Headaches are a common presentation in the emergency department and are often difficult to treat, requiring multiple treatment modalities. Paraspinous cervical nerve blocks (PCNB) are a relatively novel treatment method that are underutilized. Our objective was to develop and assess the efficacy of a simple, low-cost model to teach PCNBs to resident physicians. A Styrofoam head was used as the base. Hardened glue was used to create the “spinous processes” for landmark identification. Make-up applicator sponges were used to simulate soft tissue. Pink Hy-Tape was used to hold everything in place while creating a flesh-colored aesthetic. The total cost was $22. Thirty family medicine residents, transitional year interns, and emergency medicine interns were taught how to perform a PCNB and allowed to practice on the model. Comfort level performing the PCNB was assessed on a 4-point scale (not comfortable, mildly comfortable, moderately comfortable, very comfortable). General knowledge of the procedure was assessed based on 10 multiple choice questions. Participants' comfort level with performing a PCNB improved from a mean of 1.2 to 2.7 (p = <0.001) (from not comfortable to mildly-moderately comfortable) after being taught on this model. General knowledge improved from a mean score of 7.2 to 9.2 (p = <0.001). Using supplies that can be bought from crafts and general merchandise stores, we developed a low-cost model that effectively taught residents how to perform a PCNB.View Large Image Figure ViewerDownload Hi-res image Download (PPT)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Delayed transfer to the intensive care unit (ICU) from the general medical or surgical floor is associated with increased morbidity, mortality, and financial burden. The signs of vitality (SOV) is a novel scoring system comprised of eight weighted and three non-weighted criteria designed to identify patients at risk of clinical deterioration (Figure). We sought to evaluate the sensitivity and specificity of the SOV. We hypothesized that two or more abnormal weighted SOV is predictive of ICU transfer within 24 hours of emergency department (ED) admission. We conducted a nine-month (January 1, 2014 to September 30, 2014) retrospective chart review of adults admitted to a non-ICU setting in a community teaching hospital who had an rapid response team (RRT) activation within 24 hours of admission. Appropriate RRT activations were defined as those having two or more abnormal weighted SOV. Patients were dichotomized into those who did, and did not, meet RRT activation criteria and their disposition was tracked. The primary outcome was transfer to ICU. The sensitivity, specificity, positive predictive value and negative predictive value of abnormal SOV was calculated and expressed with 95% confidence intervals (CI). There were 273 RRT activations within 24 hours of admission in the study period. 231 (84.6%) met RRT activation criteria and 63 patients were subsequently transferred to ICU. Four patients transferred to ICU did not meet RRT activation criteria. The presence of two or more abnormal weighted SOV had a 94% sensitivity (95% CI 84-98%), 18% specificity (95% CI 15-22%), 26% positive predictive value (95% CI 21-33%), and 90% negative predictive value (95% CI 76-97%) of predicting transfer to ICU within 24 hours of admission. Tachypnea was the most common abnormal SOV, present in 53 (84.1%) transferred patients. The SOV are a sensitive but not specific indicator of need for ICU care within 24 hours of hospital admission. The sensitivity and the simplicity of the scoring system make it a useful screening tool for clinical deterioration.

Study Objectives: Emergency department (ED) wait times are considered an important facet of patient satisfaction.They can be a trigger for patient complaints and are now being advertised on billboards to attract patients.Prior studies have indicated that when asked what feature of the ED visit was most important, patients consistently rated wait time (Holden 1999), and that if the waiting time was less than expected, patients had increased satisfaction with their overall visit (Thompson 1996).The objective of this study was to determine if the patients' perception of their wait time in the ED correlated with their actual length of stay (LOS), and if the LOS would affect patients' ratings of overall satisfaction of the visit.Methods: This is a cross-sectional survey study in an academic ED with volume of 80,000 per year and was exempt by the IRB.Patients nearing the end of their stay completed an anonymous survey regarding their experience.Using a Likert scale, the survey asked them to rate the amount of time they waited to see a provider and how satisfied they were with the ED visit.When starting the survey, the patient's total LOS in the ED was recorded from electronic trackboard, which included time in the waiting room as well as the treatment room.The patients' LOS was compared to their satisfaction score, and the actual LOS and perception of wait times were evaluated using t-tests and chi-square analysis.Results: 613 surveys were completed.The average LOS was 6 hours and 22 minutes (SD 4h56min).Of the patients surveyed, 19.5% rated the time they waited for a provider as "too much"; their mean LOS was 6h51min (SD 5h07min).The remaining 80.5% of patients who felt the wait time was "about right" had a mean LOS of 6h14min (SD 4h54min).There is no statistically significant difference between these two groups' LOS (p¼0.2).The majority of patients (92%) rated their overall visit highly.There was no difference in LOS for those patients who were not satisfied (mean LOS of 6h43min SD 5h29min) and those who were satisfied (mean LOS of 5h56min SD 4h54min, p¼0.3).Although the overall rating of the visit was not affected by the LOS, perceptions of the LOS did affect the rating.The patients who rated their LOS as "about right" gave higher satisfaction ratings, while those who rated the LOS as "too much" gave a lower satisfaction score (p<0.005).Conclusions: The patients' actual LOS in the ED did not affect whether they rated their visit favorably, but those who perceived their LOS was "about right" gave better ratings of their visit.Although wait times increase when the resource capacity of providers and services is exceeded, longer wait times may not affect satisfaction scores because sicker patients usually require more time for evaluation.The initial time to seeing a provider is considered to have the strongest effect on patients' perception of wait time and satisfaction.A more meaningful metric for quality may be evaluating time to admission or discharge (Weiner 2013) as a patient's actual LOS does not correlate with their satisfaction.

1. Do patients and their accompanying persons want the emergency department (ED) to offer rapid Human Immunodeficiency Virus (HIV) testing?

Hypermagnesemia is a rare cause of coma in a patient with normal renal function. When present, it is often because of iatrogenic medication overdose. We report a fatal case of chronic Epsom salt gargles for halitosis that produced a serum magnesium of 23.6 mg/dL (9.8 mmol/L) and resulted in coma. We review the wide presentation of hypermagnesemia from subtle neurologic and cardiovascular signs to the major life-threatening clinical manifestations of shock, dysrhythmias, coma, and cardiopulmonary arrest despite emergency dialysis.

Hypermagnesemia is a rare cause of coma in a patient with normal renal function. When present, it is often because of iatrogenic medication overdose. We report a fatal case of chronic Epsom salt gargles for halitosis that produced a serum magnesium of 23.6 mg/dL (9.8 mmol/L) and resulted in coma. We review the wide presentation of hypermagnesemia from subtle neurologic and cardiovascular signs to the major life-threatening clinical manifestations of shock, dysrhythmias, coma, and cardiopulmonary arrest despite emergency dialysis.

[Brismar B, Totten V, Persson BM: Emergency, disaster, and defense medicine: The Swedish model. Ann Emerg Med February 1996;27:250-253.]