Pulmonary embolism (PE) has a mortality approaching 30% with 90% of these deaths occurring in the first 2.5 hours. Given the risks and expense of computed tomography angiography (CTA) as well as the mortality of PE if missed, emphasis on ruling out the diagnosis has led to the institution of clinical decision criteria. In the emergency department (ED), patients are individually risk stratified using these clinical decision rules and the need for further testing is determined. We investigated whether the academic and community EDs within our health network were following clinical decision rules equally when it came to ordering D-dimer and CTAs for patients with suspected pulmonary embolism. This is a retrospective chart review conducted at an academic community ED with an annual volume of 70,000 and two community-based EDs from the same health network with annual volumes of 51,000 and 47,000 respectively. The study was reviewed by the IRB and given exempt status. Two researchers blinded to the final diagnosis reviewed 1513 ED charts from the period from January 2013 to December 2013 in which a D-dimer was ordered. PERC and Well's scores for each chart were calculated. D-dimer levels were recorded as well as whether a CT was ordered. Data were analyzed using Chi Square analysis. A total of 1513 charts were reviewed. Separate chi square tests were conducted following exclusion of patients with multiple visits (62/1508, 4.1%) in order to satisfy the independence of observations assumption, leaving a total of 1446 patients for subsequent analyses. A total of 459/1446 patients (31.7%) had negative PERC scores. While the academic campus ordered fewer D-dimers when the patient was PERC negative (96.4% versus 97.5% both community), this was not statistically significant (P=.81), with the vast majority of patients from all 3 campuses receiving D-dimers (> 96.4%) despite having negative PERC Scores. Among the 459 patients (31.7%) with negative PERC scores who received CTA, the community campuses ordered fewer CTA than the academic center (21.6% and 22.8% versus 25.9%). However, there was no significant difference (P=.67), meaning a comparable percentage of CT scans were ordered at each campus despite patients having negative PERC scores. However, when looking at patients with both low Well's score and low D-dimers (783/1446 patients [54.1%]), the academic center ordered fewer CTA (1.9% versus 4.3% and 5.3%) although this was not significant (P=.12), meaning a comparable percentage of CTA were ordered at each campus despite patients having both low Wells Scores and D-Dimers. When evaluating low D-dimers alone a total of 845/1446 patients (58.4%) had low D-Dimers. Among these patients, the academic center ordered fewer CTA than the community campuses (3.2% versus 6.7% and 5.3%) although this was not statistically significant (P=.16). While not statistically significant there is a trend in ordering less testing with negative clinical decision rules in the academic center verses the community centers. And while the majority of patients with negative PERC and low D-Dimer/Well's score did not receive CTA, both our academic and community centers could have avoided up to 27% of CTA by appropriate use of PERC rule and up to 5% of CTA by calculating the pretest probability with Well's criteria.

To determine how many patients who present to an emergency department (ED) for vaginal bleeding in early pregnancy have ultrasounds (US) that are diagnostic for intrauterine pregnancy (IUP). A secondary objective was to compare the number of US positive for IUP with HCG levels of 2000 and below verses HCG levels greater than 2000.

In September 2003, Pennsylvania weakened its motorcycle helmet law. As a result, only inexperienced riders and those under the age of 21 are required to wear helmets. We analyzed data to determine if fatalities and severity of injuries in motorcycle accidents have changed since the weakening of this law.

Both the treatment and post exposure prophylaxis (PEP) of rhus induced acute contact dermatitis (ACD) are suboptimal. Previous studies have indicated that the commercial available mixture of alcohol solubles and anionic surfactants (Zanfel) is effective in treating ACD but efficacy has not been established through objective evaluation of photographs of the ACD rash. The purpose of this study was to determine if objective observers can determine whether subjects with experimentally induced ACD received Zanfel or placebo for either treatment or post exposure prophylaxis.

Study Objectives: It is often taught that patients prefer their physicians to be seated, but there are few data to support this contention in emergency care. The purpose of this prospective randomized clinical trial was to investigate the validity of this widely accepted belief, using as our primary endpoint overall patient satisfaction with medical care provided by the physician. Other endpoints included patient perception of time spent with physician and patient perception of total time spent in the emergency department (ED).

Study Objectives: Acetaminophen and ibuprofen are often combined for the treatment of pediatric fever despite the lack of data to support or refute this practice. The purpose of this prospective, controlled, randomized, double-blind clinical investigation is to determine whether the use of these two agents in combination is a more effective antipyretic than ibuprofen alone.

The prandial status of ED patients is often unknown. Because a full stomach predisposes patients to aspiration during a variety of urgent interventions, a method of determining the degree of gastric fullness would be of potential clinical importance. The purpose of this single-blind interventional trial was to determine if bedside ultrasound, performed by EPs, could accurately determine prandial status. We enrolled 20 subjects who were randomized to either a fasting or nonfasting group. Three emergency sonographers scanned each subject in both the supine and right lateral decubitus (RLD) positions and independently recorded their determination of the prandial status both before and after ingestion of water. We found that the technique was specific in identifying a full stomach but only moderately reliable in identifying an empty one. Best results (sensitivity S + 86%, specificity S- 70%, accuracy A+ 78%) were achieved only after water ingestion with the patient in the RLD position. We conclude that bedside ultrasound is of only limited value for determining prandial states in the ED setting.