Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED

Objective

The aim of our study was to assess the potential of bedside lung ultrasound examination by the attending emergency physician in the diagnosis of acute pneumonia.

Material and Methods

This observational single-center study was conducted between January 2010 and June 2012 in the emergency unit of a general hospital, and analyzed 144 adult patients. The ultrasound examination was performed by one of five trained emergency physicians, and a chest radiograph interpreted by a radiologist. The primary end point was the diagnosis of hospital discharge.

Results

We found a sensitivity of 0.95 for the ultrasound examination against 0.6 for radiography (P < .05). The negative predictive value was 0.67 against 0.25 for radiography (P < .05).

Conclusion

These results exhort to promote the use of thoracic ultrasound in the first-line diagnosis of pneumonia.     

The accuracy of paediatric limb radiograph interpretation by nurse practitioners in a single centre

BackgroundNurse practitioners (NP) are an integral part of the urgent and emergency care workforce in the United Kingdom providing safe and effective care. Despite this, there is limited research assessing the ability of NPs to correctly interpret isolated paediatric limb injury radiographs in the urgent and emergency care environment.AimThe aim of this study was to compare the accuracy in interpreting isolated paediatric limb radiographs between NPs and consultant radiologists.SettingA nurse-led urgent care centre (UCC) in central London, United Kingdom.Participants296 paediatric patients with isolated limb injuries who had a radiograph requested and interpreted by an NP.MethodsThirteen NPs (adult registered) with various backgrounds and qualifications participated in this prospective, single-centre healthcare analysis. Review of all clinical presentations at the UCC over a 3-month period (September–November 2017) identified 296 paediatric patients (aged 2–15) who received a peripheral limb radiograph. Clinical records for each patient were analysed to document demographics, mechanism of injury, NP examination findings, radiographic interpretation and formal radiologist report. NP interpretation of each radiograph was classified as definite fracture, possible fracture or no fracture. This was compared to the final radiologist report (considered the gold standard) to calculate the sensitivity and specificity of NP radiograph interpretation.ResultsNPs reported a total of 94 radiographs (32%) as definite fracture, 176 (59%) as no fracture and 26 (9%) as possible fracture, as compared to radiologists at 71 (24%), 218 (74%) and 7 (2%). A total of 242 (82%) of radiographs were correctly identified by NPs, while 54 (18%) were incorrectly interpreted. The sensitivity of the NP limb radiographic interpretation was 92%, with a specificity of 78%.ConclusionsThe findings validate the clinical and diagnostic skills of NPs in the interpretation of isolated paediatric limb radiographs.     

Left-sided Superior Vena Cava and Venous Hyperoxia Masquerading as Inadvertent Carotid Artery Catheterization

Background

A persistent left-sided superior vena cava (PLSVC) is a rare, often asymptomatic, venous anomaly that may be first diagnosed during central venous catheterization. During chest radiograph interpretation, a PLSVC can be confused with inadvertent arterial catheterization.

Case Report

We describe the presentation of a 45-year-old man with end-stage liver disease who required central venous catheterization for treatment of septic shock. An aberrantly placed catheter noted on chest radiograph and an elevated central venous oxygen saturation gave the appearance of inadvertent carotid artery catheterization.

Why Should an Emergency Physician Be Aware of This?

A persistent left-sided superior vena cava can masquerade as an inadvertent cannulation of the carotid artery during central line placement. It is important for emergency physicians to be aware of this possibility when evaluating a chest radiograph with an aberrantly placed catheter. Venous hyperoxia may further complicate attempts to differentiate between arterial and venous catheterization in patients with septic shock. After confirmatory tests, the emergency physician should consider removal of the catheter due to potential complications.     

Bedside Ultrasound for Hip Dislocations

Background

Bedside ultrasound in the emergency department is being used with increasing frequency and for an increasing scope of conditions.

Objectives

Demonstrate the use of bedside ultrasound as an adjunct for diagnosis of hip dislocation.

Case Report

A traumatic anterior hip dislocation was diagnosed with bedside ultrasound after an initial normal plain radiograph.

Conclusion

Although the current standard of care for diagnosis of hip dislocation is plain radiographs, this case demonstrates that bedside ultrasound may be used as a diagnostic adjunct in this time-sensitive and potentially catastrophic diagnosis.     

Oxygen Reservoir Bags Simulating Chest Pathology: A Case Series

Background

We present a series of plain chest radiographs taken in acute settings, with artifactual projections from oxygen reservoir bags. These artifacts are shown to simulate chest pathology in each case.

Objectives

The identification of artifacts on imaging prevents misdiagnosis and potential mistreatment of patients in acute settings. We highlight patterns of findings caused by the projection of oxygen reservoir bags in radiographs taken in the emergency setting.

Case Reports

We present plain chest films in 4 patients taken in the acute setting, either in the emergency department or acute admissions unit. In this case series, oxygen reservoir bags simulate pneumothoraces, lung edges, and bullous disease.

Conclusion

Artifacts on chest radiographs are potential causes of misdiagnosis and subsequent inappropriate treatment. By highlighting the patterns created by the projection of oxygen reservoir bags, emergency physicians, radiologists, and reporting radiographers will be aware of the potential problems.     

Sports Medicine Training and Practice Opportunities for Emergency Physicians

Background

There is growing interest among emergency physicians to seek additional training in Sports Medicine (SM) and to add it to their clinical practice. This presents unique training and practice management issues. The majority of Primary Care SM fellowship programs list that they will accept emergency physicians, and approximately one-third have already had an emergency physician as an SM fellow.

Objectives

The objective of this article is to provide an overview of the key elements for emergency physicians to consider as they pursue SM career goals.

Discussion

Training needs such as continuity of care as it pertains to the athlete, SM skills development, and practice management are reviewed. Practice challenges such as malpractice insurance and billing issues are discussed. Examples of several practice models are presented. Evolving trends in SM practice and training opportunities for emergency physicians are discussed as well.

Conclusions

Sports Medicine is a viable career option for emergency physicians and may complement their skills set in the management of acute injuries. Practice and training opportunities will continue to evolve as this pathway into the practice of SM gains further recognition.     

Pediatric clavicular fractures: assessment of fracture patterns and predictors of complicated outcome

Background

Clavicular fractures are the most common pediatric long-bone fracture, and although the vast majority heal with supportive treatment, complications do occur and can lead to pain and disability. Although many studies have characterized adult complication rates and risk factors, to our knowledge no comparable studies to date have looked at clavicular fractures in the pediatric population.

Study Objectives

The study aim was to identify the radiological and clinical variables that increase the complication rate of clavicular fractures. Identification of these variables would help emergency physicians identify patients who require more thorough follow-up or surgical intervention.

Methods

We analyzed radiographs of 537 clavicular fractures on initial presentation to the Pediatric Emergency Department at the Children's Hospital at London Health Sciences Center over a 4-year period, collecting data on variables such as displacement, angulation, and comminution, as well as demographic data such as age and gender. We then determined the outcome of each fracture by reviewing each patient’s chart, and through a logistic regression analysis, determined the variables associated with complications.

Results

Of all the fractures treated supportively (i.e., non-operatively), only 2.5% resulted in a complication. Our analysis determined that patient age was an independent predictor of complications, with each year past zero conferring an 18.1% increase in risk of complication. Furthermore, completely displaced fractures were shown to increase the odds of complication by a factor of 3.2.

Conclusion

These findings help the emergency physician identify a group of high-risk pediatric patients with clavicular fractures for which more thorough follow-up should be considered.     

Reappraisal of radiographic signs of pneumoperitoneum at emergency department

Purpose

This study aimed to evaluate the sensitivities of the reported free air signs on supine chest and abdominal radiographs of hollow organ perforation. We also verified the value of supine radiographic images as compared with erect chest and decubitus abdominal radiographs in detection of pneumoperitoneum.

Methods

Two hundred fifty cases with surgically proven hollow organ perforation were included. Five hundred twenty-seven radiographs were retrospectively reviewed on the picture archiving and communication system. Medical charts were reviewed for operative findings of upper gastrointestinal tract, small bowel, or colon perforations. The variable free air signs on both supine abdominal radiographs (KUB) and supine chest radiographs (CXR) were evaluated and determined by consensus without knowledge of initial radiographic reports or final diagnosis. Erect CXR and left decubitus abdominal radiographs were evaluated for subphrenic free air or air over nondependent part of the right abdomen.

Result

Upper gastrointestinal tract perforation was proven in 91.2%; small bowel perforation, in 6.8%; and colon perforation, in 2.0%. The positive rate of free air was 80.4% on supine KUB, 78.7% on supine CXR, 85.1% on erect CXR, and 98.0% on left decubitus abdominal radiograph. Anterior superior oval sign was the most common radiographic sign on supine KUB (44.0%) and supine CXR (34.0%). Other free air signs ranged from 0% to 30.4%.

Conclusions

Most free air signs on supine radiographs are located over the right upper abdomen. Familiarity with free air signs on supine radiographs is very important to emergency physicians and radiologists for detection of hollow organ perforation.     

Characterizing critical care physician staffing in rural America: A description of Iowa intensive care unit staffing

Purpose

This study aimed to characterize intensive care unit (ICU) physician staffing patterns in a predominantly rural state.

Materials and Methods

A prospective telephone survey of ICU nurse managers in all Iowa hospitals with an ICU was conducted.

Results

Of 122 Iowa hospitals, 64 ICUs in 58 (48%) hospitals were identified, and 46 (72%) responded to the survey. Most ICUs (96%) used an open admission model and cared for undifferentiated medical and surgical patients (88%), and only 27% of open ICUs required critical care or pulmonary consultation for admitted patients. Most (59%) Iowa ICUs had a critical care physician or pulmonologist available, and high-intensity staffing was practiced in 30% of ICUs. Most physicians identified as practicing critical care (63%) were not board certified in critical care. Critical care physicians were available in a minority of hospitals routinely for inpatient intubation and cardiac arrest management (29% and 10%, respectively), and emergency physicians and other practitioners commonly responded to emergencies throughout the hospital.

Conclusions

Many Iowa hospitals have ICUs, and staffing patterns in Iowa ICUs mirror closely national staffing practices. Most ICUs are multispecialty, open ICUs in community hospitals. These factors should inform training and resource allocation for intensivists in rural states.     

Identification of Lipohemarthrosis With Point-of-Care Emergency Ultrasonography: Case Report and Brief Literature Review

Background

Traumatic knee pain is a common complaint in the emergency department (ED). Conventional radiographs are often ordered as the initial screening study, but might not be readily available or always identify significant fractures. Ultrasonography has been shown to be useful in the evaluation of knee fractures not identified by radiography.

Objectives

To discuss and briefly review the literature regarding the use of suprapatellar bursal ultrasonography to detect lipohemarthrosis (LH) as a surrogate marker for an intraarticular knee fracture.

Case Report

A 37-year-old man presented to the ED after a traumatic knee injury. Bedside ultrasonography demonstrated the characteristic triple layer sign of LH, raising the suspicion for an intraarticular fracture. The diagnosis was later confirmed with radiography and computed tomography (CT).

Conclusions

The sonographic finding of LH may be used as a sensitive surrogate marker for intraarticular knee fracture in the ED. Ultrasound can be considered as an adjunct modality in ED patients with suspicion for fracture and negative knee radiographs.     

A Significant Cervical Spine Fracture: Think of the Airway

Background

Airway compromise is a potential complication of significant cervical spine injury.

Objectives

To alert emergency physicians to be aware of possible airway collapse after serious cervical spine injury.

Case Report

We report a case of an 87-year-old man who presented to the emergency department with an unstable cervical spine fracture after a fall. He subsequently developed complete upper airway obstruction from prevertebral soft tissue swelling, requiring a cricothyrotomy after a failed intubation attempt.

Conclusion

Patients with significant blunt cervical spine trauma can be at high risk for upper airway compromise.     

Discordance in interpretation of chest radiographs between pediatric intensivists and a radiologist: Impact on patient management

Purpose

When radiologists are not available, chest radiographs (CXRs) of pediatric intensive care unit (PICU) patients are commonly interpreted by pediatric intensivists. We prospectively investigated the frequency of errors in CXR interpretation by pediatric intensivists and their impact on patient management.

Materials and Methods

Chest radiographs of PICU patients were evaluated by 5 pediatric intensivists then by a pediatric radiologist (the “gold standard”). If the interpretation of the radiologist and intensivist differed, an independent intensivist determined whether a management change took place. A pediatric pulmonologist determined how many intensivist interpretations were different from the radiologist's interpretations.

Results

Seven hundred twenty-eight radiographic findings were identified by the radiologist in 460 CXRs. There were 33 interpretation errors by the intensivists (4.5% of the findings in 7.1% of the CXRs). Only 3/33 error corrections (0.45% of the findings in 0.7% of the CXRs) resulted in change in patient management.

Conclusions

Errors in interpretation of CXRs by pediatric intensivists were common but less than that in other series, probably because of education of the pediatric intensivists through daily rounds with the radiologist. Although interpretation errors that affected patient management were rare, their clinical importance supports the growing practice of 24/7 remote radiograph reading by radiologists.     

Perceptions of emergency department staff of the role of physiotherapists in the system: a qualitative investigation

Objectives

To investigate the perceptions of doctors, nurses and physiotherapists of emergency department physiotherapy for acute patients, and explore the scope of its contribution in an otherwise nontraditional allied health setting in Australia.

Design

Qualitative investigation using semi-structured interviews.

Setting

A large, metropolitan tertiary hospital with a well-established emergency department physiotherapy/allied health network in place.

Participants

Two emergency department doctors, two emergency department nurses and two senior physiotherapists working in an emergency department were recruited purposefully from the study hospital.

Interventions

Semi-structured interviews lasting from 20 minutes to 1 hour were conducted with each participant by the lead investigator. Data were analysed using NVivo software, coded manually and verified with member checking, facilitating constant case comparisons.

Results

Issues explored included defining the role of physiotherapists, uncovering organisational themes from the introduction of physiotherapy into the established emergency department setting, and conflicts around preserving and expanding an allied health identity in a highly-medicalised clinical environment.

Conclusions

Participants described the benefits of having physiotherapists located in the emergency department, and the physiotherapists were eager to advance their roles and responsibilities, but were, at times, restricted by a complicated organisational landscape influencing professional autonomy and capacity for professional advocacy. Ongoing evidence supporting the breadth of physiotherapy practice in the emergency department is needed to further advocate the usefulness of the profession in this acute setting.     

Assessment of Bosworth-type fracture by external oblique radiographs

Introduction

Bosworth described an unusual fracture dislocation of the ankle with fixed posterior fracture dislocation of the fibula. This ankle fracture variant is often not recognized in initial radiographs and requires a computed tomographic scan for verification. It is usually not reducible by the closed method, and repeated trials induce more damage. The purpose of this study was to verify the usefulness of simple external oblique radiographs for diagnosis of Bosworth-type fracture.

Methods

We reviewed the 327 patients who were diagnosed as unilateral malleolus ankle fracture in 2002 to 2012. Four cases of Bosworth-type fracture were identified. External oblique radiograph was taken initially, immediately after first closed reduction, and after open reduction (3 phases) was undertaken to check the position of fibula in relation with the talus. Fifty cases of bimalleolar fractures and unaffected ankle were compared. Longitudinal bisecting line along the proximal fibula was drawn, and the talus was divided in 2 parts. Anterior and posterior part of the talus was defined as part α and β. The ratio resulted from dividing α with (α + β) implies the fibula position relative to the talus.

Results

Mean α/(α + β) ratio of each phase were 0.4994, 0.4891, 0.2875, 0.2698, and 0.2709. There was significant difference in initial and first reduction phase of Bosworth-type fracture than other groups (P = < .0001). There was no significant difference in open reduced Bosworth-type fracture with bimalleolar fractures and unaffected ankles (P = .528, .602).

Conclusions

An external oblique radiograph provides useful information that can differentiate Bosworth-type fracture from other reducible bimalleolar fractures.     

Neutral to positive views on the consequences of nurse prescribing: Results of a national survey among registered nurses,nurse specialists and physicians

Background

Over the last two decades, the number of countries where nurses are legally permitted to prescribe medication has grown considerably. A lack of peer support and/or objections by physicians can act as factors hampering nurse prescribing. Earlier research suggests that physicians are generally less supportive and more concerned about nurse prescribing than nurses are. However, direct comparisons between doctors’ and nurses’ views are scarce and are often based on small sample sizes.

Objectives

To gain insight into the views of Dutch registered nurses (RNs), nurse specialists (with a master's in Advanced Nursing Practice) and physicians on the consequences of nurse prescribing.

Design

Survey study.

Participants

Survey questionnaires were sent to national samples of RNs, nurse specialists and physicians.

Methods

The questionnaire addressed, among others, respondents’ general views on the consequences of nurse prescribing for the quality of care, the nursing and medical professions, and the relationship between the medical and nursing professions.

Results

The net response rate was 66.0% for RNs (n = 617), 28.3% for nurse specialists (n = 375) and 33.7% for physicians (n = 265). It was found that all groups agreed that nurse prescribing benefits nurses’ daily practice and the nursing profession. There were few concerns about negative consequences for physicians’ practice and the medical profession. Nurse specialists gave significantly (P < 0.05) more positive scores on most items than RNs and physicians. We found relatively little difference in views between RNs and physicians. It was only on issues surrounding the quality of care and patient safety that doctors showed more concerns, albeit mild, than RNs and nurse specialists.

Conclusions

RNs, nurse specialists and physicians generally hold neutral to moderately positive views on nurse prescribing. This is beneficial for the implementation and potential success of nurse prescribing in practice, as a lack of peer support and/or objections from physicians can be a hampering factor. However, concerns about the consequences of nurse prescribing for the quality of care and patient safety remain a point for attention, especially among physicians.     

A comparison of ambulance responses to incidents of Medical Emergency Teams led by nurses and paramedics––A retrospective single-center study

Background

In Poland there are currently two main types of Medical Emergency Team: basic, run by nurses or paramedics, and specialist, led by physicians. They differ not only in professional qualifications but also in their terms of reference.

Objectives

We compared the responses to incidents of Medical Emergency Teams led by nurses and paramedics, in terms of the frequency of pharmacotherapy use and medical rescue activities.

Study design

Ambulance call reports.

Settings

Medical Emergency Teams in Eastern Poland.

Participants

Medical Emergency Teams led by nurses or paramedics. Exclusion criteria were cancelation of calls by the dispatcher, calls with no patient on the scene, and neonatal and interhospital transportation.

Methods

A retrospective analysis of ambulance call reports. A comparison of actions of nurses and paramedics taken in the field, and decisions concerning transportation of the patient to a hospital or leaving the home were collected.

Results

Of 1115 Medical Emergency Teams calls, those led by paramedics (60.5%) were more common. Paramedics, more often than nurses, provided aid solely in the field—27.5% and 16.0%, respectively—and less frequently transported patients to the hospital—38.5% and 50.7%, respectively. Significant differences in administration of oxygen therapy and analgesics were identified; paramedics used them more often than nurses. Paramedics used cervical collars, 3.6% and 1.1% (p = 0.01), respectively, and performed 12-lead electrocardiograms, 4.7% and 1.4% (p = 0.002), respectively, significantly more frequently than did nurses.

Conclusions

Despite the comparable competency of paramedics and emergency nurses in Poland, Medical Emergency Teams’ activities varied depending on whether a nurse or a paramedic was the team leader. It is recommended that further in-depth research is conducted in this area.     

Prehospital Emergency Care in Shanghai: Present and Future

Background

In Shanghai, prehospital emergency medical services are provided by the public Ambulance Services. The 60th anniversary of the local Ambulance Services is a good opportunity to provide an overview of the current trends in prehospital emergency medical care in Shanghai.

Objectives

In this report, the features of Shanghai prehospital emergency medical care are described, as well as the Shanghai model of purely prehospital emergency medical care, including the communications and dispatch system, ambulance depots and ambulances, and prehospital rescue teams. Responses to major incidents including public health emergencies and natural disasters are also discussed, with the intention of highlighting future directions in emergency medical services, as well as the influence of international trends in emergency patient care.

Discussion

Although Shanghai has the most advanced dispatch system in China (equipped with a Global Positioning System, Global Information System, and more) and can be expanded quickly in case of mass casualty incidents, there is, as yet, no uniform Emergency Medical Service (EMS) dispatching for the entire city. Nor are there certifications, degrees, or special continuing education programs available for EMS dispatchers. Although there are more and more ambulance depots spread all over Shanghai, the city struggles with inadequate prehospital emergency caregivers, because every ambulance has to be staffed with a qualified Emergency Physician, and there are also recruitment problems for ambulance physicians.

Conclusions

Although faced with many challenges, substantial progress is expected in Shanghai prehospital emergency care.     

The outcome of a rapid training program on nurses’ attitudes regarding the prevention of aggression in emergency departments: A multi-site evaluation

Background

Patient aggression is a common source of occupational violence in emergency departments. Staff attitudes regarding the causes for aggression influence the way they manage it. The Management of Clinical Aggression – Rapid Emergency Department Intervention is a 45 min educational program that aims to promote the use of de-escalation techniques and effective communication skills to prevent patient aggression.

Objective

We sought to evaluate the impact of the program on staff attitudes regarding the prevention and early management of patient aggression.

Design

A mixed methods approach was used including a pre-test post-test survey of training participants and individual interviews with key stakeholders.

Setting and sample

The setting was public sector hospital emergency departments located in metropolitan and regional Victoria, Australia. A convenience sample of eighteen emergency departments was recruited via the Victorian Department of Health.

Participants

Survey participants were nurses and midwives who were employed at the study sites. Interview participants were a purposive sample of nurse unit managers and trainers.

Methods

The Management of Aggression and Violence Attitude Scale was administered to training participants immediately before and 6–8 weeks after training. Semi-structured telephone interviews with trainers and managers occurred 8–10 weeks after the intervention.

Results

Four hundred and seventy one participants completed the pre-test and post-test. Statistically significant shifts were observed in 5/23 items (Wilcoxon Signed Ranks Test: p ≤ 0.01). Despite training, participants were undecided if it was possible to prevent patient aggression, and continued to be unsure about the use of physical restraint. Twenty-eight (82.3%) of managers’ and trainers’ eligible to be interviewed provided their perceptions of the impact of the program. Overall, these perceptions were consistent with the significant shifts observed in the survey items.

Conclusion

There was limited evidence to demonstrate that the program significantly modified staff attitudes towards the prevention of patient aggression using the Management of Aggression and Violence Attitude Scale. Additional survey items that specifically measure staff attitudes about the use of restraint in emergency settings are needed to better understand decision making about restraining practices. Further work is indicated to quantify the impact of training in practice.