Search

40-year-old man was referred to the emergency department (ED) with critical anemia after routine blood work at an outside clinic showed a hemoglobin level of 3.5 g/dL. On presentation, he reported symptoms of fatigue, shortness of breath, bilateral leg swelling, dizziness (characterized as light-headedness), and frequent heartburn. He said that the symptoms began 5 weeks earlier, after he was exposed to a relative with hand, foot, and mouth disease.

Purpose Management of postoperative pain is a significant challenge following the Nuss procedure. Epidurals, PCAs, and newer analgesia modalities have been used elsewhere without demonstrating consistent improvement in the reported length of hospital stays (LOS). We reviewed a large single surgeon experience identifying three different methods of analgesia used over time to highlight marked improvement in patient LOS. Methods IRB approval was obtained and patient clinical information was retrospectively reviewed from 2001 to 2017. The primary outcome variable was length of hospital stay. An expanded preoperative consultation reviews the issue of pain, the negative impact of anxiety on recovery, and our current success of shortened hospital stays with our patients. Results One hundred and seventy-three patients representing three different analgesia approaches had a LOS of 4.4 days (epidural); 2.2 days (PCA/intercostal nerve block); and 1.6 days (scheduled oral pain meds/intercostal nerve blocks). The current LOS for patients is 1.0 day. Patients successfully stop using narcotics by the end of the first week postoperatively. Conclusions Intraoperative intercostal nerve blocks, scheduled postoperative pain medications, and enhanced preoperative consultation aimed to educate patients about anxiety and reframe patient pain expectations have collectively decreased LOS, and reduced postoperative narcotic usage. Type of study Clinical research Level of evidence Level III

Introduction: Ischemic stroke patients who arrive by emergency medical service (EMS) receive faster emergency department evaluations and improved rates of thrombolytic treatment. However, EMS stroke recognition and compliance with prehospital stroke quality measures are inconsistent. We hypothesized that EMS stroke care is influenced by a complex interaction of knowledge, beliefs, and system-level variables that influence behavior. Methods: Focus groups of paramedics from a single urban/suburban county were assembled to discuss their experiences identifying and transporting stroke patients. Focus groups were conducted using a semi-structured interview format and audio recorded. Transcripts of focus groups were qualitatively analyzed to identify themes, subthemes, and patterns of paramedic responses. The Clinical Practice Guidelines Framework provided the initial coding scheme, which was modified during the coding process by three coders using grounded theory methods, who came to consensus on which codes to apply. Results: Three focus groups (n=13) were conducted to reach theme saturation. Overall, paramedics reported high confidence in clinical gestalt for assessing stroke patients and a strong desire to “do the right thing,” but were unfamiliar with published guidelines. Paramedics identified variability in the clinical presentations of stroke, inadequate or inconsistent hospital guidance, and lack of feedback regarding care as principle barriers to ideal prehospital stroke care. Participants reported conflicting hospital guidance regarding the appropriate time frame for a high priority transport and hospital prenotification. Feedback regarding final diagnosis was viewed as critical for developing improved clinical acumen. Direct to CT protocols were cited as an effective way to integrate EMS into hospital stroke response. Conclusion: In this qualitative analysis, paramedics expressed a desire for clear, hospital-directed guidance and consistent feedback regarding outcomes for suspected stroke patients.