Emergency Medicine Commons^™

Educational Point-Of-Care Ultrasound Discovers Adrenal Cortical Carcinoma, A Case Report: Clinical Implications And Review Of The Literature, Minh Q. Nguyen, Moshe Bengio, Vu H. Tran

HCA Healthcare Journal of Medicine

Introduction

Point-of-care ultrasound (POCUS) has become an indispensable tool for emergency physicians in assessing intra-abdominal pathology due to its real-time visualization, portability, and cost-effectiveness. While POCUS is not traditionally focused on adrenal gland assessment, incidental findings of adrenal masses during examinations have been reported. Our patient presented with a chronic obstructive pulmonary disease (COPD) exacerbation and was found to have a large adrenal mass, discovered incidentally, during thoracic ultrasound.

Case Presentation

This case report presents the discovery of an adrenal mass in a patient with respiratory distress due to a COPD exacerbation, emphasizing the importance of sonographers’ ability to identify …

A Case Of Adrenal Insufficiency Presenting With Seizures, Complicated By Developmental Cerebral Venous Anomaly And Takotsubo Cardiomyopathy: A Case Report, Katrina Villegas, Brittany Eason, Karolina Janiec, Alaa Musallam, Ahmed Hammouda, Samia Ammar Aldwaik, Radhika Tailor

Rowan-Virtua School of Osteopathic Medicine Departmental Research

BACKGROUND: Adrenal insufficiency is a potentially life-threatening condition that often presents with nonspecific symptoms. While fatigue, hypotension, and electrolyte disturbances are common features, seizures and stress-induced cardiomyopathy are rare initial manifestations. This case is reported for its atypical presentation and to highlight the diagnostic challenge it posed in the absence of classic biochemical findings.

CASE PRESENTATION: We report a case of a 68-year-old Hispanic woman with diabetes, hypertension, dyslipidemia, and hypopituitarism secondary to Sheehan syndrome, who presented with new-onset seizures after abruptly discontinuing chronic steroid therapy. Her symptoms included progressive weakness and behavioral changes over several weeks. Initial evaluation revealed …

Fatal Facial Necrotizing Fasciitis: A Case Report Highlighting Diagnostic And Therapeutic Challenges, Muhammad Sheraz Hameed, Syed Rafay Hussain Zaidi, Ali Iqbal, Muhammad Ahsan, Austin Mitchell, Azka Asad Mirza, Joshiah Gordon, Rahmat Gul Omarzai

Department of Medicine Faculty Papers

BACKGROUND: Facial Necrotizing Fasciitis (FNF) is a rare but aggressive, life-threatening infection involving the face's subcutaneous tissues and underlying musculature. It can rapidly progress to septic shock and multi-organ failure if not promptly recognized and treated. The clinical course, including severe pain, disproportionate tenderness, and systemic signs, is often the most crucial factor in diagnosis. While computed tomography (CT) can aid in identifying early signs such as soft tissue swelling and gas formation, clinical suspicion remains paramount and should not be delayed by reliance on imaging alone. Without early intervention, FNF may lead to devastating outcomes, including disfigurement, blindness, or …

Temporal Trends Of A Cellular Host Response Test For Sepsis And A Comparison With Selected Biomarkers Of Inflammation And Infection, Matthew S. Berlinger, Matt Sorrells, Christopher B. Thomas, Tonya Jagneaux, James E. Walker, Jennifer Daigle, Heather Quiriarte, Youyoung Kim, Guillaume Spielmann, Debbie Robertson, Susan Park Ochsner, Gideon Avornu, Katherine Fenstermacher, Elijah James Kurien, Camille King, Adenine Cembellin-Kao, Chase Yonamine, Querino Maia, Maciej Obrebski, David N. Hager, Roya Sheybani, Henry T.K. Tse, Ajay M. Shah, Robert Scoggins, Hollis R. O’Neal, Richard Rothman

School of Medicine Faculty Publications

Sepsis, a condition characterized by immune dysregulation, is the leading cause of in-hospital mortality and requires rapid treatment. Assessing immune dysregulation has been challenging. The IntelliSep Index (ISI), a novel biomarker which leverages microfluidic deformability cytometry to assess immune activation, has been evaluated as a test for Emergency Department use but it is unclear how the signal evolves as patient condition evolves. In a 47-patient cohort with hospital stays ≤ 14 days, ISI provided a good indicator of disease progression by blinded physician review. ISI trends correlated with clinical improvement over time. During the first 12 h following presentation, ISI …

Nurse-Initiated Improvement For Documentation Of Penicillin Adverse Drug Reactions In Pediatric Urgent Care Clinics., Elizabeth Monsees, Diane Petrie, Rana El Feghaly, Sarah Suppes, Brian R. Lee, Megan Whitt, Amanda Nedved

Manuscripts, Articles, Book Chapters and Other Papers

Background/Objective: Penicillin allergy labels (PALs) contribute to broad-spectrum antibiotic use. Thorough documentation can help prescribers identify and remove unnecessary PALs. We aimed to improve documentation of PALs in three pediatric urgent care (PUC) clinics, using a nurse-initiated quality improvement (QI) approach. Methods: QI interventions included a survey to assess prescriber and nurse confidence, an online educational module, and an algorithm to aid in clarifying PALs. We measured the percentage of PALs with a clarified reaction severity as our primary outcome using annotated control charts. Descriptive and inferential statistics evaluated survey responses between nurses and prescribers. Results: Clarified PAL reaction severity …

Patterns Of Ophthalmology-Related Interfacility Transfers To The Emergency Department By Temporal Trends, Laura E. Ramirez, Michael Waxman, Denis R. Pauze, Edward J. Wladis

Journal of Academic Ophthalmology

Background: Interfacility transfer patients are associated with inferior outcomes, higher costs, and emergency department (ED) overcrowding. Previous studies have analyzed the general trends influencing interfacility transfers, but the patterns affecting ophthalmology-related transfer rates remain unclear. The purpose of this study was to identify and quantify the patterns of interfacility ophthalmology-specific transfers to the ED by temporal trends and to determine the type of ophthalmic services required by the transferred population.

Methods: All patients transferred to the ED of a single level 1 trauma center because of ophthalmology-related complaints from 2016 to 2023 were analyzed retrospectively. Transfer and nontransfer …

Implementation Of A Triage System For The Residents At A Residential Facility To Improve Triage Assessment Skills Of The Staff As Well As Improve The Level And Timeliness Of Care, Andrew J. Choi Rn, Neha Gopal Rn, Andres N. Padilla Rn, Dana Son

Master's Projects and Capstones

Triage is an integral part of the clinical process which involves assessing patients and determining their level of care in order to get them appropriate, timely treatment. Several countries utilize a standardized triage system with established criteria to aid staff in their decision-making during assessments (Peta et al., 2023). The Nursing and Residential Triage (NaRT) tool, from the Manchester Triage System (MTS), was shown to enhance staff clinical assessment skills and help avoid inappropriate ED transfers during a study among older adults in a residential facility (Markey et al., 2024). For this project, the main issue identified at the residential …

Sustained Impact: Long-Term Application Of Diagnostic Uncertainty Communication Training, Danielle M. Mccarthy, Jethel Hernandez, Dimitrios Papanagnou, Kenzie A. Cameron, David H, Salzman, Andrew W. Long, Alexandra D. Franiek, Kristin L. Rising

Department of Emergency Medicine Faculty Papers

OBJECTIVES: More than one-third of discharged emergency department (ED) patients leave without a clear diagnosis for their symptoms. In 2019-2020, we implemented a simulation-based mastery learning curriculum across two academic medical centers to train emergency medicine residents to discuss diagnostic uncertainty during ED discharge, guided by the Uncertainty Communication Checklist (UCC). We sought to assess if this cohort continues to apply skills learned and to obtain trainee insights into the most valuable checklist items.

METHODS: A survey was emailed to all 109 participants who completed the training in 2019-2020. Questions assessed how often participants currently encountered uncertainty and used the …

Twelve Tips To Help Junior Faculty Review Medical Education Literature With Confidence, Abagayle Bierowski, Casey Morrone, Ridhima Ghei, Michael Pasirstein, Dimitrios Papanagnou

Department of Emergency Medicine Faculty Papers

Peer reviews play a critical role in maintaining the quality, credibility, and advancement of medical education scholarships. While many early career faculty members are eager to contribute to the peer review process, there are few formal resources available to guide them in how to approach this work effectively. This article offers 12 practical tips tailored specifically for junior faculty who are new to reviewing medical education manuscripts. These tips cover key aspects of the review process, including how to structure feedback, evaluate methodological rigor, assess alignment with journal aims, and communicate constructively with authors and editors. The guide also emphasizes …

Resonant Disruptions: Understanding Canadian Nurses’ Practice With Youth Survivors Of Sexual Exploitation, Danielle E. Giebelhaus, Andrew Estefan Phd, Rpn

Dignity: A Journal of Analysis of Exploitation and Violence

The sexual exploitation of youth is a global concern. Youth survivors of sexual exploitation present to and require healthcare services, but most nurses do not feel effectively equipped to care for this population. There is currently little nursing literature to guide nurses in their practice with youth survivors. In this article, we report on a qualitative, hermeneutic study undertaken to explore nursing practice with youth survivors of sexual exploitation. Hermeneutics is concerned with understanding, and is a helpful way to conduct research when little is known about a topic. In this study, we asked the research question, “How might we …

Outcomes And Resource Utilization In Hyperkalemic Emergency Department Patients Treated With Patiromer Or Sodium Zirconium Cyclosilicate., William Frank Peacock, Zubaid Rafique, Julie Gayle, James Neuenschwander, Harold Brown, Jennifer Kammerer, Jeffrey Budden, Ning Rosenthal

Ambulatory and Primary Care Articles

OBJECTIVES: Hyperkalemia (HK) is a life-threatening condition commonly treated in emergency department (ED). Real-world outcomes associated with ED administration of potassium binders are limited. This study assessed ED discharge disposition and resource utilization in hyperkalemic ED patients treated with patiromer or sodium zirconium cyclosilicate (SZC).

METHODS: We performed a retrospective cohort study using discharge data from 230 hospitals in the Premier PINC AI Healthcare Database. ED patients were included if they were ≥18 years old, had potassium ≥5 mEq/L, and received patiromer/SZC during January 1, 2019 to December 31, 2021. Descriptive statistics and multivariable logistic regression analysis were used to …

Work Impairment And Financial Outcomes Among Adults With Vs Without Long Covid, Michael Gottlieb, Ji Chen, Huihui Yu, Michelle Santangelo, Erica S. Spatz, Nicole L. Gentile, Rachel E. Geyer, Caitlin Malicki, Kristyn Gatling, Kelli N. O'Laughlin, Kari A. Stephens, Joann G. Elmore, Lauren E. Wisk, Michelle L'Hommedieu, Robert Rodriguez, Juan Carlos C. Montoy, Ralph C. Wang, Kristin L. Rising, Efrat Kean, Jonathan W. Dyal, Mandy J. Hill, Arjun K. Venkatesh, Robert A. Weinstein

Department of Emergency Medicine Faculty Papers

IMPORTANCE: While much of the focus on long COVID (LC; defined as developing new, persistent symptoms lasting 3 months or longer after SARS-CoV-2 infection) has been on health status and quality of life, the impact on individual work productivity and financial distress are less well established.

OBJECTIVES: To assess differences in work and financial outcomes among individuals with current, resolved, and no LC up to 3 years after initial infection.

DESIGN, SETTING, AND PARTICIPANTS: This prospective, multisite, longitudinal cohort study enrolled adult participants (age ≥18 years) with at least 1 reported SARS-CoV-2 infection from December 7, 2020, to August 29, …

Maximizing Relief: The Benefits Of Combining Lateral Femoral Cutaneous Nerve Block With Sciatic Nerve Block In The Emergency Department, Courtney Smith, Taryn Hoffman

Florida Journal of Emergency Medicine (FJEM)

Low back pain accounts for more than 2.6 million emergency department (ED) visits annually, with 40% of Americans experiencing sciatica at some point in their lives. Our case report describes a patient presenting with atraumatic right-sided low back pain and paresthesias in her right leg. We utilized a combination of a transgluteal sciatic nerve block and a lateral femoral cutaneous nerve block to achieve improved pain relief after an initial isolated transgluteal sciatic nerve block left her with persistent anterolateral thigh pain.

We detail the technique for performing this procedure under ultrasound guidance. Our patient experienced significant pain improvement and …

"Star Sign" Of Subarachnoid Hemorrhage, Shivani Ruf

Florida Journal of Emergency Medicine (FJEM)

A 60-year-old female who was brought to the emergency department after a syncopal episode. She was found to have a subarachnoid hemorrhage (SAH) from a ruptured anterior communicating artery aneurysm. Her CT showed the classic "star sign" of SAH.

Elderly Woman With Bilateral Finger Pain, Eric Boccio, Claudia Risi

Florida Journal of Emergency Medicine (FJEM)

N/A

Paroxysmal, Severe, And Unilateral Facial Pain In Adult Male, Eric Boccio, Joshua Mcfarlane, Jeannine Bobadilla

Florida Journal of Emergency Medicine (FJEM)

No abstract provided.

Participant Engagement In A National Longitudinal Study Of Covid-19: Insights From The Inspire Study, Kris Pui Kwan Ma, Tracy Stober, Michael Gottlieb, Rachel E. Geyer, Kristin L. Rising, Sharon Saydah, Michelle Santangelo, Kristyn Gatling, Dylan Grau, Ralph C. Wang, Juan Carlos Montoy, Ahamed Idris, Samuel Macdonald, Mandy J. Hill, Ryan Huebinger, Maria G. Prado, Nicole L. Gentile, Erica Spatz, Caitlin Maliki, Jocelyn Dorney, Joann G. Elmore, Michelle L'Hommedieu, Robert A Weinstein, Arjun K. Venkatesh, Kari A. Stephens

Department of Emergency Medicine Faculty Papers

OBJECTIVE: To examine participants' motivations and their experiences throughout a decentralized, longitudinal COVID-19 study in the U.S.

METHODS: We recruited 355 participants from the Innovative Support for Patients with SARS-CoV-2 Infections Registry (INSPIRE) between November 2022 - March 2023 to answer five qualitative survey questions anonymously. We used an inductive content analysis approach to analyze the data.

RESULTS: We identified five key themes from the analysis, which reflected participants' a) motivations to join the study, b) study benefits, c) perceptions of survey questions, d) experiences with the research process, and e) preferences for disseminating research findings. Participants were motivated to …

Impact Of Sars-Cov-2 On Healthcare And Essential Workers: A Longitudinal Study Of Promis-29 Outcomes, Jocelyn Dorney, Imtiaz Ebna Mannan, Caitlin Malicki, Lauren E. Wisk, Joann Elmore, Kelli N. O'Laughlin, Dana Morse, Kristyn Gatling, Michael Gottlieb, Michelle Santangelo, Michelle L'Hommedieu, Nicole L. Gentile, Sharon Saydah, Mandy J. Hill, Ryan Huebinger, Katherine Riley Martin, Ahamed H. Idris, Efrat Kean, Kevin Schaeffer, Robert M. Rodriguez, Robert A. Weinstein, Erica S. Spatz, Inspire Group

Department of Emergency Medicine Faculty Papers

IMPORTANCE: The mandatory service of essential workers during the COVID-19 pandemic was associated with high job stress, increased SARS-CoV-2 exposure, and limited time for recovery following infection. Understanding outcomes for frontline workers can inform planning for future pandemics.

OBJECTIVE: To compare patient-reported outcomes by employment type and SARS-CoV-2 status.

DESIGN: Data from the INSPIRE registry, which enrolled COVID-positive and COVID-negative adults between 12/7/2020-8/29/2022 was analyzed. Patient-reported outcomes were collected quarterly over 18 months.

SETTING: Participants were recruited across eight US sites.

PARTICIPANTS: Employed INSPIRE participants who completed a short (3-month) and long-term (12-18 month) survey.

EXPOSURE: SARS-CoV-2 index status and …

Best Practice Toolkit For Burnout Prevention In Emergency Department Nurses, Moises A. De Oleo

Student Scholarly Projects

Practice Problem: Burnout Syndrome (BS) is a serious problem in emergency department (ED) nurses and is associated with higher nurse turnover rates. A burnout prevention toolkit is needed.

PICOT: The project was guided by the following PICO question: "For emergency department nurses (P), how does the development of the best practice burnout prevention toolkit (I), compared to the absence of a structured intervention (C), support the establishment of nurse burnout best practices when evaluated using the CDC Program Evaluation Framework? (O)".

Evidence: The analysis of the literature supported the implementation of active interventions in the form of workshops.

Intervention: A …

Exploring The Impact Of The Emergency Department Built Environment On Physician Workplace Stress: A Qualitative Study Utilizing High-Fidelity Virtual Reality, J Matthew Fields, Alan Price, Billie Faircloth, Eden Blas, Marah Sakkal, Sabrina Naumovski, Robert Ries, Callum Hamilton, Kit Elsworth, Morgan Hutchinson, Bon Ku, Christopher Connock, Jennifer Kahoud

Department of Emergency Medicine Faculty Papers

OBJECTIVES: Physician burnout in emergency medicine has serious consequences. An underrecognized stressor for physicians may be the emergency department (ED) environment itself. EDs can be noisy and chaotic, lack natural light, and have challenging layouts that create patient care and safety concerns. This study examines the relationship between the ED-built environment and physician workplace stress.

METHODS: A qualitative study of ED-attending physicians from a level I trauma center ED in Philadelphia was conducted. Participants underwent a semistructured interview followed by a walkthrough of a high-fidelity virtual reality (VR) simulation of the participant's ED. In the VR simulation, they rated the …