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This article introduces a clinical audience to the process of emergency department (ED) design, particularly relating to academic EDs. It explains some of the major terms, processes, and key decisions that clinical staff will experience as participants in the design process. Topics covered include an overview of the planning and design process, issues related to determining needed patient capacity, the impact of patient flow models on design, and a description of several common ED design types and their advantages and disadvantages.

The COVID-19 pandemic significantly disrupted emergency medicine residents' education. Early in the pandemic, many facilities lacked adequate personal protective equipment (PPE), and intubation was considered particularly high risk for transmission to physicians, leading hospitals to limit the number of individuals present during the procedure. This posed difficulties for residents and academic faculty, as opportunities to perform endotracheal intubation during residency are limited, but patients with COVID-19 requiring intubation are unstable and have difficult airways. Case Scenario: When PPE is being rationed, who should be the one to perform an intubation on a patient with respiratory failure from severe COVID-19?We examined this case scenario using the ethical frameworks of bioethical principles and virtue ethics. Bioethical principles include justice, beneficence, nonmalfeasance, and autonomy, and virtue ethics emphasizes the provision of moral exemplars and opportunities to exercise practical wisdom. Arguments for an attending-only strategy include the role of the attending as a truly autonomous decision maker and the importance of providing residents with a moral exemplar. A resident-only strategy benefits a resident's future patients and provides opportunities for residents to exercise character. Strategies preserving the dyad of attending and resident maintain these advantages and mitigate some drawbacks, while intubation teams may provide the most parsimonious use of PPE, but may elide resident involvement.There exist compelling motivations for involving senior residents and attendings in high-risk intubations during the COVID-19 pandemic. A just strategy will preserve residents' role whenever possible, while maximizing supervision and providing alternative routes for intubation practice.

Resuscitation of cardiac arrest in coronavirus disease 2019 (COVID-19) patients places the healthcare staff at higher risk of exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Unfortunately, COVID-19 status is unknown in most patients presenting to the emergency department (ED), and therefore special attention must be given to protect the healthcare staff along with the other patients. This is particularly true for out-of-hospital cardiac arrest patients who are transported to the ED. Based on the current data available on transmissibility of SARS-CoV-2, we have proposed a protocolized approach to out-of-hospital cardiac arrests to limit risk of transmission.

Background Whether emergency physicians should utilize critical care resources for patients with advance care planning directives is a complex question. Because the cost of intensive care unit (ICU)-level care, in terms of human suffering and financial burden, can be considerable, ICU-level care ought to be provided only to those patients who would consent and who would benefit from it. Objectives In this article, we discuss the interplay between clinical indications, patient preferences, and advance care directives, and make recommendations about what the emergency physician must consider when deciding whether a patient with an advance care planning document should be admitted to the ICU. Discussion Although some patients may wish to avoid certain aggressive or invasive measures available in an ICU, there may be a tendency, reinforced by recent Society of Critical Care Medicine guidelines, to presume that such patients will not benefit as much as other patients from the specialized care of the ICU. The ICU still may be the most appropriate setting for hospitalization to access care outside of the limitations set forward in those end-of-life care directives. On the other hand, ICU beds are a scarce and expensive resource that may offer aggressive treatments that can inflict suffering onto patients unlikely to benefit from them. Goals-of-care discussions are critical to align patient end-of-life care preferences with hospital resources, and therefore, the appropriateness of ICU disposition. Conclusions End-of-life care directives should not automatically exclude patients from the ICU. Rather, ICU admission should be based upon the alignment of uniquely beneficial treatment offered by the ICU and patients’ values and stated goals of care.

Background Patients who are resuscitated with naloxone frequently refuse a period of observation, even though they may be suffering from a variety of medical and psychiatric comorbidities. Emergency physicians (EPs) are then confronted with the challenge of how best to serve patients’ interests while respecting autonomy. Objectives We sought to characterize how EPs think about this kind of dilemma and the strategies they use to resolve them. Methods We conducted qualitative semi-structured interviews with a convenience sample of 59 emergency physicians attending the American College of Emergency Physicians’ Scientific Assembly in October 2018. Three case vignettes highlighting different clinical and ethical features served as prompts. Interviews were analyzed using a constant comparative method to identify patterns of responses and derive key themes. Results Across the vignettes, EPs demonstrated diverse approaches to observation, assessing decision-making capacity and encouraging compliance. Some EPs refused to comply with a patient's wishes even when they had determined a patient demonstrated capacity. Conversely, a few EPs were willing to allow patients to leave the emergency department (ED) without assessing capacity, or despite determining that the patient lacked capacity. Common reasons for complying with patients' demands were concerns about the patients' rights and concerns about the safety of staff. Most physicians interviewed reported no institutional guidelines or education on the topic, and many physicians expressed an interest in providing medication for addiction treatment in the ED. Conclusions EPs approach this clinical and ethical dilemma in widely divergent ways. Consensus about strategies for navigating patients’ wishes relative to clinical concerns are needed to help EPs manage these challenging cases.

This article revisits the persistent problem of crowding in US hospital emergency departments (EDs). It begins with a brief review of origins of this problem, terms used to refer to ED crowding, proposed definitions and measures of crowding, and causal factors. The article then summarizes recent studies that document adverse moral consequences of ED crowding, including poorer patient outcomes; increased medical errors; compromises in patient physical privacy, confidentiality, and communication; and provider moral distress. It describes several organizational strategies implemented to relieve crowding and implications of ED crowding for individual practitioners. The article concludes that ED crowding remains a morally significant problem and calls on emergency physicians, ED and hospital leaders, emergency medicine professional associations, and policymakers to collaborate on solutions.

Influenza is a respiratory illness responsible for epidemic outbreaks of disease, and accounts for 500,000 to 1,000,000 emergency department (ED) visits in the United States each year.1 Because of the high prevalence of disease and its potential morbidity, emergency physicians must be facile in its diagnosis and treatment. In addition, some treatments for influenza, such as neuraminidase inhibitors, are associated with a higher risk of symptoms, such as gastrointestinal and central nervous system effects, which themselves can prompt ED visits.2 While front-line physicians have become adept at recognizing and managing both the symptoms of influenza and side effects of well-studied medical treatments, a further diagnostic challenge includes side effects of compounds or therapies recommended for influenza that are not well studied in Western medicine. Here, we present a report novel to the peer-reviewed medical literature of an adverse event due to the use of an herbal remedy for influenza.

The acoustical behavior of a harpsichord modeled after 17th‐century Flemish prototypes was studied using both experimental and analytical techniques. The vibrational modes of its enclosed air volume were measured and found to correspond closely to those predicted by the J0 and J9 solutions to the Bessel equation for a wedge shaped space. A modal analysis of the complete harpsichord revealed that the soundboard has 36 vibrational modes over a frequency range of 0 to 600 Hz, and that there are numerous modes where the instrument’s case has a significant amplitude of motion. Additional information is reported showing that the acoustic output of the harpsichord is reasonably flat over a frequency range of 50–2000 Hz. It is concluded that the resonance behavior of both the soundboard and the enclosed air are important to the tone quality of the harpsichord, and that its generally uniform acoustic output results from the excitation of a large number of wood and air modes by the string partials.

The tire/pavement interface zone is the origin of a major portion of the ride vibration, ride noise, and environmental noise disturbances associated with road vehicles. It is appropriate to view these separate problems asone comprehensive systems problem involving the road, the tire, the vehicle, and human response to noise and vibration stimuli. A flow chart is used to discuss the general systems problem. Main branches of the flow chart are examined based on a thorough review of the pertinent literature. Relevant and previously unpublished information is included in the paper.

The vibrations of violin strings excited by bowing or plucking are mainly in the transverse and vertical directions, and are communicated to corpus through the rocking and vertical motions of the bridge. These factors have been extensively studied, but much less is known about how the longitudinal and torsional vibrations of the string, and the out‐of‐plane motions of the birdge, affect the sound radiated by the instrument. This talk will briefly review what has been learned to date about the out‐of‐plane vibrations of the bridge. Information is then presented showing: (1) the in‐plane (y and z direction) motions of the bridge generally related at low frequency but quite different at higher frequency, and (2) the out‐of‐plane (x direction) bridge vibrations, distinctly different from the in‐plane, and in several instances providing a negative resistance that may absorb energy from the vibrating strings. It is concluded that three‐dimensional bridge motion should be considered to provide an improved understanding of violin dynamics.

The vibrational behavior of a violin is studied using modal analysis techniques. The violin was considered to be an input–output system, and impact testing was used to measure the frequency response functions for the instrument over the frequency range of 0–1300 Hz. Both the input force and the response acceleration were recorded and analyzed. The results provide a complete modal data base for this violin, information which may be used to characterize the instrument in subsequent analytical studies. It was concluded that the violin, exclusive of the strings, can be modeled as a linear second‐order system, and its vibrational behavior can be expressed as a summation of real normal modes. The neck fingerboard of the violin undergoes large amplitude motions at many frequencies, and the ‘‘feel’’ of a violin is related to these lower order modes of the instrument. The A1 air mode and the ‘‘main wood’’ resonance of the top plate are intimately interrelated and both contribute to the radiated sound of the instrument.

The effect of test speed and surface curvature on tire force and moment properties has been investigated. Lateral force at low slip angles increases linearly 8 to 9 percent for a tenfold increase in test speed. The effect of test speed on tire force and moment properties produces only a modest change in predicted steady state vehicle handling, but a rather significant change in predicted transient vehicle handling. Surface curvature tends to reduce slip and camber generated lateral force and aligning torque, but the effect is extremely complex and no simple flat to curved surface transformation relationship exist. /GMRL/

Modal analysis techniques were used to take a “first look” at how the presence of the musician alters the vibrational behavior of a violin. Animated mode shapes of a freely suspended violin will be presented, and compared to the response of the same instrument when held by five different players. The results show that the player imposes a constraint, or boundary condition, to the neck and lower bout of the violin, consisting primarily of a strong viscous damper acting in parallel with a weak spring. The resonant frequencies and mode shapes are only slightly affected, but the amplitude of the response of the violin is significantly lowered. It is concluded: (a) A variety of different violins should be measured for comparison purposes and to establish a decent data base. (b) A violin should always be measured freely suspended. Boundary conditions can always be added later in a mathematical model, but it is extremely difficult to remove a constraint that is present in the test data.

In this paper the vibrational behavior of a violin is examined under a variety of boundary conditions; held by the player, freely suspended, pinned supports, simple supports, clamps applied to the neck and corpus, and supported by sandbags. It was found that three different players imposed very similar constraints on the instrument, with the principal effect being a significant increase in the modal damping as compared to the free vibrational response of the violin. The effect of the player on the modal frequencies was negligible. It was also found that resting the instrument on a piece of foam rubber or the use of sandbags under the neck and the tail of the instrument provided a good first approximation to the influence of the player. The other boundary conditions that were investigated caused significant deviations from the normal response of the instrument, thus indicating that these mounting techniques should not be used to measure the vibrational behavior of a violin or other stringed instrument.