Johnson City Medical Center is a hospital in Johnson City, Tennessee. It is a Level I Trauma Center and one of three major tertiary referral hubs of regional provider Ballad Health. It has 445 beds, plus 86 in the attached Niswonger Children's Hospital. It is also a teaching hospital for numerous institutions, including the adjacent East Tennessee State University James H. Quillen College of Medicine.Physician and author Abraham Verghese described his experiences treating HIV in the 1980s at Johnson City Medical Center, as well as the neighboring Mountain Home VA Medical Center, in his memoir My Own Country.Since 2018 the facility has been operated by Ballad Health..
Undertriage remains a significant challenge in rural trauma systems, where over 42 million Americans live more than an hour from a Level I or II trauma center. Paramedic discretion (PD) may serve as a practical adjunct to formal activation criteria by identifying patients who fall outside standard triggers yet require trauma system resources. The goal of this study was to evaluate the systems-level role of PD as a second-tier trauma activation (STA) criterion at a rural Level I Trauma Center. This was a retrospective study including adult patients evaluated as STA at a Level I Trauma Center over the course of 4.5 years using two comparison groups: STAs meeting criteria (2283 patients) and STAs activated by PD (1115 patients). PD-activated patients demonstrated equivalent outcomes to criteria-activated patients across all primary endpoints, including hospital length of stay (LOS) ≤ 48 hours (P = 0.116), mortality(P = 0.578), discharge home (P = 0.069), and Intensive Care Unit (ICU) admission (P = 0.156). PD preferentially identified geriatric patients, those with blunt trauma mechanisms, and those with open wounds; populations recognized as being at elevated risk of undertriage. These findings suggest PD functions as an effective triage adjunct that reduces undertriage in rural trauma systems where standardized criteria alone may be insufficient.
PURPOSE:The purpose of this report is to highlight a case of utilizing weight-based enoxaparin for prophylaxis of venous thromboembolism (VTE) in an elderly, extremely underweight patient. VTE represents a significant concern for hospitalized patients. There is a dearth of literature regarding utilization of low-molecular-weight heparins such as enoxaparin or unfractionated heparin in patients who are underweight. SUMMARY:In this case, a 68-year-old female who was extremely underweight (21.8 kg) presented to the emergency department in acute respiratory distress secondary to pneumonia and a chronic obstructive pulmonary disease exacerbation. The patient had a Padua score of 5 and an IMPROVE score of 2 that signified the necessity of pharmacologic VTE prophylaxis. A clinical decision was made to utilize a weight-based enoxaparin dosing strategy for VTE prophylaxis using a pediatric dilution to deliver the dose. Enoxaparin was initiated at 0.5 mg/kg (10 mg) subcutaneously daily and monitored via anti-factor Xa peak levels to verify that the dose provided an adequate prophylactic level. Ultimately, a dose of 0.5 mg/kg resulted in an appropriate anti-factor Xa level of 0.21 units/mL, equating to suitable VTE prophylaxis. CONCLUSION:A review of the literature revealed little evidence for optimal anticoagulation dosing for VTE prophylaxis in adult patients weighing under 40 kg. Various adjustment strategies have been utilized; however, there is no available evidence pertaining to patients at the extreme of low weight represented by the reported case or to attainment of an anti-factor Xa level within the therapeutic range in such patients. This case represents the use of a weight-based enoxaparin strategy for an extremely underweight elderly patient and the attainment of a therapeutic prophylactic anti-factor Xa level.
Abstract Granulomatosis with polyangiitis (GPA) is a necrotizing small-vessel vasculitis classically involving the upper and lower respiratory tracts and kidneys. While pulmonary-renal syndrome is a recognized severe manifestation, presentation with gastrointestinal bleeding and fulminant respiratory failure is exceedingly rare. Early recognition is critical, as timely immunosuppressive therapy can be lifesaving. We report a case of GPA manifesting with massive gastrointestinal bleeding and catastrophic pulmonary-renal syndrome complicated by severe acute respiratory distress syndrome (ARDS) requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO). A 45-year-old man with a history of asthma and prediabetes presented with hematemesis and melena following two months of intermittent vomiting and one month of dark stools, acutely worsening over two days. On arrival, he was tachycardic and profoundly hypoxic (SpO2 70% on room air). Laboratory evaluation revealed severe anemia (Hgb 5.7 g/dL), marked azotemia (BUN 130 mg/dL, Cr 19.26 mg/dL), metabolic acidosis (HCO3 11 mmol/L, anion gap >18), and hyperkalemia. Chest radiograph showed diffuse bilateral airspace opacities concerning for pneumonia, and broad-spectrum antibiotics were initiated. The patient’s condition rapidly deteriorated, developing acute hypoxemic respiratory failure and oliguric renal failure requiring intubation, vasopressor support, and initiation of renal replacement therapy. Despite maximal ventilatory support, severe ARDS ensued, refractory to high PEEP and FiO2, necessitating rescue VV-ECMO. Given the concurrent respiratory and renal failure, high-dose intravenous methylprednisolone was initiated for presumed autoimmune vasculitis. Serologic testing returned positive for cytoplasmic ANCA (c-ANCA) and anti-proteinase 3 antibodies. Subsequent renal biopsy revealed chronic crescentic pauci-immune glomerulonephritis with fibrosis and crescent formation, confirming ANCA-associated vasculitis. The patient was diagnosed with GPA presenting as pulmonary-renal syndrome and treated with rituximab and a corticosteroid taper. Over several weeks, he demonstrated remarkable recovery in both renal and pulmonary function, was successfully decannulated from ECMO, and later discharged to rehabilitation. This case highlights an extraordinary presentation of GPA manifesting as gastrointestinal bleeding with life-threatening pulmonary-renal involvement. The overlap of diffuse alveolar hemorrhage and ARDS can obscure the underlying vasculitic process, delaying immunosuppressive therapy. Clinicians should maintain a high index of suspicion for ANCA-associated vasculitis in patients presenting with unexplained pulmonary infiltrates, renal failure, and anemia. Early recognition, prompt initiation of immunosuppression, and multidisciplinary coordination, including ECMO as a bridge to recovery, can significantly improve survival in catastrophic presentations of systemic vasculitis. This abstract is funded by: None
Comorbidity burden in patients with acute cholecystitis (AC) managed by percutaneous cholecystostomy tube (PCT) placement may determine whether patients progress to cholecystectomy (CCY) or require ongoing non-operative management. This retrospective observational case series examined 139 patients admitted with PCT placement for AC at a rural Appalachian tertiary referral center between October 2020 and March 2025. The most prevalent comorbidities among these patients were hypertension (79.9%), smoking (61.2%), and hyperlipidemia (47.5%). Of the 139 patients, 31.7% (n = 44) underwent subsequent CCY and had 78.7% lower 6-month mortality compared to those managed non-operatively (P < .001). Patients progressing to CCY had significantly lower Charlson Comorbidity Index (CCI) scores (3.89 vs. 5.57, P = .05) and were significantly less likely to have active cancer (P = .002), COPD (P = .001), or CHF (P = 0.032). In resource-constrained environments where advanced endoscopic alternatives are unavailable, these comorbidity profiles can guide preoperative risk stratification and inform individualized counseling regarding anticipated treatment pathways after PCT.
