The common manifestations of gastrointestinal stromal tumors (GIST) are well established. However, jejunal diverticulosis is an uncommon phenomenon to be associated with this lesion, with its rarity compounded by the relative difficulty associated with its diagnosis. Limited literature is available on this topic. This article examines one such case of jejunal diverticulitis as a result of a GIST, and the intervention of said disease.A 69 year old lady presented with abdominal pain, vomiting, and low grade fevers, on a background of ulcerative colitis. She was peritonitic, raising concerns of an acute abdomen. Her imaging identified an intra-abdominal contained perforation, prompting a transfer to theatres overnight for a laparotomy, which identified a jejunal diverticulum, which resembled a contained perforation. This was resected, and sent for histopathological analysis, identifying the lesion as a GIST.Unlike other forms of jejunal diverticular disease, those arising from GISTs tend to present perforated, necessitating resection. This disease displays a tendency towards formation on the anti-mesenteric border of the small bowel. Additionally, this particular form of GIST shows macroscopic and histopathological uniformity across reported cases to date despite significant geographical disparity.A scant number of case reports worldwide have identified jejunal diverticulitis from GISTs. We suggest diverticula be excised if perforation is suspected, while incidental findings of such be left untouched. However, overall management should be undertaken at the discretion of the operating surgeon.

Administering care during cardiopulmonary arrests (i.e. "codes") is an extremely stressful situation, especially for physicians in training.1Dias R. Neto A. Stress levels during emergency care: a comparison between reality and simulated scenarios.J Crit Care. 2016; 33: 8-13Crossref PubMed Scopus (39) Google Scholar Research shows that residents endorse being scared of codes, demonstrate performance deficits and helplessness or anxiety during mock codes/simulations and self-rate code-related anxiety at levels higher than anxiety scores reported by hospitalized psychiatric patients. The stress of these clinical scenarios may not simply be the result of being a novice. Experience can, but does not necessarily, prevent performance stress. Directly training proper mindset and psychological performance skills is a preferred strategy for becoming prepared. The importance of training mindset (mental toughness) has been recognized in other fields requiring critical performance under stress. These fields include athletics, as well as, mission critical domains including the military, policing and firefighting. Rudimentary applications of psychological skills training to surgical training were suggested almost thirty years ago.2McDonald J. Orlick T. Excellence in surgery: psychological considerations.Contemp Thought Perform Enhancement. 1994; 3: 13-32Google Scholar Such proactive approaches have not been ignored in contemporary medical and surgical training, especially the applicability of mental training skills from sport.3Cocks M. Moulton C.A. Luu S. Cil T. What surgeons can learn from athletes: mental practice in sports and surgery.J Surg Educ. 2014; 71: 262-269Crossref PubMed Scopus (53) Google Scholar However, these efforts have been typically limited either by specialty or to a specific psychological skill like mental practice.4Lorello G.R. Hicks C.M. Ahmed S.A. Unger Z. Chandra D. Hayter M.A. Mentalpractice: a simple tool to enhance team-based trauma resuscitation.CJEM. 2016; 18: 136-142Crossref PubMed Scopus (35) Google Scholar With a few exceptions, integration of a comprehensive curriculum has been absent.5Stefanidis D. Anton N.E. McRary G. et al.Implementation results of a novel comprehensive mental skills curriculum during simulator training.Am J Surg. 2017; 213: 353-361Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar We suggest that there is value, and even necessity, in providing an integrated comprehensive curriculum of psychological skills or mindset training (what we call Code Calm training) to facilitate the learning and performance of emergency skills for residents and physicians. The goals of such training are several-fold and include; providing a foundation in psychological performance skills which promote the optimal learning and application of physical and decision-making skills; providing means to mitigate the deleterious performance effects of extreme stress; preventing the degradation of little-used, yet critical skills; and optimizing other physician performance such as interpersonal communication, delivering grand rounds or testifying in court. Given the current emphasis on physician wellness and the growing problem of burnout, we propose these skills can improve physician resilience. Mindset training may reduce the impact of traumatic events; an essential benefit given that physicians can experience post-traumatic stress symptoms or even a posttraumatic stress disorder. The content of mental toughness or psychological skills training should include basic concepts such as the nature of physical arousal and performance, decision-making under stress and achieving optimal performance states. Specific techniques should include arousal control and self-regulation techniques, cognitive control, performance-enhancing mental imagery and resetting/ refocusing strategies. Evidence for the effectiveness of psychological skills training has existed in the other mission-critical domains for some time and is becoming more evident in the medical literature.5Stefanidis D. Anton N.E. McRary G. et al.Implementation results of a novel comprehensive mental skills curriculum during simulator training.Am J Surg. 2017; 213: 353-361Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Psychological skills training is clearly not a substitute for clinical and training experiences. Rather we suggest these skills are best integrated with current clinical curricula to provide a truly comprehensive approach to the preparation and performance of physicians. Per Sir William Osler:In the physician or surgeon, no quality takes rank with imperturbability …coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril.6Osler W. Aequanimitas.1889Google Scholar None.

Objective: The study sought to evaluate changes in mortality and resource utilization in patients with low level troponin elevations following a reduction in the cutoff for normal troponin I (TnI) from 0.5 ng/mL to the 99th percentile (0.06 ng/mL). Methods: This was an interrupted time series comparing emergency department (ED) patients with possible acute coronary syndrome (ACS) and TnI values 0.06-0.5 ng/mL before and after an institutional decrease in the TnI cutoff. The primary outcome was overall mortality at 90 days. Secondary outcomes included rates of rehospitalization, subsequent ACS, and coronary intervention within 90 clays, as well as rates of anticoagulation, cardiology consultation, cardiac testing, and coronary intervention during the index visit. Outcomes for the pre-cutoff change group (control) and post-cutoff change group (post) were compared using tests of proportions and odds ratios. Results: The study included a total of 1058 subjects with 529 in each cohort. No significant differences in 90 clay outcomes were observed between groups, including mortality (13.2% post vs 14.1% control, OR 0.93 [95% a: 0.65-1.34], p = 0.705). During the index visit, the post group demonstrated higher rates of cardiology consultation (55A% vs 41.2%, OR 1.77 [1.39-2261, p < 0.0001) and cardiac stress testing (16A% vs 10.6%, OR 1.66 [1.16-2.381, p = 0.006), but no significant differences in coronary intervention or short-term mortality were observed. Conclusion: A reduction in the TnI cutoff to the 99th percentile did not change mortality or rates of coronary intervention in ED patients with low level troponin elevations, but significantly increased the use of cardiology resources. (C) 2018 Elsevier Inc. All rights reserved.

In this paper, we present a memristor emulator made up of a digital potentiometer (DigPot) and a micro-controller (Arduino). The mathematical equations which govern the HP memristor model are programmed onto the Arduino which in turn communicates with the digital potentiometer through the Serial Peripheral Interface (SPI) ports updating it based on the implemented equations. The Arduino samples the voltage difference between the two terminals of the potentiometer's resistance network, then calculates the resistance using the implemented mathematical equations of the memristor and then updates the potentiometer through the SPI interface. Data is collected through the serial port and plotted in real time on a serial monitor on a computer. This hobbyist-style do-it-yourself approach which has been made simple and easily replicable can be used to initiate students into the basic theory of memristors. The emulator composed of off-the-shelf electronic components come in handy at a time where reliable physical devices are yet available for testing.

AL amyloidosis and multiple myeloma result in extracellular deposition of insoluble fibrillary protein in tissue and organs. Untreated median survival is very poor, and even worse with cardiac involvement. Chemotherapy and peripheral blood stem cell transplantation (PBSCT) have been shown to dramatically improve survival, with hematologic remission documented. Regression of cardiac changes has previously been shown, as assessed by echocardiography (TTE) and cardiac magnetic resonance imaging (CMR). This study is a comparison of TTE and CMR in long-term survivors of cardiac amyloidosis with regression.Four long-term survivors with cardiac amyloidosis and regression of cardiac features on TTE were identified. Mean age was 60 years and average survival was 139 months from the time of diagnosis of cardiac involvement. Statistically significant regression of the cardiac features of cardiac amyloidosis were demonstrated on TTE. In these survivors, post-PBSCT structural assessments were similar between TTE and CMR. Classical strain imaging features of cardiac amyloidosis were only present in 50%. All patients had diffuse, patchy gadolinium enhancement on CMR after PBSCT.Treatment of cardiac amyloidosis with chemotherapy and PBSCT may result in regression of abnormalities on TTE with marked improvement in survival. Post treatment, TTE and CMR structural assessments appear similar. Gadolinium imaging suggests that microscopic residual infiltration persists despite macroscopic regression. Significant cardiac improvements with prolonged survival are seen nonetheless. Multimodality imaging has a vital role in the management of cardiac amyloidosis.

Tuberous sclerosis complex (TSC) has an incidence of 1/6000 in the general population. Overall care may be complex and costly. We examine trends in health care utilization and outcomes of patients with TSC over the last decade.The National Inpatient Sample (NIS) database for inpatient hospitalizations was searched for admission of patients with TSC.During 2000–2010, the NIS recorded 5655 patients with TSC. Most patients were admitted to teaching hospitals (71.7%). Over time, the percentage of craniotomies performed per year remained stable (P = 0.351). Relevant diagnoses included neuro-oncologic disease (5.4%), hydrocephalus (6.5%), and epilepsy (41.2%). Hydrocephalus significantly increased length of stay and hospital charges. A higher percentage of patients who underwent craniotomy had hydrocephalus (29.8% vs. 5.3%; P < 0.001), neuro-oncologic disease (43.5% vs. 3.4%; P < 0.001), other cranial diseases (4.2% vs. 1.2%; P < 0.001), and epilepsy (61.4% vs. 40.1%; P < 0.001).Our study identifies aspects of inpatient health care utilization, outcomes, and cost of a large number of patients with TSC. These aspects include related diagnoses and procedures that contribute to longer length of stay, increased hospital cost, and increased in-hospital mortality, which can inform strategies to reduce costs and improve care of patients with TSC.

With the development of ambulatory surgery, there may be questions about the legal risk of this procedure. Indeed, the discharge of the patient from the hospital on the same day as the medical treatment raises the problem of monitoring and supervising potential complications, with a substantial delay in medical care, and the anaesthesiologists can be confronted with new areas of liability. This article specifies the French statutory and legal framework of the ambulatory surgery, and shows how the responsibility of the anaesthesiologist can be involved during patient care at all steps. The analysis of judicial precedent shows that the legal risk for the anaesthesiologist also exists in outpatient surgery. Surgery and anaesthesia are medical procedures involving a relatively high risk of damage for the patient. The damage can be attributed to malpractice from one or several health care professionals or to a medical complication (abnormal damage not related to malpractice and independent of past medical history of the patient). In the light of the ongoing and significant development in ambulatory surgery, there may be questions about the legal risk of this procedure. Indeed, the discharge of the patient from the hospital on the same day as the medical treatment raises the problem of monitoring and supervising potential complications, with a substantial delay in medical care. If the patient suffers any damage, the surgeon, the anaesthesiologist and in some cases, the hospital will have to answer in courts: the surgeon for the surgical procedure, the anaesthesiologist for the medical care and the hospital as the liable institution. After having specified the statutory framework of ambulatory surgery, we will see how the responsibility of the anaesthesiologist can be involved during patient care at all steps.

Because of their easy implementation and low maintenance, extensive green roofs have become established during the last few decades as one of the best options for integrating vegetation on the built environment. The success of these systems involves having of a plant species palette well adapted to extreme conditions, especially in drought environments. Among the available ones, the Sedum genus has stood out due to its tolerance to climate extreme conditions and its use has been widespread throughout the world. In previous research, efforts have been mainly concentrated on selecting the most drought tolerant Sedum species, without considering other important parameters for the suitable provision of ecosystem services from the green roof, such as coverage capacity, shape and structure or growth strategy, among others. In this study, five species of Sedum (Sedum album, S. sediforme, S. sexangulare, Sedum spurium cf. öCoccineum’ (syn. Phedimus spurius cf. öCoccineum’) and Sedum spurium cf. öSummer Glory’ (syn. Phedimus spurius cf. öSummer Glory’) were tested in a dry continental Mediterranean climate with the aim of observing their patterns of growth and development. Results revealed that Sedum album, S. sediforme, S. sexangulare are recommended species for their use on extensive green roofs in this climate, whereas both varieties of S. spurium, particularly var. “Coccineum”, present some limitations for their use, basically due to their shape, plant structure, pigmentation and lack of adaptation to winter conditions. Shape Index could be an adequate tool for decision-making in the selection of plant species in the design of green roofs because it provides information not only about the shape and size but also related to the growth strategy of these plants.

Background: The effectiveness of point of care (POC) right upper quadrant ultrasound (RUQ US) in the diagnosis of biliary disease has been well studied. Extrabiliary pathology that might remain undetected in the course of typical, focused POC RUQ US has not been directly examined. Objectives: Our objective was to determine the prevalence and clinical significance of extrabiliary findings (EBFs) seen on radiology-performed, comprehensive RUQ US. Methods: We conducted a retrospective review of all adult patients undergoing radiology-performed RUQ US in the emergency department (ED) between January 2007 and April 2012. Ultrasound findings and contemporaneous laboratory values were collected. EBFs were identified and further classified by clinical significance. Results: A total of 1579 charts were included, demonstrating a total of 1030 EBFs, with 747 (47.3% [95% confidence interval {CI}, 44.8-49.8%]) patients demonstrating >= 1 EBF. Of these EBFs, 184 were classified as clinically significant (CSEBFs) and 150 (9.5% [95% CI, 8.1-11.0%]) patients had >= 1 CSEBF. A total of 50 unspecified masses were seen in 47 (3.0% [95% CI, 2.1-3.8%]) patients, with 8 (0.5%) representing a previously undiagnosed malignancy. Conclusion: CSEBFs were seen in < 10% of ED patients undergoing comprehensive RUQ US. Nonspecific masses were seen in 3% of patients, but < 1% of patients were found to have a new malignancy. (C) 2016 Elsevier Inc.

Study objective: Transtracheal ultrasound has been described as a method to evaluate endotracheal tube placement. Correlation between sonologist experience and the successful use of transtracheal ultrasound to identify endotracheal tube location has not been examined. Our objectives were to evaluate emergency physicians' ability to correctly identify endotracheal tube location using transtracheal ultrasound and to evaluate the role operator experience plays in successful identification of tube placement. Methods: This was a cross-sectional, single-blinded study conducted in a cadaver laboratory. Two cadavers were used as models. One cadaver had an endotracheal tube placed in the esophagus, and the second had the tube placed in the trachea. Participants were asked to evaluate tube placement using transtracheal ultrasound and to record their interpretation. Examination clips were reviewed by the emergency ultrasound fellowship director. Descriptive statistics and chi(2) test were used for analysis. Results: Twenty-nine participants were included, 8 (27.6%) of whom were considered to be "most experienced" based on previous ultrasound experience (>150 scans). Eleven of 29 correctly identified esophageal intubation and 18 of 29 correctly identified tracheal intubation, resulting in a sensitivity of 62.0% (95% confidence interval [CI], 42.3-79.3) and a specificity of 37.9% (95% CI, 20.7-57.7). Transtracheal ultrasound performed by the most experienced sonologists showed better sensitivity and specificity, 75.0% (95% CI, 34.9-96.8) and 62.5% (95% CI, 24.5-91.5), respectively. Conclusion: Most participants obtained adequate images, but correct interpretation of the images was poor. The most experienced sonologists correctly identified tube location more often. Additional education would be required before adopting this method. (C) 2014 Elsevier Inc. All rights reserved.

BACKGROUND:The use of therapeutic hypothermia (TH) is a burgeoning treatment modality for post-cardiac arrest patients.OBJECTIVES:We performed a retrospective chart review of patients who underwent post-cardiac arrest TH at eight different institutions across the United States. Our objectives were to assess how TH is currently being implemented in emergency departments and to examine the feasibility of conducting TH research using multi-institution prospective data.METHODS:A total of 94 cases were identified in a 3-year period and submitted for review by participating institutions of the Peri-Resuscitation Consortium. Of those, seven charts were excluded for missing data. Two independent reviewers performed the data abstraction. Results were subsequently compared, and discrepancies were resolved by a third reviewer. We assessed patient demographics, initial presenting rhythm, time until TH initiation, duration of TH, cooling methods and temperature reached, survival to hospital discharge, and neurological status on discharged.RESULTS:The majority of cases had initial cardiac rhythms of asystole or pulseless electrical activity (55.2%), followed by ventricular tachycardia or fibrillation (34.5%). The inciting cardiac rhythm was unknown in 10.3% of cases. Time to initiation of TH ranged from 0 to 783 minutes with a mean time of 99 minutes (SD=132). Length of TH ranged from 25 to 2,171 minutes with a mean time of 1,191 minutes (SD=536). The average minimum temperature achieved was 32.5°C, with a range from 27.6°C to 36.7°C (SD=1.5°C). Of the 87 charts reviewed, 29 (33.3%) of the patients survived to hospital discharge.CONCLUSION:The implementation of TH across the country is extremely varied with no universally accepted treatment. While our study is limited by sample size, it illustrates some compelling trends. A large, prospective, multicenter trial or registry is necessary to elucidate further the optimal parameters for TH and its benefit in various population subsets.

Background: Systemic Inflammatory Response Syndrome (SIRS) criteria are used to classify and initiate care for patients with presumed infection. However, SIRS is also present with noninfectious causes such as burns, pancreatitis and hemorrhage. More often, SIRS implies sepsis. Since pneumonia is the most common source of sepsis, chest radiography (CXR) are routinely obtained in the evaluation of patients with SIRS, whether or not they demonstrate respiratory abnormalities (RA). Evidence is lacking that demonstrates the utility of ordering CXRs for patients who present with SIRS criteria but have no respiratory abnormalities. Study Objectives: Our objective is to determine the prevalence of pneumonia and the predictive properties of CXR in the evaluation of SIRS for patients with and without respiratory abnormalities. We hypothesize that patients who present to the emergency department (ED) with SIRS criteria and no RA have a lower prevalence of pneumonia and, therefore, do not require a CXR on initial work-up. Methods: In an institutional review board-approved retrospective chart review conducted in a community ED, consecutive patients with CXR in the ED in December 2010 were identified by billing codes. Patients with 2 or more SIRS criteria were included. Patients were excluded with age less than 18, known pneumonia at presentation, chronic abnormal CXR, or DNR/comfort care only. A standardized data collection sheet was used. Subjects were stratified by the presence or absence of RAs, defined a priori as dyspnea, cough, chest pain, hypoxia (Sats <90% on RA), tachypnea (RR>20), or focal lung findings on exam. The hospital discharge diagnosis was used as the gold standard to determine the presence or absence of pneumonia. Radiology interpretation of CXRs as a new infiltrate, opacity, or effusion was considered to be a positive test result. All other interpretations were considered negative test results. Descriptive statistics and Fisher's exact test were used. Results: 2152 CXRs were obtained in the ED in December 2010. 1053 (49%) of the patients tested with CXR in the ED during the study period were screened, and 193 met inclusion/exclusion criteria. Out of these, 39 (20.2%) had no RAs while 154 had at least one. Pneumonia was diagnosed in 14.9% (95%CI 9.9-21.8%) and 0% (95%CI 0-11.2%) in those with and without respiratory abnormalities, respectively (p=0.005). History and physical exam to assess for RAs had a sensitivity of 100% (95% CI 82-100%) and a specificity of 23% (95% CI 17-30%) for the diagnosis of pneumonia. The sensitivity and specificity of CXR in this ED population of patients with SIRS is 65% (95% CI 43-83%) and 86% (95% CI 80-91%), respectively. Of the 39 patients with no RAs, there were 2 CXRs that were false positives for pneumonia and 37 CXRs that were true negatives. No patients in this group were ultimately diagnosed with a pneumonia. Conclusion: The prevalence of pneumonia is low in patients with SIRS without respiratory abnormalities in the ED. History and physical exam outperformed CXR in the ability to predict pneumonia in this population. Chest radiography may not be routinely indicated in the ED evaluation of patients with SIRS and no respiratory abnormalities.

Introduction: Approximately 5% of all US emergency department (ED) visits are for chest pain, and coagulation testing is frequently utilized as part of the ED evaluation.Objective: The objective was to assess the cost-effectiveness of routine coagulation testing of patients with chest pain in the ED.Methods: We conducted a retrospective chart review of patients evaluated for chest pain in a community ED between August 1, 2010, and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with fresh frozen plasma or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or ST-elevation myocardial infarction.Results: Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of those 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. One of the 327 patients (0.31%; 95% confidence interval, 0.05%-1.7%) tested without indication had a clinically significant coagulopathy (internationalized normalization ratio >1.5, partial thromboplastin time >50 seconds), but none (0%; 95% confidence interval, 0%-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16780.Conclusions: Coagulation testing on chest pain patients in the ED is not cost-effective and should not be routinely performed. (C) 2012 Elsevier Inc. All rights reserved.

Study Objective: The 12-lead electrocardiogram (ECG) is an important tool in the stratification of emergency department (ED) patients with chest pain. Lead aVR is often ignored when interpreting an ECG. Prior studies have shown that ST segment deviation in aVR(devAVR) is associated with worse outcomes, including increased mortality at one year, and impaired coronary reperfusion in patients who have undergone recanalization of a vessel following a myocardial infarction. The objective of this study is to determine the importance of devAVR in ED patients with chest pain and a non-STEMI ECG. Methods: A retrospective chart review and ECG analysis of consecutive ED patients who were admitted with the diagnosis of chest pain at a 75,000 visit community hospital over a 3-month period in 2012. Patients in the study were classifide into 2 groups based on the presence or absence of devAVR. ST segment deviation was measured to the nearest 0.05 mV. ST segment deviation was considered significant if > 0.05 mV. Charts for the index admission were reviewed for cardiac endpoints (coronary artery bypass graft surgery (CABG), coronary artery stent placement, or elevated troponin). Exclusion criteria were <18 years of age, left bundle branch block, ST elevation MI, and paced cardiac rhythm. Statistical analysis included the sensitivity, specificity, and predictive values of devAVR for the end points described. Results: There were 124 chest pain patients admitted through the ED with 17 excluded. 12 of the 107 subjects had devAVR, (11.2%, 95%CI 6.4-18.7). 9 of the 107 subjects had a cardiac endpoint, 8.4% (95%CI 4.3-15.4). 3 of the 9 subjects with a cardiac endpoint had ST elevation in aVR with a sensitivity of 33%, (95%CI 12.1-64.6) and specificity 90.8%, (95%CI 83.5-95.1). Positive predictive value was 25% (95%CI 8.9-53.2) and negative predictive value was 93.7% (CI 86.9-97.1). Conclusion: ST segment deviation in lead aVR in non-STEMI chest pain patients, while not common, is a fairly specific predictor of several critical outcomes, namely the patient receiving a coronary artery stent, CABG surgery or developing a NSTEMI. The emergency physician should examine lead aVR carefully for ST segment deviation in chest pain patients with a non-diagnostic ECG.

Approximately 5% of all United States emergency department (ED) visits are for chest pain. At York Hospital coagulation tests are part of the "chest pain" order set utilized by physicians and nurses. Our objective was to assess the cost-effectiveness of routine coagulation testing of patients with chest pain in the ED. We conducted a retrospective chart review on a non-consecutive sample of patients evaluated for chest pain in the ED between the dates of August 1, 2010 and October 31, 2010. Charts were reviewed to determine the number and results of coagulation studies ordered, the number of coagulation studies that were appropriately ordered, and the number of patients requiring a therapeutic intervention or change in clinical plan (withholding of antiplatelet/anticoagulant, delayed procedure, or treatment with FFP or vitamin K) based on an unexpected coagulopathy. We considered it appropriate to order coagulation studies on patients with cirrhosis, known/suspected coagulopathy, active bleeding, use of warfarin, or STEMI. We calculated the cost of the coagulation studies ordered on patients without the listed indications. Descriptive statistics were used for analysis. 761 of the 1849 charts for patients evaluated for chest pain during the study period were reviewed. Thirteen patients were excluded due to age <18, and an additional 8 patients left against medical advice before labs were drawn. Of the 740 patients included, 406 (55%) had coagulation studies ordered. Of that 406, 327 (81%) patients with coagulation studies ordered had no indications for testing. 315 patients of the 327 were tested with PT/INR ($19.00) and PTT ($33.50). 11 of the remaining 12 patients were tested with only a PT/INR, and 1 patient was tested with only PTT. One of the 327 patients (0.31%; 95%CI 0.05-1.7%) tested without indication had a clinically significant coagulopathy (INR >1.5, PTT >50 sec), but none (0%; 95%CI 0-1.2%) of the patients with coagulation testing performed without indication required a therapeutic intervention or change in clinical plan. The cost of coagulation testing in these 327 patients was $16,780. By our estimates, routine coagulation testing without indication for patients with chest pain in the York Hospital emergency department cost $165,000 annually. Coagulation testing on chest pain patients in the ED is not cost-effective and should not be routinely performed.

Ultrasound (US)-guided central venous access is recommended by national organizations and medical societies. Increased accuracy for "needle tip" (NT) identification in a long axis orientation has been demonstrated.

To determine if post-graduate year (PGY) of training or user usual ultrasound scanning technique (long axis (LA), short axis (SA), or both) affects accuracy to identify "needle-tip" (NT) location in a standardized vascular phantom model.