Background: Patients with cardiovascular disease (CVD) are especially vulnerable to respiratory infections caused by the coronavirus. The underlying effect of cardiovascular comorbidities on patients with COVID-19, however, remains to be sufficiently understood. Methods: Hospitalized COVID-19 patients from a state-wide large health care system with completed historical clinical conditions during March - June of 2020 were included in this study. The impact of CVD on the mortality, resources utility including the uses of intensive care unit (ICU) and ventilator, length of stay (LOS) and financial burden of COVID-19 inpatients were examined. Logistic analysis was applied to analyze the relationship between CVD and mortality, and non-parametric methods were used to evaluate the impact of CVD on resources utility. Random forest method was used to rank the importance of risk factors. Results: Among 811 hospitalized COVID-19 patients, 228 (28.11%) were placed in ICU, 105 (12.95%) spent on ventilators, and there were 94 deaths (11.59%). The mean LOS was 11.93 ± 11.26 (SD, standard deviation), mean time a patient in an ICU was 2.41 ± 5.49 days, and mean ventilator time was 1.29 ± 4.62 days. The mean charge of a patient was $55242 ± 71742) with inter-quarter range of $44124. Age, gender, and race were the top 3 factors of mortality and utilities. Patients who present with heart failure vs. those who do not, have increased mortality (21.47% vs 8.97%; odds ratio [OR], 2.00 (95% CI: 1.25-3.21; P=0.004), longer LOS (12.97 ±10.09 vs. 11.61±11.46), p=0.18), higher ICU usage ( 3.32 ± 6.04 vs. 2.14 ±5.26, p=0.02) and ICU requiring ventilator (1.86 ± 4.90 vs. 1.15 ± 4.56, p=0.09), and significant higher charge ($ 66175 ± 68773 vs $ 50736 ±64142, mean difference $15439± 65193 with 95% CI: $4537-26340, p=0.01). Similar results were shown for patients with coronary artery disease or arrhythmia. Patients with hypertension vs those who do not, have increased mortality (14.81% vs. 4.92%; OR=3.22 (95% CI: 1.76-5.90, p=0.01), but the impact was not significant after adjusted by age, race and gender. Conclusions: Among COVID-19 hospitalized patients with established cardiovascular disease, there was a worse survival and adverse utility outcomes in hospital resources and financial charges.

Study Objectives: Noninvasive, positive pressure ventilation (NIV) has been shown to improve outcomes in patients with acute pulmonary edema and other forms of respiratory distress. There is additional benefit seen in applying NIV earlier in the out-of-hospital setting. Continuous positive airway pressure (CPAP) devices are used by out-of-hospital providers, but there have been theoretical concerns about the safety of Basic Life Support (BLS) rather than Advanced Life Support (ALS) providers using CPAP. In areas such as the study state which have a 2-tiered Emergency Medical Service system, BLS providers often arrive on scene before ALS providers. If it were safe for BLS providers to use CPAP, it could mean even earlier application of this beneficial device. This study sought to evaluate the recognition of need, application, and use of CPAP by BLS prior to ALS arrival.Methods: This is a retrospective observational study. Data was obtained from quality assurance documentation from calls between October 2009 and March 2012 on which BLS providers applied CPAP to patients in respiratory distress. BLS providers in this pilot program received training in CPAP use prior to participation. The data collected includes pulse-oximetry, respiratory rate, and skin color before and after application; whether CPAP was indicated, correctly applied and correctly monitored; and whether the patient outcome was "improved," "unchanged" or "worsened" (determined by a more advanced practitioner at the time of the patient encounter). Charts were reviewed for any missing data points. All the available data was compiled and analyzed.Results: Fifty-five patients had CPAP applied by BLS under the pilot program. 50 of these patients improved (90.9%), 4 of these patients were unchanged (7.3%), and one worsened (1.8%). CPAP was indicated and correctly applied by BLS 100% of the time. Only 54 of these cases had CPAP monitoring documented and 100% of these were monitored appropriately. The respiratory status was documented as managed appropriately in 100% (55/55) of the cases. See table for further secondary outcomes.Tabled 1Conclusion: Of the 55 patients who had CPAP applied by BLS providers, 98.2% of patients were either improved or unchanged, with the vast majority improving. More importantly, BLS providers were able to determine patients in whom the use of CPAP was indicated, apply it correctly, and appropriately monitor the status of these patients. This indicates that CPAP can be safely and effectively used by BLS providers with appropriate training. Study Objectives: Noninvasive, positive pressure ventilation (NIV) has been shown to improve outcomes in patients with acute pulmonary edema and other forms of respiratory distress. There is additional benefit seen in applying NIV earlier in the out-of-hospital setting. Continuous positive airway pressure (CPAP) devices are used by out-of-hospital providers, but there have been theoretical concerns about the safety of Basic Life Support (BLS) rather than Advanced Life Support (ALS) providers using CPAP. In areas such as the study state which have a 2-tiered Emergency Medical Service system, BLS providers often arrive on scene before ALS providers. If it were safe for BLS providers to use CPAP, it could mean even earlier application of this beneficial device. This study sought to evaluate the recognition of need, application, and use of CPAP by BLS prior to ALS arrival. Methods: This is a retrospective observational study. Data was obtained from quality assurance documentation from calls between October 2009 and March 2012 on which BLS providers applied CPAP to patients in respiratory distress. BLS providers in this pilot program received training in CPAP use prior to participation. The data collected includes pulse-oximetry, respiratory rate, and skin color before and after application; whether CPAP was indicated, correctly applied and correctly monitored; and whether the patient outcome was "improved," "unchanged" or "worsened" (determined by a more advanced practitioner at the time of the patient encounter). Charts were reviewed for any missing data points. All the available data was compiled and analyzed. Results: Fifty-five patients had CPAP applied by BLS under the pilot program. 50 of these patients improved (90.9%), 4 of these patients were unchanged (7.3%), and one worsened (1.8%). CPAP was indicated and correctly applied by BLS 100% of the time. Only 54 of these cases had CPAP monitoring documented and 100% of these were monitored appropriately. The respiratory status was documented as managed appropriately in 100% (55/55) of the cases. See table for further secondary outcomes. Conclusion: Of the 55 patients who had CPAP applied by BLS providers, 98.2% of patients were either improved or unchanged, with the vast majority improving. More importantly, BLS providers were able to determine patients in whom the use of CPAP was indicated, apply it correctly, and appropriately monitor the status of these patients. This indicates that CPAP can be safely and effectively used by BLS providers with appropriate training.

Background: Studies have shown that women in emergency medicine (EM) lag behind their male counterparts in academic productivity. Objectives: We compared the proportion of female attending physicians from EM academic programs to the proportion of female first or second authors of original scientific manuscripts and case reports from four major EM journals in a single year. Methods: We used a retrospective cross-sectional design. Original scientific manuscripts and case reports from four major EM journals published in 2005: Academic Emergency Medicine, Annals of Emergency Medicine, American Journal of Emergency Medicine, and Journal of Emergency Medicine were reviewed to determine genders of first and second authors. The proportion of female first or second authorship was then compared to the proportion of female EM attending physicians from 134 academic EM programs in the United States. Data were analyzed using Pearson's chi-squared and Clopper-Pearson binomial confidence intervals as appropriate. A p-value of <= 0.05 was considered significant. Results: The percentage of female faculty; 940/3571 (26.32%, 95% confidence interval [CI] 24.9-27.8%) vs. the percentage of female first or second authorship 289/1123 (25.73%, 95% CI 23.3-28.4%) was not statistically significant (p = 0.562). There was no difference in the proportion of male and female authors with multiple manuscripts (p = 0.889). Conclusions: As measured by first and second authorship, there was no discrepancy between the proportion of female EM faculty and the proportion of female authorship in EM literature from 2005. (C) 2011 Elsevier Inc.

Lumbar puncture is an important diagnostic procedure in emergency medicine. Data have been published showing improved success rate with ultrasound assistance and the ability of emergency medicine physicians to recognize sonographic lumbar spinous anatomy. However, with educational models and the push for improved patient safety, procedural skills should be practiced on phantoms rather than the “see one, do one, teach one” of the past. There are no currently available phantoms for ultrasound-assisted lumbar puncture training. We have produced a phantom that can be used to train physicians on ultrasound-assisted lumbar puncture with respect to both imaging and procedural competency. A plastic fluid-filled bladder was immersed in gelled opacified mineral oil, a safe and easily used tissue mimic that obscures direct visualization of structures. Spinous anatomy is replicated with the use of wooden struts supporting wooden disks that mimic lumbar spinous processes. The spine analog was mounted over the plastic bladder and surrounded with gelled mineral oil. The phantom produces images similar to human lumbar anatomy. The phantom allows insertion of spinal needles into the “interspinous spaces” with inability to pass the needle outside of those locations. Fluid collection and repeated punctures can be performed on the phantom. Appearance and performance of the phantom were evaluated by physicians with expertise in ultrasound-assisted lumbar puncture. The only limitation is that external appearance is not realistic. This model performs well, is made from readily available materials, and can be used to train physicians in ultrasound-assisted lumbar puncture.

Ultrasound (US) use for thoracentesis guidance is becoming more common. US-guided procedural skills must be practiced prior to patient care situations, most commonly with ultrasound procedure phantoms. Commercial phantoms are available, but are costly. Our goal was to construct a low cost thoracentesis phantom and report its performance by physicians skilled in ultrasound.

Background: Gallbladder ultrasonography is a commonly performed test in the emergency department. It is unknown whether a non-fasting state alters the visualization of the gallbladder by emergency medicine (EM) residents. Objectives: We conducted this study to determine whether EM residents are able to visualize the gallbladder in volunteers who have recently consumed a fatty meal. Methods: This study used a prospective, single-blinded, randomized controlled design. Initial scans were performed on fasting volunteers. A fatty meal was then consumed. Thirty minutes after eating, a different resident, who was unaware of whether the volunteer had eaten or fasted, performed a second scan. To control for operator bias, 10% of subjects remained fasting between scans. Student's paired-samples t-test, Pearson's chi-squared, and McNemar test were determined as appropriate. Results: A total of 92 scans from 46 volunteers were analyzed. EM residents were able to visualize the gallbladder in all 40 pre-prandial scans (100%) and all 40 post-prandial scans (100%). Gallbladder area as measured in the longitudinal axis decreased 20% from a mean baseline of 11.58 +/- 4.86 cm(2) (95% confidence interval [CI] 11.17-12.98) to 9.2 +/- 5.04 cm(2) (95% CI 7.74-10.66, p = 0.0009) after food intake. Total time to scan for the fasting volunteers (110.2 s, 95% CI 84.34-136) did not change significantly from non-fasting volunteers (129.7 s, 95% CI 110.29-149.01, p = 0.153). Conclusions: EM residents are able to visualize the gallbladder in non-fasted healthy volunteers. (C) 2010 Elsevier Inc.

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.

Use of ultrasound guidance for Central Venous Catheter insertion has been associated with decreased complications and increased success rates. Previous reports show low rates of use among physicians.Evaluation of the frequency of Ultrasound Guidance use for Central Venous Catheter insertion among residents at a teaching institution.A cross sectional electronic survey of resident physicians at a tertiary care teaching hospital was conducted to evaluate use of Ultrasound Guidance for Central Venous Catheterization. Assessment included self reported frequency of ultrasound guidance use, and volume of central venous catheter placement. Attitudes toward the use of ultrasound were assessed using Likert scales.There is a high rate. over 90%, of ultrasound guidance use for Internal Jugular central venous catheters among residents. The majority of residents use sterile real-time imaging with a single operator with a reported success rate greater then 80%.Resident use of ultrasound guidance for Internal Jugular central venous catheter insertion can be much higher than previously reported in the literature.

To determine whether a long-axis transducer orientation is more accurate for identification of “needle-tip” (NT) location. A secondary objective was to determine whether transducer orientation affects operator certainty of location.

Studies have shown that women in emergency medicine (EM) lag behind their male counterparts in academic productivity.

Ascertain whether antibiotics added to I & D alter treatment outcome in skin infections caused by community-acquired, methicillin-resistant Staphylcoccus aureus (CA-MRSA).

Using data from the European Community Household Panel, this paper evaluates the impact of the exogenous reductions in weekly working hours induced by reforms implemented in Portugal and France on worker wellbeing. Difference-in-differences estimation results suggest that reduced working hours generated significant and robust increases in job and leisure satisfaction of the workers affected in both countries (from 0.07 to 0.15 standard deviation increases), with the rise in the former mainly being explained by greater satisfaction with working hours and working conditions. Further results suggest that staff representative bodies are important for ensuring that working-time reductions lead to welfare gains.

OBJECTIVES:To correlate the simple triage and rapid treatment (START) colors to trauma injury severity scores (ISS).DESIGN:Six volunteer healthcare providers unfamiliar with START were trained to triage. Each chart was designated a START color by a volunteer healthcare provider and the "expert" trainer. The colors and corresponding ISS were recorded.SETTING:Level I trauma center at a suburban tertiary care hospital.PATIENTS, PARTICIPANTS:One hundred charts of patients at least 65 years old who appear in Christiana Hospital's Trauma Registry were randomly chosen for the study, and 98 charts with complete data were included.MAIN OUTCOME MEASURE(S):Cohen's Kappa score measures the level of agreement between the "volunteer" and "expert" reviewers. Pearson correlation determines the association between the START colors and mean ISS.RESULTS:The Cohen's Kappa score between the volunteer and expert reviewers was 0.9915, indicating a highly significant agreement between the reviewers on the triage category of the patients. The mean ISS for each color was as follows: green = 11, yellow = 12, red = 20, black = 24. The mean ISS increases as the acuity of the triage category increases, with a Pearson correlation of 0.969.CONCLUSIONS:The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers can undergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation with the trauma ISS, with higher ISS more likely to be triaged "red" or "black."

OBJECTIVE:Evidence showing the systematic utility of ultrasound imaging during lumbar puncture (LP) in the emergency department is lacking. Our hypothesis was that ultrasound-assisted LP would increase the success rate and ease of performing LP with a greater benefit in obese patients. METHODS:This was an Institutional Review Board-approved, randomized, prospective, double-blind study conducted at the emergency department of a teaching institution. Patients undergoing LP from January to December 2004 were eligible for enrollment. Patients were randomized to undergo LP using palpation landmarks (PLs) or ultrasound landmarks (ULs). Data collected included age, body mass index, number of attempts, ease of performance and patient comfort on a 10-cm Visual Analog Scale, procedure time, success, and traumatic LP. Statistical analysis of data included relative risk (RR), the Mann-Whitney U test, and the Student t test. RESULTS:A total of 46 patients were enrolled, 22 randomized to PLs and 24 to ULs. There were no differences between the groups in mean age or body mass index. Six of 22 attempts failed with PLs versus 1 of 24 with ULs (RR, 1.32; 95% confidence interval, 1.01-1.72). In 12 obese patients, 4 of 7 PL attempts failed versus 0 of 5 UL attempts (RR, 2.33; 95% confidence interval, 0.99-5.49). The ease of the procedure was better with ULs versus PLs. There were no statistical differences in the number of attempts, traumatic LPs, patient comfort, or procedure length. CONCLUSIONS:The use of ultrasound for LP significantly reduced the number of failures in all patients and improved the ease of the procedure in obese patients.

Purpose: Bystander CPR is one of the crucial links in the chain of survival from cardiac arrest. We conducted this study to determine how often bystander CPR was performed in the out-of-hospital se...