Pneumopericardium diagnosis by point‐of‐care ultrasonography

Focused cardiac ultrasound by the emergency physician has become a fundamental tool to expedite the diagnostic evaluation of the patient at bedside. We report the case of a patient admitted to the emergency department for respiratory distress. He was examined by an emergency physician who performed a bedside echocardiography. Bright spots were seen rapidly moving along the pericardial layer during diastole with comet‐tail artifacts extending across the whole image of the heart and disappearing during systole, suggesting pneumopericardium. © 2012 Wiley Periodicals, Inc. J Clin Ultrasound, 2013     

Solar‐Powered Point‐of‐Care Sonography: Our Himalayan Experience

The benefits of sonography utilization in low‐resource communities has been thoroughly demonstrated in the literature.^1–3 As ultrasound units have become smaller and more portable, the feasibility of bringing these imaging devices into more remote areas is becoming a reality. One factor that limits ultrasound use in austere environments is battery life. Although solar power has been used for oxygen delivery^5,6 in resource‐limited settings, its use in sonography has not been previously described. This report describes the use of a Lumify (Philips; Amsterdam, Netherlands) for a month‐long trip into a remote Himalayan region of India powered exclusively with an Anker (Shenzhen, China) solar panel for the entirety of the trip. According to the Palmetto Health Institutional Review Board, this does not qualify as “research” as defined by the US Department of Health and Human Services and therefore does not meet the requirements for institutional review board review.     

Out‐of‐hospital emergency care providers' work and challenges in a changing care environment

Acutely ill patients are often treated on site instead of being transported to hospital, so wide‐ranging professional competence is required from staff. The aim of this study was to describe and produce new information about out‐of‐hospital emergency care providers' competence, skills and willingness to engage in self‐development activities, and to uncover challenges experienced by care providers in the midst of changing work practices. A quantitative questionnaire was sent to out‐of‐hospital emergency care providers (N = 142, response rate 53%) of one Finnish hospital district. Data were analysed using spss for Windows 22 software. Almost all respondents found their work interesting and their ability to work independently sufficient. The majority found the work meaningful. Almost 20% felt that work was dominated by constant rush, and 40%, more than half of 25‐year‐olds but <10% of over 45‐years‐olds, found the work physically straining. The majority indicated that they had a sufficient theoretical–practical basis to perform their regular duties, and more than one‐third felt that they had sufficient skills to deal with multiple patient or disaster situations. Over 20% stated that they were unsure about performing new or infrequent procedures. A number of factors experienced as challenging were revealed. The results provide a basis for improving care providers' initial and further training.     

Patient‐related violence against emergency department nurses

In a finding that reflects international experiences, nurses in Australia have been identified as the occupation at most risk of patient‐related violence in the health‐care sector. A search of the literature was undertaken to explore this concept, with a focus on the emergency department and triage nurses. Significant findings included the fact that nurses are subjected to verbal and physical abuse so frequently that, in many instances, it has become an accepted part of the job. This attitude, combined with the chronic under‐reporting of violent incidents, perpetuates the normalization of violence, which then becomes embedded in the workplace culture and inhibits the development of preventative strategies and the provision of a safe working environment. Nurses are entitled to a safe workplace that is free from violence under both the occupational health and safety legislation and the zero‐tolerance policies that have been adopted in many countries including Australia, the UK, Europe, and the USA. Therefore, policy‐makers and administrators should recognize this issue as a priority for preventative action.     

Asteroid Hyalosis Masquerading as Vitreous Hemorrhage on Point‐of‐Care Sonography

Point‐of‐care ocular sonography is frequently used in the emergency department to evaluate patients with vision disorders. We describe a case series of 3 patients who ultimately had a diagnosis of asteroid hyalosis, a lesser‐known condition that on point‐of‐care sonography may be mistaken for vitreous hemorrhage. Asteroid hyalosis is considered a benign degenerative condition. In contrast, vitreous hemorrhage may be an ocular emergency that warrants an urgent ophthalmologic consultation if there is an underlying retinal tear or detachment. Although similar in appearance on sonography, recognition of the subtle pathognomonic sonographic features along with their clinical presentations can differentiate these diseases, with vastly different management strategies and dispositions.     

Review of mannequin‐based high‐fidelity simulation in emergency medicine

The spectrum of uses of high‐fidelity simulation in emergency medicine has increased in the past 10 years and ranges from teaching isolated skills to improving complex team behaviours in critical situations. This review will describe these published uses and explore the evidence supporting the use of high‐fidelity simulation, as well as the future directions and difficulties of using this technology in our specialty.     

Re‐presentation and suicide rates in emergency department patients who self‐harm

Objective: To investigate adult presentations to North Shore Hospital, Auckland, New Zealand, following deliberate self‐harm, determine re‐presentation and suicide rates and investigate the characteristics of those patients who re‐present. Methods: Retrospective review of a cohort of adult patients presenting to North Shore Hospital Emergency Care Centre in Auckland, New Zealand, with deliberate self‐harm between 1 January 2001 and 31 August 2002, using data from the National Minimum Data Set and Hospital Discharge Database. The re‐presentation rate was calculated as the percentage of patients presenting a second time within 1 year of their index presentation. The suicide rate was calculated as the percentage of patients with a coroner's verdict of suicide within 1 year of their index presentation of deliberate self‐harm. Results: There were 1055 presentations by 754 people during the presentation period. Of these 754 people, 136 presented for a second time within a year of the index case (136/754 [18.0%, 95% CI 15.5–21.0]). Eight of the seven hundred and fifty‐four people went on to commit suicide within 1 year (8/754 [1.1%, 95% CI 0.5–2.1]). Self‐poisoning was the most common method of self‐harm. Minor tranquillizers were used more commonly in the group who re‐presented. Conclusion: Re‐presentation and suicide rates in our study were similar to previously published rates. Further research is needed to identify strategies to reduce re‐presentations and excess mortality in all people who deliberately self‐harm.     

Do Knowledge and Experience Have Specific Roles in Triage Decision‐making?

Accuracy of triage decisions is a major influence on patient outcomes. Triage nurses' knowledge and experience have been cited as influential factors in triage decision-making. The aim of this article is to examine the independent roles of factual knowledge and experience in triage decisions. All of the articles cited in this review were research papers that examined the relationship between triage decisions and knowledge and/or experience of triage nurses. Numerous studies have shown that factual knowledge is an important factor in improving triage decisions. Although a number of studies have examined the role of experience as an independent influence on triage decisions, none have found a significant relationship between experience and triage decision-making. Factual knowledge appears to be more important than years of emergency nursing or triage experience in triage decision accuracy. Many triage education programs are underpinned by the assumption that knowledge acquisition will result in improved triage decisions. A better understanding of the relationships between clinical decisions, knowledge, and experience is pivotal for the rigorous evaluation of education programs.     

Effects of a Triage Process Conversion on the Triage of High‐risk Presentations

Objectives: The objective was to determine effects of a modification in triage process on triage acuity distribution in general and among patients with conditions requiring time‐sensitive therapy. Methods: The authors retrospectively reviewed triage acuity distributions before and after modification of their triage process that entailed conversion from the Canadian Triage and Acuity Scale (CTAS) to the Emergency Severity Index (ESI). The authors calculated the ratio of the odds of being triaged to a nonemergent level (3, 4, or 5) under ESI to the odds of being triaged as nonemergent under CTAS. The authors calculated sensitivity and specificity of triage to an emergent acuity level (1 or 2) for identifying patients with common presentations who required time‐sensitive care. Results: There were shifts from higher to lower acuity levels for all subsets, with odds ratios ranging from 2.80 (95% confidence interval [CI] = 2.75 to 2.86) for all patients to 21.39 (95% CI = 14.66 to 31.21) for patients over 55 years of age with a chief complaint of chest pain. The sensitivity of triage for identifying abdominal pain patients requiring admission to an intensive care unit (ICU) or operating room (OR) or emergency department (ED) death was 80.7% (95% CI = 73.2 to 86.5) before versus 50.8% (95% CI = 43.5 to 58.1) following the transition to ESI. Specificity under CTAS, 55.2% (95% CI = 54.0 to 56.4), was significantly lower than under ESI, 83.6% (95% CI = 82.7 to 84.4). The authors found similar effects for patients presenting with chest pain. Conclusions: Monitoring for changes in the sensitivity of the triage process for detecting patients with potentially time‐sensitive conditions should be considered when modifying triage processes. Further work should be done to determine if the decreased sensitivity seen in this study occurs in other institutions converting to ESI, and potential causative factors should be explored.     

Safety and effectiveness of high‐dose midazolam for severe behavioural disturbance in an emergency department with suspected psychostimulant‐affected patients

Objectives: To trial high‐dose midazolam sedation protocol for uncooperative patients with suspected psychostimulant‐induced behavioural disorders. End‐points were effectiveness and safety. Methods: A prospective pilot study was undertaken with a convenience sample of adult, uncooperative patients with suspected psychostimulant‐induced severe behavioural disorders. The protocol was midazolam in 10 mg increments, i.m. or i.v., at 10 min intervals, up to four doses and titrated to an end‐point of rousable drowsiness. Results: Sixty‐two patients were enrolled. Two‐thirds of the patients required only one dose of midazolam; 88% of the sample were sedated with two doses. Six and a half per cent of patients were not sedated after four doses. A Glasgow Coma Score of eight or less was prolonged in eight patients. Airway problems requiring an adjunct were present in four patients. Recent psychostimulant use was present in only 55% after full assessment. Conclusions: High‐dose midazolam protocols cannot be supported as universally safe. High‐dose protocols for severe behavioural disturbance are not more effective, with failures occurring even after repeated dosing.     

Mental health‐related learning needs of clinicians working in Australian emergency departments: A national survey of self‐reported confidence and knowledge

Objective: To identify the mental health‐related learning needs of doctors and nurses working in Australian EDs. Methods: A purpose‐designed survey was developed, and face validity was verified by 12 doctors and nurses. A cross‐sectional survey of a national sample of nurses and senior doctors (registrars and consultants) working in EDs across Australia was then undertaken. The survey consisted of 130 items and required approximately 20 min for completion. The survey was delivered online through email invitation by the College of Emergency Nurses Australasia or the Australasian College for Emergency Medicine. A hardcopy format of the survey was also delivered at a national conference. Results: Mental health presentations that involved a diagnosis of personality disorder, psychosis or behavioural disturbance, and the management of these conditions were patient factors that were considered problematic by up to 46.3% (118/255; 95% CI 40.26–52.40) of doctors and 66.1% (72/109; 95% CI 56.74–74.28) of nurses. Determining care plans, conducting mental status examinations, assessing risk of self‐harm, pharmacology for treatment and for chemical restraint, management of patient aggression or violence, and alcohol or drug intoxication were also found to be areas of knowledge deficit. Conclusion: Doctors and nurses reported deficits in confidence and knowledge in tasks and patient presentations that they might frequently be expected to manage. These data can be used to inform future curricula at both undergraduate and postgraduate levels. Ultimately, this might pave the way for improved care and management of patients with mental health problems presenting to the ED.     

Informing emergency care for COVID‐19 patients: The COVID‐19 Emergency Department Quality Improvement Project protocol

Objectives: There is an urgency to support Australian ED clinicians with real‐time tools as the COVID‐19 pandemic evolves. The COVID‐19 Emergency Department (COVED) Quality Improvement Project has commenced and will provide flexible and responsive clinical tools to determine the predictors of key ED‐relevant clinical outcomes. Methods: The COVED Project includes all adult patients presenting to a participating ED and meeting contemporary testing criteria for COVID‐19. The dataset has been embedded in the electronic medical record and the COVED Registry has been developed. Results: Outcomes measured include being COVID‐19 positive and requiring intensive respiratory support. Regression methodology will be used to generate clinical prediction tools. Conclusion: This project will support EDs during this pandemic.