagnostic accuracy of ECG-gated coronary computed tomography angiography (CCTA) to detect coronary artery disease (CAD) among survivors of out-of-hospital circulatory arrest (OHCA).We prospectively studied head-to-pelvis computed tomography (CT) scanning (6 h from hospital arrival) in OHCA survivors. This sub-study tested the primary outcome of CCTA diagnostic accuracy to identify obstructive CAD (≥50% stenosis) compared to clinically-ordered invasive coronary angiography. Patients were not optimized with beta receptor blockade or nitroglycerin. Secondary analyses included CCTA accuracy for CAD in major coronary arteries, obstructive disease at ≥70% stenosis threshold, and where non-evaluable CCTA segments were considered either obstructive or non-obstructive.Of the 104 enrolled OHCA survivors, 28 (27%) received both CT and invasive angiography in this sub study. All CCTA studies were evaluable although 49/346 (14%) individual coronary segments were unevaluable, primarily due to being too small to evaluate (65%). Patient-level diagnostic accuracy for the ≥50% stenosis threshold was high at 0.93 (95% CI 0.77-0.98) with a specificity of 1.0 (95% CI 0.8-1.0), sensitivity of 0.85 (95%CI 0.58-0.96), negative predictive value of 0.88 (95% CI 0.66-0.97) and positive predictive value of 1.0 (0.74-1.0). When non-evaluable segments were considered obstructive, the sensitivity rose to 0.92 (95% CI 0.67-0.99) with lower specificity of 0.27 (95% CI 0.11-0.52).Early CCTA of OHCA survivors has high diagnostic accuracy to detect obstructive coronary artery disease. However, the number of non-diagnostic coronary segments is high suggesting further CCTA refinement is needed, such as the pre-CCTA use of nitroglycerin.NCT03111043 https://clinicaltrials.gov/ct2/show/record/NCT03111043.

Background As efforts continue to diversify the physician workforce so that it better matches the patient population, the number of medical students with disabilities will increase. U.S. medical schools and emergency medicine (EM) clerkships should be prepared to provide full and meaningful access to learners with disabilities. Methods We created a novel means of providing access to a senior medical student with a mobility disability (secondary to a cervical spinal cord injury) to participate in a fourth-year EM clerkship. We hired four second-year medical students as intermediaries to perform senior medical student-directed physical examination maneuvers, during his 15 required 8-hour emergency department shifts. The senior medical student dictated his documentation using Dragon Natural Speaking (Nuance Communications, 2015) voice recognition software. Results The senior medical student successfully completed the required clinical clerkship and earned a honors grade for his work. Both the senior medical student and the second-year medical student intermediaries gave positive feedback about the experience. Conclusions Given the significant prevalence of disability among medical students in U.S. medical schools, medical educators should provide greater access to students with disabilities and opportunities for advanced education for all learners by creating innovative clinical curriculum. The authors recommend the student intermediary model for senior medical students with physical disabilities in required clinical clerkships.

Background As undergraduate medical students are acculturated into clinical practice, they develop a set of refined professional values that impact their decision making. We aimed to use students' reflective narratives on ethical dilemmas to identify how students experience moral distress while working in the emergency department (ED) to better understand how to support them in the development of their own agency to act ethically. Methods Students rotating in our emergency medicine clerkship are required to submit an essay describing an ethical dilemma they encountered. We selected a random sample of these reflective pieces from the 2015 and 2016 academic years and used an exploratory qualitative thematic analytic approach to identify frequently recurring themes. This process was continued until thematic sufficiency was reached. Results Two-hundred essays were coded, and seven unique themes were identified. The moral distress students described in reflective writing narratives stemmed from patient-provider discord, uncertainty, and social injustices. In each case, students were expressing the cognitive dissonance they experienced as they began to reconcile the difference between their perceptions of optimal patient care and the actual care delivered to the patient. Conclusion Understanding medical students' cognitive dissonance in the ED will help educators support their students as they negotiate the differences between preferences and principles while being acculturated into clinical practice. Future work should develop specific interventions to promote educator understanding of learners' moral distress and to develop novel models of support for learners.

Aim To review data for non-invasive imaging in the diagnosis of non-traumatic out-of-hospital cardiac arrest (OHCA). Data sources We searched MEDLINE, EMBASE, Cochrane library, and clinicaltrials.gov databases from inception to January 2017 for studies utilizing non-invasive imaging to identify potential causes of OHCA [computed tomography (CT), ultrasound including echocardiography, and magnetic resonance (MRI)]. Study selection Inclusion criteria were the following: (1) randomized control trials, cohort studies or observational studies; (2) contained a population ≥18 years old with non-traumatic OHCA who underwent diagnostic imaging with CT, MRI, echocardiography, or abdominal ultrasound; (3) imaging was obtained for diagnostic purposes; (4) patients were alive or were undergoing cardiopulmonary resuscitation at the time of imaging; (5) contained potential causes of OHCA. Endpoints studied were the number of potential OHCA causes identified, diagnostic accuracy measures (sensitivity, specificity, positive and negative predictive values), and diagnostic utility (number of imaging findings with reported changes in clinical management). Results Of the total 5722 studies identified, 17 (0.3%) met inclusion criteria. The majority of studies assessed the utility of CT in OHCA (n = 10), and potential causes of OHCA were found in 8–54% of patients following head, abdominal and/or chest CT. Only 1/17 (6%) studies reported diagnostic accuracy measures, and 9/17 (53%) studies included a time to imaging criteria within 24 h. Conclusion Although non-invasive imaging is commonly performed in patients after OHCA, its diagnostic utility remains poorly characterized. Prospective studies are needed for appropriate imaging selection and their potential impact on treatment and outcome.

Objectives Spitting is an occupational hazard of police work with increased risk due to the COVID-19 pandemic. We sought to calculate the prevalence of spitting on police officers in use of force incidents, as well as the demographic and situational factors associated with spitting. Methods Data on spitting were compiled from more than 10,000 use of force incidents occurring at 81 agencies in eight different states in the US. Results Spitting occurred in 3.6% of cases. Female and younger subjects and those using drugs and/or alcohol are more likely to spit on officers. Spitting is more likely to occur in incidents of longer duration, when officers use less force relative to subject resistance, when subjects are assaultive or engage in self-harm, and when subjects are hobbled. Conclusions Spitting on officers is common and may now constitute a significant work hazard. Implications for police practice are discussed.

Use of excessive force (UOEF) is an important and controversial topic but little is known about how injury severity is related to allegations of UOEF. We hypothesized that such complaints would be associated with more significant traumatic injuries. Emergency department records were searched for all individuals making UOEF complaints against an urban police department from 2010 to 2012. Demographic, diagnosis, and other medical data, including Injury Severity Score, were obtained. From police records, force used, suspect resistance and threat, and other call data were obtained. The same data were collected for a control group randomly chosen from all use-of-force events identified during the study period. Of the 235 complaints filed, 42 (18%) subjects had medical evaluation. The control group was significantly younger and more likely to be male; there was no significant difference in race or income. Major injuries were infrequent. No significant difference was found in Injury Severity Score or other medical variables between the 2 groups. Among the law enforcement variables, the only significant difference was a higher likelihood of psychiatric-related calls in the control group. The majority of patients alleging UOEF did not require immediate medical attention, and we found no relationship between injury severity and UOEF complaints.

Incarcerated individuals represent a significant proportion of the US population and face unique healthcare challenges. Scarce articles have been published about emergency department (ED) care of these patients. We studied the ED visits from one urban jail to better describe this population.A cohort study design was used, identifying patients who were sent to the ED from a city jail in 2015. Demographics, triage information, length of stay, number of studies, billing codes, diagnoses, and disposition data were collected. These were compared to the overall ED patient population in the same year.868 ED visits by jail patients occurred, representing 1.3% of the ED census. Compared to the general population, incarcerated patients were younger (32.1 years vs. 44.0 years, p .01), healthier based on Elixhauser comorbidity scores (0.71 vs. 0.98, p .01), and had lower admission rates (11.29% vs. 21.54%, p .01). An abnormal vital sign was noted in 25% of incarcerated patients. Laboratory (61% vs. 57%, p .02) and radiologic (63% vs 45%, p .001) testing was more frequent for inmates and length of stay was longer (271 vs. 225 min, p .01).ED visits from jail were common, involving a relatively young and healthy population with a low incidence of abnormal vital signs and admission. Given the high costs associated with ED care and the medical resources available at some jails, further study should evaluate if increased jail medical capabilities could improve care and decrease costs by decreasing ED visits.

Author(s): Brown, Alisha Emily Cutler; Jauregui, Joshua; Ilgen, Jonathan S.; Riddell, Jeff; Schaad, Douglas; Strote, Jared; Shandro, Jamie | Abstract: Introduction: Social media is a novel medium to host reflective writing (RW) essays, yet its impact on depth of students’ reflection is unknown. Shifting reflection on to social platforms offers opportunities for students to engage with their community, yet may leave them feeling vulnerable and less willing to reflect deeply. Using sociomateriality as a conceptual framework, we aimed to compare the depth of reflection in RW samples submitted by medical students in a traditional private essay format to those posted on a secure social media platform.Methods: Fourth-year medical students submitted a RW essay as part of their emergency medicine clerkship, either in a private essay format (academic year [AY] 2015) or onto a closed, password-protected social media website (AY 2016). Five raters used the Reflection Evaluation for Learners’ Enhanced Competencies Tool (REFLECT) to score 122 de-identified RW samples (55 private, 67 social media). Average scores on two platforms were compared. Students were also surveyed regarding their comfort with the social media experience.Results: There were no differences in average composite REFLECT scores between the private essay (14.1, 95% confidence interval [CI], 12.0-16.2) and social media (13.7 95% CI, 11.4-16.0) submission formats (t [1,120] = 0.94, p = 0.35). Of the 73% of students who responded to the survey, 72% reported feeling comfortable sharing their personal reflections with peers, and 84% felt comfortable commenting on peers’ writing.Conclusion: Students generally felt comfortable using social media for shared reflection. The depth of reflection in RW essays was similar between the private and social media submission formats.

Background Emergency physicians encounter patient concerns of police use of excessive force (UOEF). However, unlike other forms of potential assault, there are no guidelines for documentation of these encounters. Our objective was to examine the adequacy of emergency department documentation of injuries from police encounters where formal complaints of UOEF were later filed with the law enforcement agency. Methods A retrospective cohort design was used, identifying all citizen complaints of UOEF to a single police department in a 3-year period. Emergency department records associated with these encounters were then accessed and evaluated using standards for other forms of abuse and assault. Results Of 235 complaints, 33 (14.0%) presented to the emergency department within 7 days of the incident and were able to provide a history. For these subjects, 13 charts (39.4%) contained 3 or more of the 4 components thought to be necessary in cases of potential assault, and 11 (33.3%) contained documentation that should not be present: the guilt of the patient, subjective terminology by the provider, and/or documentation of law enforcement's description of the events as the only factual history. Of the total, 14 charts (42.4%) documented the patient's concern for UOEF. Conclusions In this limited study, documentation of encounters where patients later filed a formal complaint of UOEF by law enforcement did not meet the standards for other forms of assault and abuse, having the potential to impact both the citizens and officers involved. Further study is necessary to identify the best practice guidelines for emergency physicians when they encounter patients injured in police encounters.

Background Pressure cookers are common kitchen appliances with a good safety record and only rare associated explosions. Case Report Here we present a case of unintentional pressure cooker explosion leading to polytrauma with injuries including pneumothorax, intracranial hemorrhage, open skull fracture, and multiple facial fractures. Why Should an Emergency Physician Be Aware of This? Extreme forces and temperatures are involved in pressure cooking. Given the infrequent but real risk of mechanical failure and the increasing use of such devices to create intentional explosions, emergency physicians should be aware of the potentially significant blast injuries that can be associated with them.

Being a 75-year-old emergency physician at the start of a viral pandemic skewed toward older victims is something. But despite pleas from the chair and many others for him to take a leave, the most senior of our faculty by at least a decade continued to work; he even volunteered to do extra shifts if some preferred to stay home.

Objectives Many police officers receive medical training for limited assessments and interventions. In most situations where medical issues arise, however, emergency medical services (EMS) are called for evaluation, treatment, and transport. Given the limited amount of information about such encounters we examined officer calls for EMS help in a single system to better describe these encounters. Methods Requests for medical help from a fire-based EMS system by police in a moderate-sized city in 2014 and 2015 were identified. In this system, fire department resources are requested for initial evaluations of any medical complaint. Data were extracted from fire records including disposition, transportation from scene, type of injury or illness, and vital signs. Data analysis used descriptive statistics. Results 4,792 calls were made, representing 2.2% of all police-citizen interactions and 4.2% of all EMS calls. A total of 61.2% of calls resulted in transport to hospital. Of those, 5.6% required fire-based advanced life support; the remainder were transported by private basic life support ambulance or non-medical means. Most requests were for trauma (51.4%), followed by medical (24.7%), drug/alcohol use (17.1%), and psychiatric (6.7%). Vital signs tended to be within normal limits including 72.7% of pulses, 65.1% of systolic blood pressures, and 90.5% of respiratory rates. Conclusion Requests for EMS assistance from police were common. Most calls involved patients with normal vital signs who did not require advanced life support transport. Further research is needed to identify situations where increased officer training and change in protocols could potentially change EMS response models and improve efficiency of the system.

Author(s): Jauregui, Joshua; Bright, Steven; Strote, Jared; Shandro, Jamie | Abstract: Introduction: Peer-assisted learning (PAL) is the development of new knowledge and skills through active learning support from peers. Benefits of PAL include introduction of teaching skills for students, creation of a safe learning environment, and efficient use of faculty time. We present a novel approach to PAL in an emergency medicine (EM) clerkship curriculum using an inexpensive, tablet-based app for students to cooperatively present and perform low-fidelity, case-based simulations that promotes accountability for student learning, fosters teaching skills, and economizes faculty presence. Methods: We developed five clinical cases in the style of EM oral boards. Fourth-year medical students were each assigned a unique case one week in advance. Students also received an instructional document and a video example detailing how to lead a case. During the 90-minute session, students were placed in small groups of 3-5 students and rotated between facilitating their assigned cases and participating as a team for the cases presented by their fellow students. Cases were supplemented with a half-mannequin that can be intubated, airway supplies, and a tablet-based app (SimMon, $22.99) to remotely display and update vital signs. One faculty member rotated among groups to provide additional assistance and clarification. Three EM faculty members iteratively developed a survey, based on the literature and pilot tested it with fourth-year medical students, to evaluate the course. Results: 135 medical students completed the course and course evaluation survey. Learner satisfaction was high with an overall score of 4.6 on a 5-point Likert scale. In written comments, students reported that small groups with minimal faculty involvement provided a safe learning environment and a unique opportunity to lead a group of peers. They felt that PAL was more effective than traditional simulations for learning. Faculty reported that students remained engaged and required minimal oversight. Conclusion: Unlike other simulations, our combination of brief, student-assisted cases using low-fidelity simulation provides a cost-, resource- and time-effective way to implement a medical student clerkship educational experience.

Introduction The radiation risk posed by diagnostic computed tomography (CT) is a growing concern. The use of model-based iterative reconstruction (MBIR) technology reduces radiation exposure but requires additional processing time. The goal of this study was to compare MBIR and a standard CT reconstructive protocols in terms of emergency department (ED) visit duration and reduction in radiation exposure. Methods A retrospective, matched, case-control design was used to compare patients who received MBIR and standard protocol abdomen and pelvis CTs. ED length of stay (LOS) and radiation exposure were the 2 primary outcome variables. Results During the study period, 121 patients met inclusion criteria and were matched to controls for a total of 242 subjects. Although the low-dose group LOS was slightly longer, there was no significant difference in LOS. Mean differences were 18 minutes overall (520 vs 502 minutes; P = .497), 11 minutes for admitted patients (587 vs 576 minutes; P = .839), and 22 minutes for discharged patients (490 vs 468 minutes; P = .482). The mean volume CT dose index for the standard-dose CT was 11.6 ± 8.3 and 7.7 ± 4.6 mGy for the reduced-dose CT, a 34% decrease ( P Conclusion Use of MBIR in the ED may provide decreased radiation exposure while minimally impacting ED LOS.

Background Law enforcement restraint–related death is frequently associated with excited delirium syndrome (ExDS). Because such deaths are rare, the pathophysiology underlying ExDS deaths remains unknown, making identification of high-risk situations challenging. This study describes the medical conditions and situations surrounding restraint of individuals identified by law enforcement to be experiencing ExDS. Methods Individuals with ExDS as determined by law enforcement officers during use of force encounters over a 3-year period were identified. For subjects who were brought to the emergency department after restraint, medical records and police narratives were reviewed to identify circumstances surrounding restraint, abnormalities found during evaluation, and final diagnoses. Results Sixty-six cases were identified, of which 43 had emergency department evaluation. On presentation, 36 (84%) were tachycardic and 3 (7%) were hyperthermic; 35 (77%) had toxicology studies positive for stimulants; 2 (5%) had a pH level less than 7.2, and 5 (12%) had an elevated lactate; and 3 (7%) had a creatinine kinase level higher than 1500 U/L. Two (5%) patients were admitted to the hospital for medical reasons: one had had a field pulseless electrical activity arrest prior to restraint and the other was admitted for rhabdomyolysis. Conclusion Officer-identified cases of ExDS infrequently involved individuals requiring extensive restraint or with medical conditions that objectively placed them at high risk for sudden death. The low specificity of this syndrome in predicting risk of sudden death may present a challenge to law enforcement and emergency physicians.

Prehospital personnel and physicians working in acute care settings need to be cognizant of the issues related to law enforcement use of force in order to properly evaluate and manage these patients. Types of force used by law enforcement range along a spectrum from physical presence to lethal use of firearms. Although the vast majority of use of force incidents does not lead to significant injury, certain weapons and situations may require more extensive evaluation and higher levels of concern.

A healthy 19-year-old boy presented to our emergency department with abdominal pain. His history, examination and laboratory evaluation raised concern for appendicitis. A CT study of the abdomen and pelvis was carried out by the radiologist and emergency physician and was notable only for a large amount of unexpected high-attenuation intraluminal material. With further history, this was thought to be most likely retained bismuth from over-the-counter medicine ingestion. The patient was discharged home without a diagnosis. Further review of the CT scan by a second radiologist revealed a concern for appendiceal enlargement and associated free fluid. The patient was called back for further evaluation and treatment and ultimately an appendectomy was performed. Physicians should be aware of the causes and impact of unexpected radiopaque intraluminal contents on radiological studies. Most commonly from ingested medicine, such findings can obscure mucosal details, mimic active bleeding or create a distraction from other abnormalities.

Rationale and Objectives Cardiac computed tomography (CCT) in the emergency department may be cost saving for suspected acute coronary syndrome (ACS), but economic outcome data are limited. The objective of this study was to compare the cost of CCT-based evaluation versus standard of care (SOC) using the results of a clinical trial. Materials and Methods We developed a decision analytic cost-minimization model to compare CCT-based and SOC evaluation costs to obtain a correct diagnosis. Model inputs, including Medicare-adjusted patient costs, were primarily obtained from a cohort study of 102 patients at low to intermediate risk for ACS who underwent an emergency department SOC clinical evaluation and a 64-channel CCT. SOC costs included stress testing in 77% of patients. Data from published literature completed the model inputs and expanded data ranges for sensitivity analyses. Results Modeled mean patient costs for CCT-based evaluation were $750 (24%) lower than the SOC ($2384 and $3134, respectively). Sensitivity analyses indicated that CCT was less expensive over a wide range of estimates and was only more expensive with a CCT specificity below 67% or if more than 44% of very low risk patients had CCT. Probabilistic sensitivity analysis suggested that CCT-based evaluation had a 98.9% probability of being less expensive compared to SOC. Conclusion Using a decision analytic model, CCT-based evaluation resulted in overall lower cost than the SOC for possible ACS patients over a wide range of cost and outcome assumptions, including computed tomography–related complications and downstream costs.

ACADEMIC EMERGENCY MEDICINE 2011; 18:255–260 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: There is a growing awareness of the effects of patient death on physician well-being, and the importance of cultural and educational changes to improve coping mechanisms. The objective of this study was to explore both the effects of patient death on academic emergency physicians (EPs) and the coping mechanisms they use to deal with these events. Methods: Faculty at a convenience sample of four emergency medicine (EM) residency programs were questioned about their responses to patient death in a 15-question on-line survey. Descriptive analysis of the data was performed. Independent variables were analyzed for differences in complaints of physical symptoms or consideration of important life changes after patient death. Results: Of 207 EPs surveyed, 145 (70%) responded. Patient death was experienced frequently, with 95 (66%) witnessing a death at least every month. No training on coping with patient death had occurred for 35 (24%); 93 (64%) had less than 6 hours of training. The most common coping mechanisms included talking with colleagues (113; 78%) or friends and family (100; 69%), as well as simply continuing to work (89; 61%). Postdeath debriefing occurred rarely or never for 93 (64%) of respondents. Most EPs had experienced physical responses to patient death, the most common being insomnia (54; 37%) and fatigue (21; 14%). Common emotional responses included sadness (112; 70%) and disappointment (55; 38%). No significant differences in response rates for physical symptoms or consideration of life changes were found for any of the variables. Conclusions: Patient death was reported to lead to both physical and emotional symptoms in academic EPs. Postdeath debriefing appears to happen infrequently in teaching settings, and most respondents reported that they themselves received limited training in coping with patient death. Further study is needed to both identify coping mechanisms that are feasible and effective in emergency department settings and develop teaching strategies to incorporate this information into EM residency training.

INTRODUCTION:: Controversy persists over the safety of conducted electrical weapons (CEWs), which are increasingly used by law enforcement agencies around the world. The purpose of this study was to examine injury patterns and physiologic conditions after CEW use under real life conditions. METHODS:: A retrospective, cohort design was used, examining all CEW uses by one police department during a 6-year period. Data were collected from use-of-force forms and medical records and included conditions surrounding the use of force, medical histories, and data from emergency department evaluations and hospital admissions. RESULTS:: Of 1,101 individuals subjected to (Taser M26 and X26) CEW use during the study period, 92.6% were male, the average body mass index was 26.2, and the age range was 9 to 73 years. Of the 886 (80.5%) with medical records, 46.8% had a psychiatric history and 72.9% had a substance abuse history. Emergency department (ED) evaluations occurred for 295 (26.8%) incidents. Of chief complaints, 41.7% were trauma related, 26.8% were for altered mental status, and 21.7% were for psychiatric evaluation. On presentation, 17.6% had a pulse >120, 1.7% were febrile, and 30.9% were altered; 1.4% met criteria associated with "excited delirium." When laboratory workup occurred, 70.6% had positive urine toxicology and 44.8% had positive alcohol levels. Troponin I was positive for one patient. Other laboratory abnormalities were rare, although extensive evaluations were infrequently done. Admission occurred in 24.4% of ED presentations (6.5% of all subjects); of discharge diagnoses for these patients, 59.7% were psychiatric, 22.2% were for unrelated trauma, 11.1% were for restraint-related trauma, and 6.9% were for unrelated medical diagnoses. No patients died. CONCLUSIONS:: Significant injuries related to 6 years of law enforcement CEW use in one city were rare. A large percentage of those subjected to CEW use had diagnoses of substance abuse and/or psychiatric conditions. Most admissions after CEW use were unrelated to law enforcement restraint. Language: en

BACKGROUND: Patients' complaints of excessive use of force (EUOF) by police occur frequently in emergency departments (EDs). Limited, if any, education or guidelines exist for documenting alleged EUOF despite extensive instruction for other forms of potential abuse or assault. Our objective was to examine the documentation by ED staff when patients complained of EUOF. METHODS: A retrospective cohort design was used, identifying every use of force over a 1-year period by a single law enforcement agency that was followed by an ED visit within 24 hours. Charts were then analyzed for complaints of excessive force. For these cases, documentation was evaluated using standards for other forms of abuse and assault. RESULTS: Of 187 ED visits, 32 (17%) involved patients who were unable to give a history and 20 (11%) had nontrauma evaluations only. Of the remaining 135, there were 13 documented complaints (10%) of EUOF. Of these, 8 complaints (62%) described the mechanism of injury completely and 10 complaints (77%) had a complete description of the injury. No charts discussed whether the examination was consistent with the history. Inappropriate subjective terminology was used in 7 charts (54%), and the police description of events was described as fact in 7 charts (54%). Guilt was assigned in 5 charts (39%). DISCUSSION: In one ED, EUOF complaints were not documented to the standards for other forms of alleged assault and abuse. There may be a benefit to further education and guidelines on how to deal with ED presentations of EUOF. Language: en

The current standard-of-care workup of low-risk patients with chest pain in an emergency department takes 12-36 hours and is expensive. We hypothesized that negative 64-MDCT coronary angiography early in the workup of such patients may enable a shorter length of stay and reduce charges.The standard-of-care evaluation consisted of serial cardiac enzyme tests, ECGs, and stress testing. After informed consent, we added cardiac CT early in the standard-of-care workup of 53 consecutive patients. Fifty patients had negative CT findings and were included in this series. The length of stay and charges were analyzed using actual patient data for all patients in the standard-of-care workup and for two earlier discharge scenarios based on negative cardiac CT results: First, CT plus serial enzyme tests and ECGs during an observation period followed by discharge if all were negative; and second, CT plus one set of enzyme tests and one ECG followed by discharge if all were negative. Comparisons were made using paired Student's t tests.For standard of care and the two CT-based earlier discharge analyses, the mean lengths of stay were 25.4, 14.3, and 5.0 hours; mean charges were $7,597, $6,153, and $4,251. Length of stay and charges were both significantly less (p0.001) for the two CT-based analyses.In low-risk patients with chest pain, discharge from the emergency department based on negative cardiac CT, enzyme tests, and ECG may significantly decrease both length of stay and hospital charges compared with the standard of care.

Loperamide is a common over-the-counter antidiarrheal considered safe in a broad range of dosages and thought devoid of abuse potential. We describe the first case of a patient with loperamide dependence due to misuse of its opiate-like effects achieved by chronic massive oral ingestions. A 26-year-old man who was taking 800 mg of loperamide per day presented requesting detoxification referral. Loperamide has potential for euphoric effects and information on how to facilitate such effects is easily available. It is important for physicians to be aware of the potential for misuse of and dependence on loperamide, with symptoms mimicking opiate use.

Superwarfarin, a common component of rat poison, can cause long-lasting, severe coagulopathy and life-threatening hemorrhage when ingested. We report a case of intentional rat poison consumption with subsequent hemorrhage and hypotension requiring rapid coagulopathy reversal and resuscitation in the emergency department. In addition to traditional blood products, prothrombin complex concentrate was administered. Although prothrombin complex concentrate is increasingly used for severe hemorrhage in anticoagulated patients, it may be particularly useful in superwarfarin ingestions given the extreme, persistent coagulapathies that can occur.

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Bouveret syndrome is a rare presentation of gastric outlet obstruction caused by a gallstone in the proximal duodenum via a bilioenteric fistula. This is an infrequent although clinically significant cause of abdominal pain, almost exclusively in the elderly. The clinical presentation is similar to that of a small bowel obstruction with abdominal pain, nausea and vomiting. Surgery or endoscopy is often required for definitive diagnosis and therapy. We describe the case of a young woman with this condition who had a delayed diagnosis in part because of her age and the rarity of the condition. [West J Emerg Med. 2015;16(1):151-153.]

Rapid glucose testing is a valuable tool for emergency medical services (EMS) patient evaluation and treatment. In most EMS systems, paramedics, but not emergency medical technicians (EMTs), are authorized to use glucometry.To evaluate the influence of EMT glucometry on paramedic involvement in a two-tiered EMS response system.King County, Washington, EMTs underwent training in glucometry to determine blood sugar levels for specific patient presentations. The authors conducted a prospective cohort study of the first 500 EMT uses of glucometry, from October 2003 through March 2004, during which time EMTs recorded their subjective assessments of this additional information on their decisions to involve paramedics.Overall, glucometry results appeared to influence EMT decisions to involve paramedics. Glucometry prompted EMTs to upgrade the triage level and request paramedic evaluation for 5% of patients (n = 22); glucometry caused EMTs to downgrade the triage level, canceling already dispatched paramedics for 5% of patients (n = 23); and glucometry allowed EMTs to function without paramedics when they otherwise would have called for assistance for 11% of patients (n = 52). In an additional 12% of patients (n = 54), paramedic involvement was not actually influenced, but EMTs still indicated that glucometry would have had an effect on triage had paramedics not been present.Use of glucometry by EMTs appears to influence the decision to involve paramedics, potentially enabling more efficient and appropriate triage.

Purpose: To examine the prevalence and changing patterns of ecstasy use among college students, and to determine characteristics, associated behaviors, and interests of ecstasy users. Methods: The study analyzes data regarding ecstasy use and related behaviors from the 1997 and 1999 Harvard School of Public Health College Alcohol Study. This is a survey of a nationally representative sample of over 14,000 college students at 119 U.S. four-year colleges. Changes in self-reported annual ecstasy use were examined, and lifestyle and high-risk behaviors associated with Ecstasy use were identified. Data were analyzed using 2 2 Chi-square tests and multiple logistic regression fitted by the generalized estimating equations (GEE). Results: The prevalence of past year ecstasy use rose from 2.8% to 4.7% between 1997 and 1999, an increase of 69%. This increase was observed across nearly all subgroups of student and college type. A smaller sample of ten colleges revealed that the increase continued in 2000. Ecstasy users were more likely to use marijuana, engage in binge drinking, smoke cigarettes, have multiple sexual partners, consider arts and parties as important, religion as less important, spend more times socializing with friends, and spend less times studying. Unlike other illicit drug users, ecstasy users were not academic underachievers and their satisfaction with education was not different from that of non-ecstasy users. Conclusion: Ecstasy use is a high-risk behavior among college students which has increased rapidly in the past decade. © Society for Adolescent Medicine, 2001

Features consistent with the syndrome known as excited delirium (ExDS) have been associated with law enforcement restraint-related death. The pathophysiology and exact causative factors of restraint-related death associated with ExDS remain unclear. We present a case of successful field resuscitation of a man with ExDS who experienced cardiopulmonary arrest while being restrained by law enforcement officers. Despite the presence of a severe lactic acidosis on emergency department admission, the patient recovered following prehospital treatment with advanced cardiac life support measures and intravenous sodium bicarbonate, likely in part due to early recognition of the disease process.

Aims. To examine rates and patterns of marijuana and other illicit drug use among different types of students and colleges in 1999, and changes in use since 1993. Design. Self-administered mail survey (Harvard School of Public Health College Alcohol Study). Setting. One hundred and nineteen nationally representative US 4-year colleges. Participants. A representative sample of 15 403 randomly selected students in 1993, 14 724 students in 1997 and 14 138 students in 1999. Measurements. Self-reports of marijuana and other illicit drug use in the past 30 days and in the past year, cigarette use, drinking behavior, and age of initiation of smoking, drinking and using marijuana. Findings. The prevalence of past 30-day marijuana use rose from 12.9% to 15.7% between 1993 and 1999, an increase of 22%. Almost all of this change occurred by 1997. An increase was observed at 66% of the 119 colleges. The prevalence of 30-day and annual marijuana use increased in nearly all student demographic subgroups except for Hispanic students, and at all types of colleges except for colleges with low binge drinking rates. Rates of illicit drug use in the past 30 days increased slightly for other illicit drugs in the 4-year interval except for LSD. Nine out of 10 students (91%) who used marijuana in the past 30 days used other illicit drugs, smoked cigarettes and/or engaged in binge drinking. Of students who used any other illicit drug in the past 30 days, 87% used another substance or binge drank. Twenty nine per cent of past 30-day marijuana users first used marijuana and 34% began to use marijuana regularly at or after the age of 18, when most were in college. Conclusions. Use of marijuana and other illicit drugs has increased on campuses across the United States in most student subgroups and all types of colleges. This may reflect earlier increases in middle schools and secondary schools among this cohort. However, nearly one-third of students initiated marijuana use in college and one of three began to use it regularly. Intervention efforts should be directed at college students, as well as secondary school students.