Acute nontraumatic joint pain has an extensive differential. Emergency physicians must be adept at identifying limb and potentially life-threatening infection. Chief among these is septic arthritis. In addition to knowing how these joint infections typically present, clinicians need to be aware of host and pathogen factors that can lead to more insidious presentations and how these factors impact the interpretation of diagnostic tests.

Objective To evaluate the association of 25-hydroxyvitamin D (25(OH)D) level on sepsis severity and risk of hospitalisation in emergency department (ED) septic patients when categorised as vitamin D insufficiency according to the level of 25(OH)D<30 ng/mL. Design Cross-sectional observational study. Setting A 900-bed academic tertiary hospital with an ED residency training programme in Bangkok, Thailand. Participants An observational study of 101 ED septic patients aged ≥18 years was conducted between March 2015 and September 2015. Outcome measures The level of 25(OH)D was analysed and correlated with sepsis severity assessed by Acute Physiology Age Chronic Health Evaluation-II (APACHE-II) and Mortality in ED Sepsis (MEDS) scores, and the risk of hospitalisation. Results One hundred and one patients were enrolled, with an average age of 68±18 years, 56% female, APACHE-II score of 14±6, MEDS score of 8±5 and 25(OH)D level was 19±11 ng/mL. The prevalence of vitamin D insufficiency in our ED septic patients was 87% and the admission rate was 88%. A significant association between 25(OH)D level and sepsis severity scores was found, which was measured by APACHE-II and MEDS scores (−0.29; 95% CI −0.41 to −0.17, p<0.001 and −0.15; 95% CI −0.25 to −0.06, p=0.002, respectively). However, vitamin D insufficiency could not determine hospitalisation (OR=1.42; 95% CI 0.27 to 7.34; p=0.68 and OR=1.65; 95% CI 0.07 to 41.7; p=0.76 when adjusted by baseline covariates). Conclusions The vitamin D insufficiency of septic patients in our ED was high and had a significant negative association with sepsis severity. However, vitamin D insufficiency status cannot predict the hospitalisation of septic patients who were admitted to the ED. Further research is needed to investigate the role of vitamin D supplementation in the ED in affecting sepsis severity. Trial registration number TCTR20151127001.

Summary Statement In light of the COVID-19 pandemic, protocols to reduce risk of exposure to healthcare teams have been implemented. The use of an acrylic box during intubation and cardiopulmonary resuscitation has been adopted worldwide. A study was conducted to assess the effectiveness of an acrylic box in limiting contamination. The findings indicate that healthcare workers are still vulnerable to exposure despite the use of personal protective equipment (PPE) and an acrylic box. The causes of contamination were related to improper PPE donning and doffing and incomplete coverage by the acrylic box. Institutions should focus on ensuring proper donning and doffing of PPE and incorporating high-fidelity simulation training to prepare teams to resuscitate COVID-19 patients.

Introduction: Point-of-care ultrasonography (POCUS) is increasingly utilized in emergency departments (EDs) throughout Thailand.Although emergency medicine (EM) residents are trained in POCUS, Thai medical students receive limited training.An introductory POCUS course was implemented for medical students to prepare them for internships.Objective: This study described the perception and use of POCUS by graduates of an introductory POCUS course.Materials and Methods: Medical students who completed the POCUS course were surveyed during their intern year from 2012 to 2015.The survey collected demographic characteristics.The Likert Scale was used to assess POCUS practice patterns and perceptions of the course.Results: There were 230 respondents (98% response rate).All thought that POCUS was important.Furthermore, 96% of respondents felt that the POCUS course meaningfully impacted their ability to deliver care.POCUS use was greatest for obstetrics/gynecology and trauma cases.Over half of respondents (55.2%) felt very confident with using extended-Focused Assessment with Sonography in Trauma.Most respondents (81.8%) were positively impacted by the course, and 61.7% were satisfied with the scope of the course.Recommendations for improvement included increasing the course length, the content, and the hands-on time for POCUS practice. Conclusion:Graduates positively perceived the course and felt it dramatically impacted their clinical practice as novice physicians.An introductory POCUS course should be incorporated into the medical school curriculum to prepare graduates for practice.Future goals include increasing the scope of POCUS practice to help guide interns and residents in emergency patient care such as lung ultrasound in COVID-19 or pneumonia patients and studying the impact this course has on patient outcomes.

Some patients (pts) with "sepsis", as classically defined, are nonetheless "treated and released" (Tx/Rel) from the emergency department (ED). ["Sepsis" means at least 2 "SIRS" criteria with an infectious diagnosis (dx)]. Careful ED physicians (EDPs) probably use "physician gestalt" to identify septic pts for this strategy. Prior peer-reviewed outcomes studies of septic pts have included only those hospitalized. Thus, no peer-reviewed literature exists to support an ED "Tx/Rel" strategy for any septic pts.

Background: Spinal epidural hematoma (SEH) is an uncommon but serious emergency condition rare cases of spontaneously or following a minor traumatic event without bony injury. Objective: We report the rare case of SEH associated with traditional massage initially presenting with delayed lower paraplegia. Case report: A 20-year-old man presented with bilateral lower extremity weakness and numbness 3 h prior to presentation. 3 days prior he was given a layperson Thai massage by a friend. Magnetic resonance imaging revealed a spinal epidural lesion suspicious for hematoma extending from C6 to T2 levels. Emergent surgical intervention for cord decompression was performed. An epidural hematoma with cord compression at C6-T2 levels was identified intraoperatively. No evidence of abnormal vascular flowor AV malformations was identified. Similar to chiropractic manipulation, massage may be associated with spinal trauma. Conclusion: Emergency physicians must maintain a high index of suspicion for spinal epidural hematomas in patients with a history of massage or chiropractic manipulation with neurologic complaints, because delays in diagnosis may worsen clinical outcome. (C) 2019 Elsevier Inc. All rights reserved.

BACKGROUND:Colonoscopy is a frequently performed medical procedure; complications associated with this procedure often present to the emergency department (ED). Splenic laceration is a rare but life-threatening complication of colonoscopy. We report the unique case of a patient with a splenic laceration who presented after a recent colonoscopy and had no history of trauma.CASE REPORT:A 52-year-old man presented to our ED with abdominal pain and lightheadedness the day after a routine colonoscopy. Ultrasound demonstrated hemoperitoneum, and contrast-enhanced computed tomography of the abdomen revealed a large hemoperitoneum with active contrast extravasation from the laceration of the superior pole of the spleen. After resuscitation, the patient was managed with an emergency splenectomy. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Colonoscopy complications are frequently identified and managed in the ED. Splenic laceration should be on the differential for patients that present with abdominal pain or hypotension after colonoscopy. Splenic injury carries a high mortality risk, and prompt, accurate diagnosis can be lifesaving.

OBJECTIVE:The objective was to develop an acceptable clinical decision support (CDS) system to facilitate evidence-based sexual health care for adolescents in the emergency department (ED). METHODS:In this multiphased iterative process, we engaged an expert group to synthesize evidence on a wide range of sexual health services (e.g., contraception, condoms, identification and treatment of previously diagnosed sexually transmitted infection). We created a computerized questionnaire and embedded our decision tree, utilizing patient-entered responses to create tailored, evidence-based recommendations, and embedded links to study-related resources such as the emergency contraception (EC) quick guide. We utilized mixed methodology to explore perspectives of adolescents aged 14 to 19 years and clinicians at two general and two pediatric EDs after they interacted with the system. Clinicians reported usefulness (Likert scale 1 = not at all, 4 = very); adolescents reported acceptability. We used the chi-square test to compare responses between subgroups. We collected adolescents' verbatim responses to open-ended questions; clinicians self-entered responses. Four authors independently generated themes from qualitative responses before compiling key findings and achieving consensus on final themes. RESULTS:Among 57 clinicians (23 physicians, 23 nurses, 11 nurse practitioners; 54% female; 65% aged < 40 years), the mean system usefulness rating was 3.4 ± 0.7. Sex, age, clinician role, or ED type were not associated with rating the system "somewhat/very" useful. Clinicians identified barriers (e.g., time constraints) that could be overcome by implementation considerations (e.g., training) as well as benefits including improved care. For future assessments, providers preferred computer (65%) over face-to-face interview (26%). Among 57 adolescents (mean age = 16.2 years; 75% female; 56% sexually experienced), nearly all (95%) reported that it was "very/somewhat easy" to complete the computerized questionnaire and to understand the questions. Most adolescents understood the EC quick guide and correctly identified that ulipristal, compared to levonorgestrel, required a prescription and was more effective. For future assessments, adolescents preferred computer (69%) over face-to-face interviews (9%). CONCLUSIONS:We developed a sexual health CDS system that is easy to use and can facilitate evidence-based care to reduce health outcome gaps. Evaluation of system impact on service delivery and, ultimately, health outcomes is needed.

"Sepsis" was defined by Bone et al. in 1992 as the presence of at least 2 Systemic Inflammatory Response Syndrome (SIRS) criteria, plus suspected presence of infection. Subsequently, 3 "Surviving Sepsis Campaigns" (SSC) have occurred. Each advocated updated, research-based approaches for "best practices" for the septic patient admitted to a hospital, such as prompt administration of appropriate antibiotics and crystalloids. However, no prior publications exist regarding septic patients who are treated and released from an emergency department (ED).

Learners are faced with the challenges of a constantly growing knowledge base, combined with multiple, competing information sources. These problems are exacerbated by increased work intensity related to duty hour limits. Web 2.0, the era of user-generated content, has heralded multiple resources and tools that allow for creative solutions, including podcasts.Podcasts are audio files distributed via the Internet to share information asynchronously. Users can subscribe to podcasts (for automatic download), which offer highly customizable learning materials ideal for graduate medical education (GME). Users can now dictate the “who,” “what,” and “when” of their learning experience. Podcasts can vary in length and their episodic release can occur daily to monthly. Podcast use has grown exponentially relative to other asynchronous resources,1 with learners devoting the most time to podcasts and perceiving podcasts to be a more beneficial resource over traditional books and journals.2Whether assigned by a faculty member or selected by a resident, podcasts enable trainees to acquire information at their own pace, are usually free of charge, and afford users immediate access to expert educators. For instructors, podcasts can deliver content to learners in advance of scheduled curriculum sessions to support application of knowledge through interactive learning activities. By recording key topics as downloadable content, educators can create podcasts that reach learners on the local, national, or international level. High-quality podcasts can also advance faculty careers and promote one's program beyond its home institution.3

Introduction: Residents and faculty in emergency medicine (EM) residency programs might be unaware of the professional and legal risks associated with the use of social media (SM). The objective of this study was to identify and characterize the types and reported incidence of unprofessional SM behavior by EM residents, faculty, and nurses and the concomitant personal and institutional risks. Methods: This multi-site study used an 18-question survey tool that was distributed electronically to the leaders of multiple EM residency programs, members of the Council of Emergency Medicine Residency Directors (CORD), and the residents of 14 EM programs during the study period May to June 2013. Results: We received 1,314 responses: 772 from residents and 542 from faculty. Both groups reported encountering high-risk-to-professionalism events (HRTPE) related to SM use by residents and non-resident providers (NRPs), i.e., faculty members and nurses. Residents reported posting of one of the following by a resident peer or nursing colleague: identifiable patient information (26%); or a radiograph, clinical picture or other image (52%). Residents reported posting of images of intoxicated colleagues (84%), inappropriate photographs (66%), and inappropriate posts (73%). Program directors (PDs) reported posting one of the following by NRPs and residents respectively: identifiable patient information (46% and 45%); a radiograph, clinical picture or other image (63% and 58%). PDs reported that NRPs and residents posted images of intoxicated colleagues (64% and 57%), inappropriate photographs (63% and 57%), or inappropriate posts (76% and 67%). The directors also reported that they were aware of or issued reprimands or terminations at least once a year (30% NRPs and 22% residents). Residents were more likely to post photos of their resident peers or nursing colleagues in an intoxicated state than were NRPs (p=0.0004). NRPs were more likely to post inappropriate content (p=0.04) and identifiable patient information (p=0.0004) than were residents. Conclusion: EM residents and faculty members cause and encounter HRTPE frequently while using SM; these events present significant risks to the individuals responsible and their associated institution. Awareness of these risks should prompt responsible SM use and consideration of CORD’s Social Media Task Force recommendations.

We investigated whether racial/ethnic disparities exist in asthma management among 1785 adults requiring emergency department ( ED ) treatment. In this multicentre study, non‐ H ispanic blacks with increased chronic asthma severity were only as likely ( P > 0.05) as non‐ H ispanic whites or H ispanics to utilize controller medications or see asthma specialists before ED presentation and to be prescribed recommended inhaled corticosteroids at ED discharge. Improved ED education on evidence‐based chronic disease management is needed to address continuing race/ethnicity‐based asthma disparities.

Among the myriad of skills required of emergency medicine (EM) physicians, communicating concise and effective transitions in care is one of the most critical for patient safety. EM physicians transition care daily, both within their own department and among other specialties. We will discuss the crucial link between care transitions and patient safety, the processes and challenges in the hand-over exchange, and recommend an approach to improve your current system with transitions in care.

Background: Emergency Medicine (EM) is increasingly becoming an international field. The number of fellowships in International EM in the USA is growing along with opportunities to complete international health electives (IHEs) during residency training. The impact on host institutions, however, has not been adequately investigated. The objective of this study is to assess the experience of several South American hospitals hosting foreign EM residents completing IHEs.Methods: Anonymous, semi-structured one-on-one interviews were conducted with physicians working in Emergency Departments in three hospitals in Lima, Peru and one hospital in Buenos Aires, Argentina. All participants reported previously working with EM foreign rotators. Interviews were analyzed qualitatively and coded for common themes.Results: Three department chairs, six residents, and 15 attending physicians were interviewed (total = 24). After qualitative analysis of interviews, two broad theme categories emerged: Benefits and Challenges. Most commonly reported benefits were knowledge sharing about emergency medical systems (78%), medical knowledge transfer (58%), and long-term relationship formation (42%). Top challenges included rotator Spanish language proficiency (70%) lack of reciprocity (58%), and level of training and rotation length (25%). Spanish proficiency related directly to how involved rotators became in patient care (e. g., taking a history, participating in rounds) but was not completely prohibitive, as a majority of physicians interviewed felt comfortable speaking in English. Lack of reciprocity refers to the difficulty of sending host physicians abroad as well as failed attempts at building long-lasting relationships with foreign institutions. Lastly, 25% preferred rotators to stay for at least 1 month and rotate in the last year of EM residency. This latter preference increased knowledge transfer from rotator to host.Conclusions: Our research identified benefits and challenges of IHEs in Emergency Medicine from the perspective of physician hosts in several hospitals in South America. Our results suggest that IHEs function best when EM residents rotate later in residency training and when relationships are maintained and deepened among those involved including host physicians, rotators, and institutions. This leads to future rotators, project collaboration, research, and publications which not only benefit individuals involved but also the wider field of Emergency Medicine.

Background: Pericardiocentesis is a rare but potentially life-saving procedure. Improper technique can lead to life-threatening complications. Discussion: Described is a cadaveric training model developed to train providers. Conclusion: This cadaveric model allows trainees to familiarize themselves with both proper landmark and ultrasound-based pericardiocentesis technique. (C) 2013 Published by Elsevier Inc.

Acute poisoning is a major public health threat worldwide, including Thailand, a country in Southeast Asia with over 67 million inhabitants. The incidence and characteristics of poisoning in Thailand vary greatly depending on the reporting body. This systematic review aims to provide a comprehensive description of the state of poisoning in Thailand. It identifies common trends and differences in poisoning by reporting centers and regional studies. Almost half of the cases and three-fourths of the deaths involved pesticide poisonings associated with agricultural occupations. However, increasing urbanization has led to an increase in drug and household chemical poisoning. Though the majority of reported poisonings remain intentional, a trend towards unintentional poisonings in pediatric and geriatric populations should not be dismissed. Unique poisonings such as mushroom, botulism, and tetrodotoxin poisonings are also closely related to the Thai lifestyle. Following this extensive review of the Thai poisoning literature, it is apparent that further support of the poison control center in Thailand is needed to improve poisoning surveillance, research, prevention, and intervention.

Study Objective: Emergency medicine in the US is increasingly becoming an international field. The number of fellowships in international emergency medicine is growing along with opportunities for emergency medicine residents to complete international electives. The impact on foreign host institutions, however, has not been adequately investigated. The objective of this study is to assess the experience of several South American hospitals that host foreign rotators in their emergency department (ED). Methods: Anonymous, semi-structured one-on-one interviews were conducted with 24 physicians in the ED of 4 hospitals in Peru and Argentina. All participants had experience working with foreign rotators. Interviews were analyzed qualitatively and coded for common themes. Results: Three department chairs, 6 residents, and 15 attending physicians were interviewed. Two broad theme categories emerged: Barriers and Benefits. Knowledge sharing about emergency medical systems, including differences in out-of-hospital care, triage and implementation of clinical guidelines, was the most common perceived benefit, identified by 78% of respondents. 58% reported medical knowledge transfer in the form of discussions, lectures, or skills demonstrations given by visiting physicians as a benefit. Hosts also enjoyed teaching rotators about common pathologies, procedures, and clinical practices utilized in the host hospital. 42% believed the formation of long-term relationships that led to future rotators, collaborations, and research was another advantage. The most common barrier was language proficiency, cited by 70% of interviewees. Spanish proficiency related directly to how involved rotators became in patient care (ie, taking a history, participating in rounds) but was not completely prohibitive, as a majority of physicians interviewed felt comfortable speaking in English. Another disadvantage, discussed by 58% of host physicians, was a lack of reciprocity due to the difficulty of completing a rotation in the U.S. as well as failed attempts at building long-lasting relationships with other institutions. Lastly, 25% preferred if a rotator stayed for at least a month and came in the last year of residency or while already in practice. This latter preference increased knowledge transfer from rotator to host. Conclusion: This is the first study that we are aware of that investigates the perspectives of residents and physicians working in emergency departments in South America that host foreign rotators. It identifies clear benefits and barriers by the hosts themselves. Language proficiency improved a rotator's ability to participate in direct patient care and a rotation completed later in residency for at least at month was preferred. Hosts enjoyed knowledge sharing about emergency medicine systems and practice. They expressed a desire to form long-term, reciprocal institutional relationships. The difficulty of rotating in US emergency medicine departments, however, was a major hindrance. In the future, emergency medicine residency programs and professional organizations may identify ways to facilitate foreign rotators coming to the US. An additional study that simultaneously measures experiences of both rotators and hosts in an established emergency medicine international elective might lead to further insights into how to improve emergency medicine international educational exchanges.

BACKGROUND:Pulmonary vein thrombosis is a rare and potentially life-threatening condition. Reported cases of pulmonary vein thrombosis commonly occur as a complication of pulmonary surgery. There is a paucity of literature describing its clinical manifestations and non-operative causes.OBJECTIVE:We report the unique case of pulmonary vein thrombosis associated with a large hiatal hernia in a patient initially presenting with renal infarction.CASE REPORT:A 68-year-old man initially presented with increasing intensity of left lower quadrant pain. Contrast-enhanced computed tomography of the abdomen revealed left renal infarctions. Searching for an embolic source, further investigation revealed left inferior pulmonary vein thrombosis in the setting of venous compression in the lung tissue adjacent to a large hiatal hernia.CONCLUSION:Large hiatal hernias may be a nidus for pulmonary vein thrombosis, a potential source of left-sided emboli.

BackgroundPericardiocentesis is rare but life saving procedure that all emergency physicians should be competent in performing. Improper technique can place patients at significant risk for iatrogenic injury. Proper training is needed to familiarize physicians with proper pericardiocentesis technique.Training ModelIn order to facilitate training of this relatively rare procedure, a cadaveric pericardiocentesis model was developed. Described is a step by step procedure for creating a cadaveric model that can be used to train and evaluate providers in pericardiocentesis competency.UtilizationThis unique teaching innovation can be utilized in a variety of settings to train providers, including those in resource limited environments. It has already been utilized in the training of emergency medicine residents in Thailand and in the United States.