IntroductionMarijuana is a commonly used drug in the United States. Many states have legalized the recreational use of marijuana. The effects of marijuana on mental health are unknown. MethodsIn this prospective survey study, eligible participants included ED patients age 18 and older, who had ever used recreational marijuana. A survey instrument was developed, piloted, and revised. Data collected included reasons for marijuana use, marijuana's perceived effectiveness, and history of mental health conditions, including depression, anxiety, and suicidal thoughts. ResultsAmong 303 participants (86% response rate), the median age of first marijuana use was 16 ([IQR 14, 19], range 6-65). The most commonly cited reasons for marijuana use included recreational use (70%; n = 211), to treat anxiety (30%; n = 89), to treat pain (25%; n = 74), and to treat depression (17%; n = 51). Mental health issues were common in the study population. A majority of patients reported anxiety in the last 30 days (59%; n = 176), and a significant minority of patients reported serious depression in the last 30 days (46%; n = 137). Some patients reported suicidal thoughts in the last 30 days (9%; n = 29). Participants who used marijuana more frequently reported more days of anxiety (median 15.5, compared to 1; P = 0.001). Among participants with mental health conditions, most began using marijuana before the onset of the mental health conditions (77%, n = 167). Earlier age of starting to use marijuana was correlated with higher number of years of anxiety or tension in lifetime (r = -0.11, P = 0.05, n = 301). Perceived effects of marijuana use on mental health were variable. Most participants stated that marijuana improved their mental health (62%; n = 163), and some reported that marijuana did not improve their mental health (37%; n = 98). ConclusionsMany ED patients have used marijuana, either currently or in the past. Mental health conditions are also common, including anxiety, depression, and suicidal thoughts. Most participants reported marijuana use starting at an age under 18. Marijuana use preceded the onset of mental health conditions in the majority of participants.

National Highway Traffic Safety Administration (NHTSA) reports that seat belt use results in a significant decrease in MVC mortality. The rate of obesity is currently extensive. There is limited data on the impact of seat belt use and body mass index (BMI) on mortality and trauma outcomes following MVCs. This study aimed to evaluate the impact of seat belt use and BMI on outcomes in adult trauma patients.A four-year review using our Level I Trauma Center registry. Patients were divided by BMI into normal weight BMI < 25 (NL-BMI), overweight BMI 25–29.9, and obese BMI ≥ 30. Groupings were subdivided by seat belt use into patients wearing a seat belt at the time of injury (seatbeltPOS) and those who were not (seatbeltNEG).11,792 patients involved in MVCs were included in our study. 4515 (38.3%) were NL-BMI, 4583 (38.9%) were overweight, and 2694 (22.8%) were obese. SeatbeltPOS patients had significantly lower mortality compared to seatbeltNEG, regardless of BMI, with 12/1394 (0.86%) in seatbeltPOS compared to 274/10,398 (2.64%) deaths in seatbeltNEG patients (p ≪ 0.001). Evaluated by BMI, overweight and obese seatbeltPOS patients had significantly less deaths 7/900 (0.78%) vs overweight and obese seatbeltNEG patients 179/6377 (2.81%) (p = 0.0004). NL-BMI seatbeltPOS patients also had significantly lower mortality 5/494 (1.01%) compared to NL-BMI seatbeltNEG patients 95/4021 (2.36%), (p = 0.048).Use of a seat belt reduced Trauma Center mortality regardless of BMI. Seat belts should be used by all patients as a mechanism to significantly reduce mortality.

1. Feeling nervous, anxious, or on edge 118 (36.9%) 58 (18.1%) 49 (15.3%) 95 (29.7%) 2. Not being able to stop or control worrying 130 (40.6%) 57 (17.8%) 40 (12.5%) 93 (29.1%) 3. Worrying too much about different things 101 (31.6%) 54 (16.9%) 55 (17.2%) 110 (34.4%) 4. Trouble relaxing 93 (29.1%) 62 (19.4%) 49 (15.3%) 116 (36.3%) 5. Being so restless that it's hard to sit still 153 (47.8%) 47 (14.7%) 48 (15.0%) 72 (22.5%) 6. Becoming easily annoyed or irritable 97 (30.3%) 74 (23.1%) 57 (17.8%) 92 (28.8%) 7. Feeling afraid as if something awful might happen 186 (58.1%) 54 (16.9%) 22 (6.9%) 58 (18.1%)

Non-contrast magnetic resonance imaging (MRI) and ultrasound studies in pediatric patients with suspected appendicitis are often non-diagnostic. The primary objective of this investigation was to determine if combining these non-diagnostic imaging results with white blood cell (WBC) cutoffs improves their negative predictive values (NPVs).A retrospective chart review was conducted including patients ≤18 years old with suspected appendicitis who had MRI performed with or without a preceding ultrasound study in a pediatric emergency department. Imaging results were sorted into 2 diagnostic and 5 non-diagnostic categories. NPVs were calculated for the non-diagnostic MRI and ultrasound categories with and without combining them with WBC cutoffs of <10.0 and <7.5 × 109/L.Of the 612 patients with MRI studies included, 402 had ultrasound studies performed. MRI with incomplete visualization of a normal appendix without secondary signs of appendicitis had an NPV of 97.9% that changed to 98.1% and 98.2% when combined with WBC cutoffs of <10.0 and <7.5, respectively. Ultrasound studies with incomplete visualization of a normal appendix without secondary signs had an NPV of 85.3% that improved to 94.8% and 96.5% when combined with WBC cutoffs of <10.0 and <7.5, respectively.In pediatric patients with suspected appendicitis, MRI studies with incomplete visualization of a normal appendix without secondary signs have a high NPV that does not significantly change with the use of these WBC cutoffs. In contrast, combining WBC cutoffs with ultrasound studies with the same interpretation identifies low-risk groups.

This study aims to evaluate the serum S100B levels to predict neuronal damage and poor clinical outcomes associated with the use of synthetic cannabinoids.Thirty patients identified as synthetic cannabinoid users and 30 healthy controls were included in the study. S100B levels were compared between healthy controls and synthetic cannabinoid users. The following were considered to be composite outcomes: the need for endotracheal intubation, incidence of seizures, the need for intensive care unit admission, and in-hospital mortality. Clinical and laboratory findings associated with composite clinical outcomes were examined.The mean S100B level was 19.3 (95% CI: 17.7 to 21.4) pg/mL in patients who use synthetic cannabinoid, and 15.9 (95% CI: 15 to 16.9) pg/mL in the controls; mean df: –3.6 (95% CI: –5.6 to − 1.6). In patients with and without composite clinical outcomes, the mean S100B level measured 24.5 (95% CI: 21.2 to 27.9) pg/mL and 17.4 (95% CI: 15.8 to 18.4) pg/mL, respectively; mean df: –7.4 (95% CI: –10.2 to − 4.6). With the cut-off value for S100B set at 20 pg/mL based on the highest sensitivity, the sensitivity, specificity, PPV, and NPV for S100B were 89.9%, 52.0%, 44.4%, and 91.9%, respectively; odds ratio: 13.2, 95% CI (2.1 to 28.1).Our data suggest that serum S100B levels are elevated in patients using synthetic cannabinoids. These results show that S100B can help clinicians stratify risk or may have a role in excluding those with neuronal damage.

Background: Emergency department (ED) visits for unintentional opioid overdoses have increased dramatically. Naloxone hydrochloride (Narcan (R)) is an opioid antagonist commonly used to treat these overdoses. Objective: This study was undertaken to identify experiences regarding naloxone use among ED patients with opioid overdose. Methods: This prospective survey study was conducted at an urban level I trauma center. A survey was administered to eligible ED patients after unintentional opioid overdose. This study identified current and previous use of naloxone among ED patients with opioid overdose. Results: Eight-nine ED patients with accidental overdose of opioids participated (90% participation rate). Most participants reported a history of opioid overdose (n = 62 [70 %]). A significant minority stated they have had access to a naloxone kit (n = 28 [31 %]). Most participants with a naloxone kit stated that their frequency and dosage of opiate use did not change after access to naloxone (n = 17 [63 %]), and a few used opiates more often (n =1 [4 %]) or less often (n = 9 [33 %]). There was a significant negative correlation between total dose and age (Spearman p -0.27; p = 0.01). There was no association between dose and sex. Conclusions: Many patients presenting with opioid overdose have had a history of opioid overdose. Patients with opioid overdose required a highly variable dose of naloxone. Higher doses of naloxone were associated with lower age. Despite widespread availability of naloxone to consumers, a minority of patients in this study reported access to naloxone. Participants who had access to a naloxone kit stated that their frequency and dosage of opioid use did not change. (C) 2018 Elsevier Inc. All rights reserved.

Introduction: Treatment for pain and related conditions has been identified as the most common reason for Emergency Department (ED) visits. Concerns exist regarding the effects of opioid pain medications on cognition and patient ability to consent for procedures, hospital admission, or to refuse recommended medical interventions. This study was undertaken to identify cognitive skills before and after opioid pain medication in the ED setting. Methods: This was a prospective study comparing performance on the Mini-Mental Status Examination (MMSE) and Montreal Cognitive Assessment (MoCA) before and after administration of opioid pain medications. Eligible participants included ED patients with pain, who received opioid treatment. Participants were randomized to receive either the MMSE before pain medication and the MoCA after medication, or the reverse. MoCA scores were converted to MMSE equivalent scores for comparison. Results: Among 65 participants, the median age was 36 and median triage pain score was 8.35% of patients were considered cognitively impaired based on their MMSE score prior to any opioid medication (MMSE < 27). There was a median decrease in pain scores of 1 point following pain medication, p-value < 0.001. There was a median decrease in MMSE scores of 1 point following pain medication, p-value = 0.003. The range of change in scores (post minus pre) on the MMSE-equivalent was -7 to 3.35 patients (56%) had a decrease in scores, 6 (10%) had no change, and 21 (34%) had an increase. After medication, 31 (48%) were abnormal (MMSE score < 27). No differences in MMSE scores were identified by gender, ethnicity, mode of arrival, insurance, age, triage pain scores, opioid agent given, or ED diagnosis. Conclusions: There is an association between opioid pain medication and decrease in cognitive performance on the MMSE. Because of the wide range of cognitive performance following opioid pain medication, assessment of individual patients' cognitive function is indicated. (C) 2017 Elsevier Inc. All rights reserved.

IntroductionThe presentation of an ill appearing patient with profuse diarrhea should raise a concern for systemic effects beyond dehydration. We describe a woman who presented to the Emergency Department (ED) due to severe diarrhea who had a significant coagulopathy secondary to depletion of vitamin K dependent clotting factors.CaseA 31year old female presented to the ED complaining of generalized weakness, abdominal cramping, and profuse diarrhea. The symptoms began after initiation of chemotherapy for gastric adenocarcinoma. The patient was three months postop from partial gastrectomy and four days post-op from a dilation and curettage for a missed abortion. Laboratory studies showed dehydration with a metabolic acidosis and significant coagulopathy with PT=118.9seconds, PTT- 59.3seconds, and INR- 11.2. Platelets, fibrinogen, and ddimer were all elevated. Imaging showed no acute pathology.DiscussionThe abrupt onset of coagulopathy was thought to be multifactorial due to chemotherapy related diarrhea. Disproportionate elevations of PT and INR with mild elevation in PTT were consistent with severe vitamin K deficiency. The coagulopathy may be related to inadequate intake, insufficient absorption, and/or decreased synthesis due to changes in gut flora. Vitamin K deficiency is likely under recognized and should be considered in patients with severely restricted diet or prolonged significant gastrointestinal losses. This case demonstrates the importance of evaluating the hematologic manifestations of diarrhea in critically ill patients.

Assess the impact of scribes on an academic emergency department's (ED) throughput one year after implementation.A prospective cohort design compared throughput metrics of patients managed when scribes were and were not a part of the treatment team during pre-defined study hours in a tertiary academic ED with both an adult and pediatric ED. An alternating-day pattern one year following scribe implementation ensured balance between the scribe and non-scribe groups in time of day, day of week, and patient complexity.Adult: Overall length of stay (LOS) was essentially the same in both groups (214 vs. 215 min, p = 0.34). In area A where staffing includes an attending and residents, scribes made a significant impact in treatment room time in the afternoon (190 vs 179 min, p = 0.021) with an increase in patients seen per hour on scribed days (2.00 vs. 2.13). There was no statistically significant changes in throughput metrics in area B staffed by an attending and a nurse practitioner/physician assistant, however scribed days did average more patients per hour (2.01 vs. 2.14).Pediatric: All throughput measurements were significantly longer when the treatment team had a scribe; however, patients per hour increased from 2.33 to 2.49 on scribed days.Overall patient throughput was not enhanced by scribes. Certain areas and staffing combinations yielded improvements in treatment room and door to provider time, however, scribes appear to have enabled attending physicians to see more patients per hour. This effect varied across treatment areas and times of day.

The utility of the gum-elastic bougie (GEB) as an assistive device for tracheal intubation during chest compressions has not been sufficiently validated. This study aimed to compare the utility of the GEB during chest compressions on an adult manikin.Seventeen novice physicians performed tracheal intubation on an adult manikin using the GEB with or without chest compressions. Intubation success rate, intubation time, subjective difficulty of laryngoscopy, and tube passage through the glottis were measured. P < .05 was considered as significantly different.All novice physicians successfully secured the airway without chest compression with and without the GEB. In contrast, during chest compressions, 7 failed without the GEB, whereas only 1 failed with the GEB (P = .007). Intubation time was significantly longer with chest compressions regardless of GEB use (P < .001). Both laryngoscopy and tube passage through the glottis were perceived as significantly more difficult with chest compressions, regardless of GEB use (P < .001). Subjective difficulty of tube passage through the glottis during chest compression was perceived as significantly more easy by GEB application (P < .001).These findings suggest that the GEB facilitates tracheal intubation during chest compressions performed by novice physicians in adult simulations.

Patient satisfaction, a commonly measured indicator of quality of care and patient experience, is often used in physician performance reviews and promotion decisions. Patient satisfaction surveys may introduce gender-related bias.Examine the effect of patient and physician gender concordance on patient satisfaction with emergency care.We performed a cross-sectional analysis of electronic health record and Press Ganey patient satisfaction survey data of adult patients discharged from the emergency department (2015-2018). Logistic regression models were used to examine relationships between physician gender, patient gender, and physician-patient gender dyads. Binary outcomes included: perfect care provider score and perfect overall assessment score.Female patients returned surveys more often (n=7 612; 61.55%) and accounted for more visits (n=232 024; 55.26%). Female patients had lower odds of perfect scores for provider score and overall assessment score (OR: 0.852, 95% CI: 0.790, 0.918; OR: 0.782, 95% CI: 0.723, 0.846). Female physicians had 1.102 (95% CI: 1.001, 1.213) times the odds of receiving a perfect provider score. Physician gender did not influence male patients' odds of reporting a perfect care provider score (95% CI: 0.916, 1.158) whereas female patients treated by female physicians had 1.146 times the odds (95% CI: 1.019, 1.289) of a perfect provider score.Female patients prefer female emergency physicians but were less satisfied with their physician and emergency department visit overall. Over-representation of female patients on patient satisfaction surveys introduces bias. Patient satisfaction surveys should be deemphasized from physician compensation and promotion decisions.