emergency medicine thesis topics

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• v.21(5); 2020 Sep

Resident Research in Emergency Medicine: An Introduction and Primer

James h. paxton.

* Wayne State University, Department of Emergency Medicine, Detroit, Michigan

Anne M. Messman

Nicholas e. harrison, adrienne n. malik.

† Kansas University Medical Center, Department of Emergency Medicine, Kansas City, Kansas

Raina J. Burke

‡ Wheeling Hospital, Department of Emergency Medicine, Wheeling, West Virginia

Phillip D. Levy

Training in research methodology represents an important aspect of emergency medicine (EM) resident education, but best methods for design, implementation, and dissemination of resident research remain elusive. Here we describe recommendations and best practices from the existing literature on EM resident research, including helpful tips on how to best implement a resident research program.

INTRODUCTION

When René Laënnec, a French physician in 1816, failed to adequately percuss the thorax of a young woman with heart disease, he improvised. Laënnec wrote, “I rolled a quire of paper into a sort of cylinder and applied one end of it to the region of the heart and the other to my ear.” 1 After numerous revisions, his invention was revealed to the medical community, and quickly caught on. Within a few years, primitive stethoscopes could be found in medical shops throughout Paris. Had Laënnec stopped with that rolled-up piece of paper, his one-time improvisation would have been lost to the annals of history. Fortunately, he chose to build upon his initial discovery and, crucially, to share his breakthrough with the world. Laënnec’s journey charts an enduring and fundamental trajectory of medical innovation: from observation, through inspiration, refinement and testing, to dissemination.

Development of a research project can be especially daunting to physicians already engaged in an emergency medicine (EM) residency training program. But execution of a research project during residency remains a worthwhile experience, allowing participants to meaningfully contribute to medical knowledge and develop an investigative spirit. 2 Residents participating in research appear to attain greater job satisfaction, 3 and can objectively frame everyday questions and methodically seek answers 3 to problems including (among others) staffing issues, wait times, and communication barriers. 4 – 5

The Accreditation Council for Graduate Medical Education Residency Review Committee for EM recognizes the importance of these efforts, mandating resident completion of a “scholarly project” prior to graduation. Their requirement cites the following as examples of qualifying activities: “…the preparation of a scholarly paper such as a collective review or case report, active participation in a research project or formulation and implementation of an original research project.” 6 These activities should include problem identification, data collection, analysis, and conclusion. 7 Performance and documentation of these projects are vital to the acceptance of a scholarly project, whether a case report, community project, development of medical software, or traditional research project. 7 Recent reports from within the EM community have emphasized the importance of scholarly activity to EM resident education. 8 – 9

Advancing the state of scientific knowledge is not a requirement for success in resident research, but it is a potential benefit of this exercise. It is the responsibility and privilege of those involved in residency administration to facilitate the training of EM resident researchers in the development and execution of research projects that support not only the professional careers of residents but also the advancement of our specialty. 8 – 9

What is Resident Research?

It has been suggested that “resident research” is, “research where a resident has a principal role in the implementation and completion of the project.” 10 We suggest that the resident research experience be defined by the engagement of the resident learner in the research process, focusing upon the educational value of the project rather than the resident’s official role or involvement in the design and execution of the project. Research studies are intended to create new generalizable knowledge that can be applied to other populations and settings. 11 Consequently, we propose that “resident research” be defined as any systematic investigation designed to yield new information that actively engages the resident-learner and facilitates the acquisition of a greater understanding of the scientific method. This is in distinction to quality improvement projects, which seek to apply existing knowledge to improve healthcare outcomes within a local healthcare institution or setting. 12

Setting Realistic Expectations

One purpose of resident research is to expose residents to the methods by which research is conducted, creating “educated consumers” of the medical literature. However, residencies hoping to establish a resident research program de novo must recognize the additional workload that resident research projects impose upon faculty. Mentors should be primarily responsible for guiding and supervising resident research, but should be adequately vetted to ensure that the research experience yields a positive result for all involved. Research directors should provide guidance relating to funding opportunities, deadlines for abstract submission to key research conferences, important institutional and federal regulations, and departmental resources. 13 Departmental leadership should create an environment in which research is actively promoted, providing appropriate funding and protected time for mentors and other research faculty. 13

Getting Started

Clinical experiences, journal club articles, or experiences with different teaching modalities may generate an appropriate resident research topic including relevant clinical or educational questions. 2 , 14 – 15 Additional ideas may come from the resident’s personal interests or experiences.

Learning Research Methodology

Most programs will offer training through didactic presentations, journal clubs or evidence-based literature discussions. However, a focused educational effort specifically targeting research methodologies has been shown to correlate with improved resident skills, knowledge, and research productivity. 16 Nearly one in four EM training programs offers a fixed rotation in research. 5 , 17 A more feasible format for the busy trainee might be the Advanced Research Methodology Evaluation and Design video series available from the Society of Academic Emergency Medicine (SAEM), including “how-to” webinars and podcasts produced by senior researchers. 18

The Research Question

A general research question must be formulated, which will generate a testable hypothesis. 3 , 19 All possible outcomes should be considered, and at least one of them must be worthwhile. 20 The FINER criteria may be used to assess the relative merits of the proposal: 14 – 15 , 21

Can the project be completed within the time allotted using the given resources? Can the proposed investigation enroll enough patients to demonstrate a difference in the proposed outcome measures?

Is the topic engaging enough to be worth the effort?

Is the proposed investigation different enough from what has been done before to add knowledge on the subject?

Does the proposed investigation respect the morals of the community, the patient, and the profession?

Are the results likely to be applicable to many patients? Will the results be useful and contribute to the greater good?

Formulating a Hypothesis

A suitably refined and meaningful research question will help in generating a hypothesis, providing a clear delineation of what the investigation will attempt to prove. Investigation of a well-designed hypothesis will be interesting even if a negative result is found.

A mentor experienced in the resident’s area of research interest can be an invaluable resource by offering hints at project scope, helping with setbacks, and tailoring the learning experience to the resident’s needs. 22 Most often, the mentor is an established researcher within the department but could include a specialist in another field, or even a non-physician investigator. 5 , 23 – 24 Goals and expectations should be discussed early on, to avoid frustration for both parties. 5 Terregino has shown that, in general, EM residents are relatively unfamiliar with what resources are available to them, which can lead to significant amounts of time wasted. 25 Most hospitals provide research support that is invisible to the outside observer, including project coordinators, departmental research directors, and biostatisticians. 25 The mentor should be aware of all available institutional resources.

The Literature Search

A valid research project must be informed by past work. Most literature reviews will begin with a search of PubMed.gov , the database of the National Library of Medicine, or OVID.org , which includes textbooks as well as journals. 26 Search terms used must be carefully selected, and the proper Boolean operators assigned. One study has shown physicians to be especially inept at crafting effective search strings. 27 Any doubts about the literature search process or its results should be referred to a librarian.

Each paper identified from the literature review should be thoroughly read. Investigators should avoid citing abstracts alone, as they are often incomplete in their data presentation. This process is labor-intensive but necessary to form a strong foundation for the research project. All references cited within each article should be assessed for relevance. The selected literature should be reviewed to better understand the subject matter and to develop context for the proposed work. If adequate data from existing sources are uncovered, one may consider a retrospective evaluation of prior results including a meta-analysis. 2 , 28 – 29

Research Design

The novice researcher should look to the existing medical literature for guidance in how to properly design a new study. Selection of the proper research methodology will depend upon multiple factors, including the research question, hypothesis, and predetermined outcome measures. A timeline should be implemented to ensure that all tasks are achievable within the allotted time. Resident physicians should develop a team approach, incorporating input from the faulty mentor as well as a staff epidemiologist or biostatistician. The required sample size will depend upon a variety of factors, including the acceptable level of significance, power of the study, expected effect size, underlying event rate in the population, and standard deviation in the population. 30 – 31 Efforts should be made to collect an inclusive and truly random sampling, to avoid convenience selection bias. 32 Early consultation with the biostatistician will also inform the researcher’s decisions on the most appropriate methods for the statistical analysis of data derived from the study. For further information about study design specifics, the reader is referred to several existing publications. 2 , 4 , 13 , 33 – 34

The Institutional Review Board

Any research project that involves human participants or their data requires submission to the local institutional review board (IRB). Research protocols submitted to the IRB can fall into one of three categories: full submission; expedited; or exempt. Research involving greater than minimal risk to human subjects will require a thorough review by the IRB and development of an informed consent document. Prospective projects involving only minimal risk may be approved via the expedited process, where a single reviewer may approve the work in lieu of the convened board. Studies that include only retrospective data from the electronic health record may be exempt from IRB review, but this determination should be made by the IRB, rather than by the investigator. Investigators should confer with their local IRB to confirm what level of IRB review is required before beginning data collection.

Conducting the Study

After the research protocol has been IRB-approved or exempted, data collection can commence. Prior development of a data collection tool will greatly enhance the efficiency of this process, facilitating both IRB approval and the subsequent data analysis. Subject enrollment can also be improved with use of a trained research assistant. This problem may be circumvented through creation of an “academic associate program,” which integrates EM research with undergraduate education. 35

Research Funding

Resident research projects usually require little external funding. On occasion, additional costs may be incurred to help pay for statistical analysis, or the purchase of required equipment. 36 Internal sources, as well as the Emergency Medicine Foundation 37 and the SAEM Foundation 38 represent potential sources for funding.

Presentation and Publication

Once the data have been collected and analyzed, the researcher should consider how the results will be disseminated. The annual meeting of SAEM, the Research Forum at the American College of Emergency Physicians’ annual scientific assembly, and the Annual Assembly of the Council of Residency Directors in Emergency Medicine (CORD) represent the premier locales for presentation of EM research. 39

Ideally, the resident research experience should lead to a manuscript, although the lack of immediate publication must not be interpreted as failure. Only 40% of EM abstracts go on to become full article publications. 15 , 40 Most manuscripts are published 1–2 years after initial presentation. 17 Appropriate journal selection for submission enhances the likelihood of success, as does a thorough understanding of manuscript preparation techniques and review criteria. 41 – 43

While any research resultant from a resident’s scholarly project is unlikely to have the impact of Laënnec’s stethoscope, EM residents may still gain much from engaging in clinical research. For some, it will light an investigative fire that will burn for an entire career. At the least, resident research projects can provide an opportunity to explore issues central to the practice of EM, helping the resident to become a more well-rounded physician.

Section Editor: Whitney Johnson, MS, MD

Full text available through open access at http://escholarship.org/uc/uciem_westjem

Conflicts of Interest : By the West JEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

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Greatest Hits in Emergency Medicine Research: 2023

Keeping abreast of all the high-impact papers in em is no easy feat..

EMRA’s Research Committee, in partnership with other EMRA committees, has compiled a quick review of some of the most practice-affirming or practice-changing papers recently published. This is by no means a definitive list, but our summaries of these noteworthy papers will be good to know for your next shift!

Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial.

Review by Sierra F. Williams, MS, OMS-IV

This double-blind, randomized clinical trial sought to determine whether administration of calcium during out-of-hospital cardiac arrest (OHCA) improves return of spontaneous circulation (ROSC) in adults. In this trial, 397 adult patients were randomized to receive up to 2 intravenous or intraosseous doses of 5 mmol of calcium chloride (n = 197) or saline (n = 200). A dose of calcium chloride or saline was administered immediately following a dose of epinephrine. The primary outcome of the study was sustained ROSC (defined as ROSC without need for further CPR for 20 minutes), while the secondary outcome included survival and a favorable neurological outcome at 30 and 90 days, with a modified Rankin Scale score of 0-3. The trial was stopped early due to concerns of harm in the calcium group. Sustained ROSC was achieved in 19% of patients in the calcium group and 27% in the saline group (risk ratio, 0.72 [95% CI, 0.49 to 1.03]; risk difference, −7.6% [95% CI, −16% to 0.8%]; p=0.09). At 30 days, 5.2% of patients in the calcium group survived compared to 9.1% of patients in the saline group (risk ratio, 0.57 [95% CI, 0.27 to 1.18]; risk difference, −3.9% [95% CI, −9.4% to 1.3%]; p=0.17). 3.6% of patients in the calcium group reached a favorable neurological outcome compared to 7.6% of patients in the saline group (risk ratio, 0.48 [95% CI, 0.20 to 1.12]; risk difference, −4.0% [95% CI, −8.9% to 0.7%]; p=0.12). The study showed that administration of calcium during OHCA in adults did not improve sustained ROSC and can potentially cause harm.

Critique and Implications for Practice Prior to the COCA trial, evidence regarding the use of calcium in OHCA has been conflicting and lacking. However, guidelines often continue to recommend its use. There is sufficient evidence to support the use of calcium in select patient populations that were not included in this study, such as hyperkalemia, hypocalcemia, and CCB toxicity. Although the results were not statistically significant due to the low power of the study, the use of calcium in OHCA appears to be correlated with patient harm that cannot be ignored. This indicates that calcium in OHCA is not suitable for all patients and should not be used routinely. It is also important to keep in mind that there has been no study to date to demonstrate that a single medication administered during cardiac arrest made a difference in survival with a favorable neurological outcome. Early, high-quality CPR in addition to early defibrillation in the appropriate patients are the only 2 treatments that have shown improvement in these outcomes.*

*Referenced First10EM and Salim Rezaie EBM review during ResusX 2022 conference

Prehospital & Disaster Medicine, Health Systems

Using the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program Data to Monitor Trends in U.S. Emergency Department Visits for Firearm Injuries, 2018 to 2019

Review by Muhammad Waseem, MD, MS & David Gordon, MS3

The authors utilized a retrospective analysis of the CDC National Syndromic Surveillance Program dataset to analyze near-real time data between January 2018 and December 2019, capturing 215 million ED visits. The study used a set of ICD-9 and ICD-10 diagnosis codes and chief complaint keywords to filter for firearm injury records. Of those visits, 132,767 were firearm related (61.6 per 100,000 ED visits). This study revealed that males aged 15-24 had higher firearm injury-related ED visit rates relative to other demographic age groups. Overall, the rate of fire-arm related injury increased for all age groups between 15 and 64 years over the interval studied. Analyzed by region, the rate of ED visits for firearm injury significantly increased in the northeast, southeast, and southwest regions. These results are consistent with other studies but were able to be reported with less lag due to the study’s near real time surveillance methods.

Critique and Implications for Practice Firearm-related injury is a major public health issue, but there is lag between when ED visits relating to firearm injury occur and when traditional reports for firearm injury are captured. This study highlights the epidemiology of firearm-related visits to the emergency department, raising awareness of the problem and noting the need for prevention strategies. The rate of firearm-related injury and presentation to the ED is only increasing. Awareness of the epidemiology of firearm injury can help target community-based public health violence prevention, facilitate training, and guide rapid response strategies. On a systems level, this method analysis can also inform resource allocation, particularly identifying where firearm visits make up a substantial portion of ED visits. In contrast to a typical 2-year data lag from traditional ED surveillance systems used to monitor firearm injury ED visits, this study utilized near-real time electronic medical record national surveillance data. Where data is available, incorporating methods that leverage real-time surveillance could provide further insight into other clinical applications as well.

Critical Care, Airway Management

Effect of Use of a Bougie vs Endotracheal Tube with Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial

Review by Elisa Quince DO, MS

This multicenter, randomized clinical trial assessed if utilizing a bougie or an endotracheal tube with stylet would increase the likelihood of success on the first attempt. In this study, referred to as the “BOUGIE” trial, 1,102 critically ill adults who required tracheal intubation were randomly assigned the utilization of a bougie or endotracheal tube with a stylet. The study found an 80% success rate with the utilization of the bougie versus 83% with a stylet. Overall, the study found that using a bougie did not significantly increase the incidence of successful intubation on the first attempt compared to using an endotracheal tube with a stylet.

Critique and Implications for Practice This study challenges the perception that a provider should primarily use a bougie during difficult intubations. This perception was shaped by previous observational studies and 1 RCT concluding that using a bougie was associated with increased incidence of first-attempt intubation. It encourages providers to focus more on utilizing the method the operator is most comfortable with at that time. When comparing the BEAM trial to this study, one difference is that the BEAM trial was limited to one single emergency department in Hennepin County Medical Center, while the BOUGIE trial received data from 7 different emergency departments and 8 ICUs in the United States. Differences in training styles and experiences can lead to the differences seen in the results of these studies but can lead to the implication that for difficult intubations, how one is trained can dictate comfort level, and comfort level can lead to successful intubation on the first attempt.

Pediatric EM

Effect of Amoxicillin Dose and Treatment Duration on the Need for Antibiotic Re-treatment in Children with Community-Acquired Pneumonia: The CAP-IT Randomized Clinical Trial

Review by David Leon, MD

This study is a multi-center 2x2 RCT with children who required amoxicillin for community-acquired pneumonia (CAP), randomized to receive either 35-50 mg/kg/d or 70-90 mg/kg/d of amoxicillin for a treatment duration of 3 or 7 days. The primary outcome was if it was clinically indicated to re-treat with antibiotics for respiratory infection within 28 days after randomization. There was no significant difference between the high- and low-dose groups, nor the 3-day vs 7-day groups. The secondary outcomes addressed CAP-related symptom severity. Cough duration was slightly prolonged in the 3-day course group. No significant interaction was noted between dose and duration groups. Outpatient treatment of CAP in children with a lower dose of amoxicillin was noninferior to traditional high-dose amoxicillin, and 3-days of antibiotics was noninferior to 7-days, with respect to the need for antibiotic retreatment within a month.

Critique and Implications for Practice For children with mild to moderate CAP who are not in need of significant support, such as those appropriate for discharge or only requiring overnight observation, it seems adequate to treat with both lower dose and shorter course of antibiotics. However, this data may not be applicable to children with severe CAP. Local antibiogram and resistance must be considered given that the study only included amoxicillin. This is of particular interest as there was a nationwide shortage of amoxicillin this year.

CT or Invasive Coronary Angiography in Stable Chest Pain

Review by Sandra Gad, MSc

Randomly assigned 3,561 patients (56.2% female), follow-up was complete for 3523 (98.9%). Major adverse cardiovascular events occurred in 2.1% in the CT group and in 3% of the ICA group (hazard ratio, 0.70; 95% confidence interval [CI], 0.46 to 1.07; P=0.10). Major procedure-related complications occurred in 0.5% of the CT group and in 1.9% of the ICA group (hazard ratio, 0.26; 95% CI, 0.13 to 0.55). Angina during the final four weeks of follow-up was reported in 8.8% of the patients in the CT group and 7.5% of those in the ICA group (odds ratio, 1.17; 95% CI, 0.92 to 1.48). The DISCHARGE trial group found that the incidence of major adverse cardiovascular events did not differ between the CT group and the invasive coronary angiography group in patients with stable chest pain.

Critique and Implications for Practice CT can be a reliable option with similar diagnostic abilities to ICA when diagnosing CAD in patients with stable chest pain. Using CT can significantly reduce patients’ concerns regarding the invasive nature of ICA, as well as alleviate the financial burden associated with ICA. Further, CT can speed up diagnosis and ensure timely treatment.

Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial

Review by Nathan Dreyfus, MD

This multi-center, retrospective cohort analysis compared the outcomes of pediatric in-hospital cardiac arrest cases (p-IHCA) between patients who received intra-resuscitation sodium bicarbonate and those who did not. Children analyzed were those who received chest compressions between ages =>37 weeks post-conceptual age and <= 18 years between October 2016 to March 2021. Various child characteristics including their Pediatric Risk of Mortality score (PRISM) and Vasoactive Inotropic Score (VIS) were collected across 10 clinical sites. The main outcome of investigation was the duration of survival to hospital discharge. Other outcomes included ROSC, neurological outcomes, and presence of new morbidity. It was shown that sodium bicarbonate was used more in children with cardiac diagnoses, increased severity of illness and longer CPR duration. Of 1,100 CPR events, use of sodium bicarbonate was associated with lower rates of survival to hospital discharge and discharge with favorable neurologic outcomes.

Critique and Implications for Practice While the propensity-weighted model in this study omits several potential confounders, the results echo similar recent papers in adult populations providing evidence against the routine or indiscriminate use of sodium bicarbonate for cardiac arrest. One limitation is that sodium bicarbonate use was more common in medical and surgical cardiac patients than non-cardiac patients, as well as with children with higher PRISM and VIS scores which could contribute to the poorer outcomes seen. Intra-arrest lab values such as pH were not analyzed so it is unknown how sodium bicarbonate would play a role for severe intra-arrest metabolic acidosis. Also, the time to first sodium bicarbonate administration was not analyzed which could pose limitations. Although sodium bicarbonate remains a part of the ACLS and PALS guidelines for cardiac arrest, its utility is not evidence-based per this study as well as per other studies. I will be thoughtful about when I choose to administer sodium bicarbonate during code situations, as this study suggests there might even be harm in doing so.

Prehospital & Disaster Medicine, Critical Care

One and Done Epinephrine in Out-of-Hospital Cardiac Arrest? Outcomes in a Multiagency United States Study

Review by Luke Wohlford, MD, MPH

A pre- and post-intervention study investigating patient outcomes when comparing the existing protocol of epinephrine every 3-5 minutes in non-traumatic cardiac arrest to a 1-time epinephrine dosing protocol. Adults included in this study among 5 North Carolina EMS agencies were assessed for survival to hospital discharge and ROSC pre- and post-implementation. After controlling for patient factors, the single-dose approach demonstrated comparable survival to discharge rates (adjusted odds ratio 0.88, 95% confidence interval 0.77–1.29), but with lower rates of ROSC (adjusted odds ratio 0.58, 95% confidence interval 0.47–0.72). With neurological outcomes as the more patient-centered outcome, an argument can be made about the validity of a 1-time epinephrine dosing protocol.

Critique and Implications for Practice Further work and additional studies may need to be done to further elucidate neurological outcomes among those with survival to hospital discharge, this study demonstrates equipoise with a 1-time epinephrine dosing protocol that may allow higher proportions of time spent on CPR during resuscitations and free up more resources for high-quality cardiac arrest care.

Performance of the Paracetamol-Aminotransferase Multiplication Product in Risk Stratification After Paracetamol (Acetaminophen) Poisoning: A Systematic Review and Meta-Analysis

Review by Mason Jackson, MD

This systematic review and meta-analysis evaluated the acetaminophen cross-product as a marker of hepatotoxicity. The cross product is calculated by multiplying the higher of the aminotransferases (AST or ALT) by the acetaminophen concentration and can be used to determine hepatotoxicity risk in scenarios excluded by the original acetaminophen overdose studies, which primarily looked at single dose, acute and timed overdoses. Target measurements were a lower threshold of 1,500 and upper threshold of 10,000. When used as a diagnostic predictor of hepatotoxicity, and hepatotoxicity in staggered ingestions, and ingestions older than 8 hours, the cross product produced a lower limit OR of 31 to 85 and a higher limit OR of 99 to 367. This demonstrates that the acetaminophen cross product is a strong diagnostic tool that can aid the emergency physician in acute acetaminophen overdose alongside the Rumack-Mathew nomogram, generating profound changes in diagnostic certainty.

Critique and Implications for Practice In patients presenting with staggered overdoses or delayed presentation of an acetaminophen overdose, utilization of the cross product will help decide the need for N-acetyl cysteine in the ED. It serves as a useful marker for intensivists and toxicologists caring for these patients on inpatient services as well.

Medical Education

Communicating Diagnostic Uncertainty at Emergency Department Discharge: A Simulation-Based Mastery Learning Randomized Trial

Review by Hannah Seyller, MD , and Kay Nicole Tipton, DO, MS

This multi-center randomized control trial examined the ability of resident physicians to communicate diagnostic uncertainty through simulated patient encounters. Though many patients leave the ED without a formal diagnosis, residents have little training communicating diagnostic uncertainty to their patients.

In this trial, 109 residents participated in a simulation-based learning curriculum that included online modules, a mobile learning application, and 3 simulated telehealth practice sessions with a standardized patient. Participants were divided into immediate and delayed intervention groups, which did not receive the intervention curriculum until after the second patient encounter. The primary outcome was each physician’s “mastery” of communicating diagnostic uncertainty after the second encounter based on the Uncertainty Communication Checklist.

Regardless of training site or stage of training, residents in the immediate access group showed an increased mastery compared to the delayed group, who had not yet received the intervention. Two-thirds of participants felt the curriculum increased their communication skills, and 60-65% said they applied skills they learned to their clinical practice. Limitations include unblinded participants and internal development of the objective scoring tool used to determine mastery.

Critique and Implications for Practice Residents are often not properly trained on how to communicate diagnostic uncertainty with patients. This article provides a framework that can be implemented in current or future practice within residencies to improve communication at discharge when the exact cause of patients’ symptoms remains unknown. Although the article did demonstrate a difference between early and late intervention groups within the measurement of the study, it did not show a difference when translated to clinical practice. Further studies will need to be performed to evaluate how this framework and others can affect clinical practice in emergency departments.

Effect of Moderate vs. Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest. The CAPITAL CHILL Randomized Clinical Trial

Review by Charles Sanky, MD, MPH

This single-center, double-blinded, stratified, randomized-controlled, clinical superiority trial was the first study to compare hypothermia at 31°C with 34°C in survivors of out-of-hospital cardiac arrest. It sought to determine whether this difference in moderate versus mild hypothermia improved clinical outcomes in comatose survivors of out-of-hospital cardiac arrest. Patients were randomly assigned to temperature management with a target body temperature of 31 °C (n = 193) or 34 °C (n = 196) for a period of 24 hours. Outcomes included all-cause mortality, ICU length of stay, neurological outcome, and adverse effects. This study found no significant difference in the composite of mortality and poor neurological outcome, occurring in 48.4% (31°C group) and 45.4% (34°C group), 95% CI, −7.2% to 13.2%; P = 0.56. However, the 31°C group had a 3-day longer median length of stay in the ICU (10 vs. 7 days; 95% CI -1.2 to 4.1; P=0.004).

Critique and Implications for Practice Numerous studies have suggested that going beyond the targeted temperature management of 32 to 36 degrees, the updated post-cardiac arrest TTM guidelines. Studies have consequently attempted to determine what the optimal temperature might be, including the much larger TTM trial in 2021, which did not find a difference in normothermia versus hypothermia. Still, the impact on ICU length of stay is concerning, possibly reflecting that moderate hypothermia could mask fevers that otherwise would have received treatment. This study may not change my practice yet but is worth considering in the wake of new ACLS guidelines regarding TTM.

Wilderness Medicine

A New Multi-Disciplinary Approach Supported by Accident and Field Test Data to Optimize Survival Chances in Rescue and First Aid of Avalanche Patients

Review by Chelsea McAuslan, MS4

This retrospective analysis of 1070 full avalanche burials from accident databases and large prospective field test datasets were used to develop evidence-based algorithms exclusively for the avalanche rescue environment. AvaLife provides a holistic and tailor-made tool for avalanche first aid with its consideration of adapted sequence of actions, inclusion of rescue tactical considerations, advice for cases with multiple burials where there is a shortage of resources, considerations of using recovered subjects as a resource in the ongoing rescue, the adapted definition of “injuries incompatible with life,” reasoning behind the importance of rescue breaths, and the updated BLS iCPR algorithm.

Critique and Implications for Practice This study highlights the method AvaLife in the rescue and treatment of patients trapped from the effects of an avalanche. It provides ALS and BLS providers with the methods of triage to allow for the best chances of survival for patients who undergo entrapment. The principle of the “greatest good for the greatest number” is shown crucial in these cases of situational resource shortage. Rescuers must analyze the environment, take into consideration the forces that could prolong excavation, and proceed with appropriate survival techniques according to AvaLife Protocol in patients with injuries resulting from avalanche and burial.

Admin & Operations

The use of the word "quiet" in the emergency department is not associated with patient volume: A randomized controlled trial

Review by David Gordon, MS3

This randomized control trial evaluates if hearing the word “quiet” bears any change in patient volume and perception of the business of an ED shift. In this trial, 506 staff surveys were collected over a sample of 47 shifts. For each, a researcher approached staff members with a greeting. If the day were randomized to the intervention, the researcher asked, “Has it been quiet in here?” Three hours later, the researcher returned to the staff member to administer the survey, which assessed crowdedness of ED, feelings toward patient volume entering ED, and the belief that the word quiet affects business of the day. There was no association between the word “quiet” and increased patient volumes. However, staff members who perceived that the word “quiet” influenced patient volumes reported a perception of a more crowded ED with more patients after hearing the word “quiet.” Some staff members provided qualitative responses that shifts had “worsened” following hearing the word “quiet,” citing acutely ill patient cases they were managing.

Critique and Implications for Practice Throughout an ED shift, someone might approach an ED staff member and ask if the day is a “quiet” day. ED providers care for patients as they enter the department, but the word “quiet” does not influence patient volume. Though this study was conducted at a single site, the methodology of the study provides a robust analysis to address a common concern among emergency department staff. Staff members who feel as though there is an increase in ED volume and business following hearing the word “quiet” likely have a preconceived belief that this is true. A staff member’s initial preconceived notions of factors that trigger business within the ED may contribute to their perceptions of the ED shift. Generalizing on the study’s results, if staff adopts a mindset that the word “quiet” does not affect patient volumes, they may perceive decreased business over the course of the shift.

Any papers we missed? Let the EMRA Research Committee know a nd we can discuss it at an upcoming journal club!

This list was compiled and edited by EMRA Research Committee members Charles Sanky, MD, MPH; David Gordon, MS3; Kristina Pagano, MS3; and Nathan Roberts, MD, PhD.

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Explore the latest in emergency medicine, including prehospital care, resuscitation, trauma, respiratory failure, arrhythmias, and more.

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This cohort study examines patients’ insurance type and the decision to withdraw life-sustaining treatment in trauma patients who are critically injured using data from level I and level II trauma centers in the US.

• Does a Patient’s Ability to Pay For Health Care Make Their Life Worth Saving? JAMA Network Open Opinion July 24, 2024 Surgery Ethics Health Care Economics, Insurance, Payment Trauma and Injury Health Policy Full Text | pdf link PDF open access

This cross-sectional study examines the number of injuries and hospitalizations associated with electric vs conventional bicycles and scooters from 2017 to 2022.

This randomized study uses electronic health record data to investigate how a monthly cash benefit delivered to low-income individuals affects emergency department and outpatient care utilization in a low-income US city.

This cohort study examines the association of changes in emergency department pediatric readiness with pediatric mortality at US trauma centers between 2013 and 2021.

This cohort study assesses the association of medication for opioid use disorder (MOUD) initiation after hospitalization or an emergency department (ED) visit with subsequent fatal or nonfatal opioid overdose at 6 and 12 months.

This systematic review and meta-analysis assesses the associations of sepsis alert systems in emergency departments with mortality and adherence to sepsis management guidelines.

This quality improvement study evaluates the use of artificial intelligence to accelerate triage of patients presenting to the emergency department with chest pain.

This case report describes a diagnosis of iridodialysis in an 11-year-old boy who presented with decreased vision and inflammation after direct blunt trauma to the left eye.

This cross-sectional study investigates if there are racial, ethnic, or gender disparities in the length of boarding in emergency departments for youth awaiting inpatient psychiatric care.

This quality improvement study evaluates the association of hospice use with a novel multidisciplinary hospice program to rapidly identify and enroll eligible patients presenting to the emergency department near the end of life.

This cross-sectional study of US adults compares rates of injuries related to firearm use vs motor vehicles crashes relative to community-level social determinants of health.

This secondary analysis evaluates temporal associations between end-tidal capnography and return of spontaneous circulation among patients with out-of-hospital cardiac arrest in the Pragmatic Airway Resuscitation Trial.

This cross-sectional study evaluates growth of transport policies and policy components that directed emergency medical services (EMS) to bypass local emergency departments for the closest certified stroke centers as a proven treatment for stroke.

This survey study reports on the required community consultation and public disclosure activities for level I trauma centers participating in an Exception From Informed Consent (EFIC) trial in the US.

This cohort study examines whether the National Surgical Quality Improvement Program Pediatric criteria for assessing appendicitis severity proposed in 2016 can be used to estimate the risk of adverse events and resource use in children with appendicitis.

This systematic review and meta-analysis examines the use of termination of resuscitation rules to estimate patient survival of out-of-hospital cardiac arrest.

• Optimizing the Value of β-Lactam Antibiotics Through Extended Infusion JAMA Network Open Opinion July 2, 2024 Infectious Diseases Sepsis Critical Care Medicine Resuscitation Pharmacy and Clinical Pharmacology Full Text | pdf link PDF open access

This cohort study assesses whether extended-infusion β-lactam therapy is associated with survival, adverse events, and/or emergence of resistance in adults with gram-negative bloodstream infections.

This diagnostic study evaluates the performance of a prediction model of acute pancreatitis in a prospective cohort of patients presenting to the emergency department with serum lipase levels elevated to 3 times the upper limit of the reference range.

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Research & Innovation

Leading in the advancement of emergency medicine through innovation and scientific discovery..

Emergency Medicine is a rapidly-developing field, and Stanford is leading research in many facets of care. The department benefits from collaboration with other disciplines at Stanford, within local Silicon Valley, and across the globe.

Stanford is leading research efforts to transform health care for  all  through Precision EM. Precision Emergency Medicine utilizes information and technology to effectively, efficiently, and authentically deliver acute care for our patients and our communities.

RESEARCH AREAS INCLUDE: Pre-hospital Care; AI; Telehealth; Informatics; Medical Education; Pediatric EM; Global EM; Population Health; Wilderness Medicine; Ultrasound; Wellness; and Diagnostics.

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PROFILES IN INNOVATION

Take a deeper dive into select emergency medicine research initiatives at Stanford, from informatics, to diagnostics, to education. More   

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Call for papers "enhancing stroke care worldwide: identifying barriers and bridging gaps for improved prognosis".

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Have a look at the IJEM mentions through social media in the past month & discover the most trending articles

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The MINUTES bundle for the initial 30 min management of undifferentiated circulatory shock: an expert opinion

Authors: Ahmed Hasanin, Filippo Sanfilippo, Martin W Dünser, Hassan M Ahmed, Laurent Zieleskiewicz, Sheila Nainan Myatra and Maha Mostafa

Catecholamine concentration as a predictor of mortality in emergency surgical patients

Authors: João Isuk Suh, Daiane Leite da Roza, Filipe Matheus Cadamuro, Luiz Marcelo Sá Malbouisson, Talita Rojas Sanches and Lúcia Andrade

A diagnostic dilemma: distinguishing a sulfasalazine induced DRESS hypersensitivity syndrome from a CD30 + lymphoma in a young patient

Authors: Natalija Aleksandrova, Jonas De Rop, Frederic Camu, Ives Hubloue and Katleen Devue

Comparing online and onsite simulation modules for improving knowledge and confidence in disaster preparedness among undergraduate medical students

Authors: Vimal Krishnan S, Aaditya Katyal, Soumya S Nair and Kirtana Raghurama Nayak

“Iliacus muscle abscess as an unexpected cause of posterior hip pain in a healthy young adult female”: a case report

Authors: Caleb Weihao Huang and Mathew Yi Wen Yeo

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Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review

Authors: Natasha Shaukat, Daniyal Mansoor Ali and Junaid Razzak

Fluid resuscitation in trauma: what are the best strategies and fluids?

Authors: G. H. Ramesh, J. C. Uma and Sheerin Farhath

Intractable nausea and vomiting in naïve ingestion of kratom for analgesia

Authors: Vir Singh, Nadir Mulla, James Link Wilson, Aaron Umansky, Jenny Lee, Trilok Stead and Latha Ganti

Disaster management of the psychological impact of the COVID-19 pandemic

Authors: Mohamud Sheek-Hussein, Fikri M. Abu-Zidan and Emmanuel Stip

Tenecteplase vs. alteplase for acute ischemic stroke: a systematic review

Authors: Neha Potla and Latha Ganti

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The University of Washington provides an exceptional environment for research and is considered a top-funded public research institution, receiving over one billion dollars each year in research funding. UW resources and infrastructure provide unparalleled opportunities for investigation and collaboration.

Within our department, our investigators are engaging in scientific inquiry, promoting evidence-based research, and advancing education and training on a variety of topics. Research is being conducted by our faculty in a broad range of topics, including basic and translational trials.

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The top 100 cited articles published in emergency medicine journals

Affiliations.

• 1 Division of Emergency Radiology, Department of Radiology and Imaging Sciences, Emory University Hospital, Atlanta, GA; Department of Emergency Medicine, Hospital General de la Plaza de Salud, Santo Domingo, Dominican Republic. Electronic address: [email protected].
• 2 Department of Clinical Epidemiology and Public Health, Universidad Autónoma de Santo Domingo, Santo Domingo, Dominican Republic.
• 3 Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan.
• 4 Department of Emergency Medicine, Hospital General de la Plaza de Salud, Santo Domingo, Dominican Republic.
• 5 Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY.
• PMID: 25979301
• DOI: 10.1016/j.ajem.2015.04.047

Introduction: Our objective was to identify trends and examine the characteristics of the top 100 cited articles in emergency medicine (EM) journals.

Methods: Scopus Library database was queried to determine the citations of the top 100 EM articles. A second database (Google Scholar) was used to gather the following information: number of authors, publication year, journal name, impact factor, country of origin, and article type (original article, review article, conference paper, or editorial). The top 100 cited articles were selected and analyzed by 2 independent investigators.

Results: We identified 100 top-cited articles published in 6 EM journals, led by Annals of Emergency Medicine (65) and American Journal of Emergency Medicine (15). All top-cited articles were published between 1980 and 2009. The common areas of study were categorized as cardiovascular medicine, emergency department administration, toxicology, pain medicine, pediatrics, traumatology, and resuscitation. A statistically significant association was found between the journal impact factor and the number of top 100 cited articles (P < .005).

Conclusion: The top-cited articles published in EM journals help us recognize the quality of the works, discoveries, and trends steering EM. Our analysis provides an insight to the prevalent areas of study being cited within our field of practice.

Copyright © 2015 Elsevier Inc. All rights reserved.

PubMed Disclaimer

• Am J Emerg Med. 2015 Dec;33(12):1837-8
• Top cited articles and journal impact factors. Lee CH. Lee CH. Am J Emerg Med. 2015 Dec;33(12):1837. doi: 10.1016/j.ajem.2015.09.023. Epub 2015 Sep 21. Am J Emerg Med. 2015. PMID: 26458535 No abstract available.
• The author replies. Shuaib W. Shuaib W. Am J Emerg Med. 2015 Dec;33(12):1837-8. Am J Emerg Med. 2015. PMID: 27010044 No abstract available.

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• Top-cited articles in emergency medicine. Tsai YL, Lee CC, Chen SC, Yen ZS. Tsai YL, et al. Am J Emerg Med. 2006 Oct;24(6):647-54. doi: 10.1016/j.ajem.2006.01.001. Am J Emerg Med. 2006. PMID: 16984831
• Bibliometric analysis of the top 100 cited cardiovascular articles. Shuaib W, Khan MS, Shahid H, Valdes EA, Alweis R. Shuaib W, et al. Am J Cardiol. 2015 Apr 1;115(7):972-81. doi: 10.1016/j.amjcard.2015.01.029. Epub 2015 Jan 15. Am J Cardiol. 2015. PMID: 25670637 Review.
• An Analysis of the Top-cited Articles in Emergency Medicine Education Literature. Munzer BW, Love J, Shipman BL, Byrne B, Cico SJ, Furlong R, Khandelwal S, Santen SA. Munzer BW, et al. West J Emerg Med. 2017 Jan;18(1):60-68. doi: 10.5811/westjem.2016.10.31492. Epub 2016 Nov 23. West J Emerg Med. 2017. PMID: 28116010 Free PMC article.
• The 100 top-cited articles published in psychiatric journals. Mazhari S. Mazhari S. J Psychiatr Pract. 2013 Jul;19(4):327-38. doi: 10.1097/01.pra.0000432604.06835.da. J Psychiatr Pract. 2013. PMID: 23852109
• Top-cited articles in endodontic journals. Fardi A, Kodonas K, Gogos C, Economides N. Fardi A, et al. J Endod. 2011 Sep;37(9):1183-90. doi: 10.1016/j.joen.2011.05.037. Epub 2011 Jul 20. J Endod. 2011. PMID: 21846531 Review.
• A Bibliometric Analysis of the Top 100 Cited Papers in Retinal Detachment. Asahi MG, Pakhchanian H, Doepker C, Raiker R, Gallemore RP. Asahi MG, et al. J Vitreoretin Dis. 2021 May 18;5(6):467-478. doi: 10.1177/24741264211007378. eCollection 2021 Nov-Dec. J Vitreoretin Dis. 2021. PMID: 37007181 Free PMC article.
• A bibliometric analysis of systematic reviews and meta-analyses in ophthalmology. Fu Y, Mao Y, Jiang S, Luo S, Chen X, Xiao W. Fu Y, et al. Front Med (Lausanne). 2023 Mar 2;10:1135592. doi: 10.3389/fmed.2023.1135592. eCollection 2023. Front Med (Lausanne). 2023. PMID: 36936241 Free PMC article.
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• Endodontic Microbiology: A Bibliometric Analysis of the Top 50 Classics. Karobari MI, Maqbool M, Ahmad P, Abdul MSM, Marya A, Venugopal A, Shaik GM, Scardina GA, Messina P, Noorani TY. Karobari MI, et al. Biomed Res Int. 2021 Jun 1;2021:6657167. doi: 10.1155/2021/6657167. eCollection 2021. Biomed Res Int. 2021. PMID: 34746305 Free PMC article. Review.
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Home > College of Public Health > PREP_ED > Theses & Dissertations

Theses & Dissertations: Emergency Preparedness

Theses/dissertations from 2022 2022.

1-Check UNMC Mobile App Usage: A Quantitative Analysis of the Data , Molly Pofahl

Theses/Dissertations from 2021 2021

Fire Service COVID-19 Infection Prevention and Control Policy Comparison , Saaddedine Dichari

Theses/Dissertations from 2020 2020

Exploring Paramedic Students’ Level of Preparedness for Disaster Response in Hajj 2019 , Nawaf Albaqami

Planning and Facilitating the Training of Emergency Medical Services on the Safe Transport of Patients with Highly Infectious Diseases , Mohammed Alhallaf

Comparative Analysis of National Emergency Management Charters: A Pilot Study Towards Achieving a Standardized Global Emergency Management Framework , Wael ElRayes

The Escape POD: Utilizing Escape Room Methodologies to Train Public Health Volunteers on Open Point-of-Dispensing Operations , Melanie R. Thompson

Theses/Dissertations from 2019 2019

Common areas for improvement from After Action Reports (AARs) generated after exercises or actual disasters, as reported by a national sample of U.S. hospitals , Abdoulaye Abdoulaziz

Theses/Dissertations from 2018 2018

Attitudes of Sinjari Yezidis in Iraq Regarding the Rape of Yezidi Women and the Babies Born from Rape During the ISIS Genocide , Jordan Greaser

Pandemic Planning: Estimating Disease Burden of Pandemic Influenza to Guide Preparedness Planning Decisions for Nebraska Medicine , Angelia Wimberly

Theses/Dissertations from 2017 2017

Tuberculosis Contact Investigation in an Urban Omaha High School , Kyra L. Crepin

Bridging the Gap between National and Local Safety through a Comprehensive Review of Emergency Preparedness Plans in a Large, Urban High School located in Delray Beach, Florida within The Palm Beach County School District , Retha Prescod

Theses/Dissertations from 2016 2016

Barriers to Pediatric Triage Guideline Compliance: A Survey of Nebraska Emergency Departments , Jonathon J. Gruba

Exploring Emergency Communication Experiences in Response to the 2010 Haiti Earthquake: Lessons Learned from International Donors and Local Government Agencies , Pierre Marie Barbara Roussel

Establishment of Comprehensive Training Center in Tajikistan , Umeda Sadykova

Using Homeland Security Exercise Evaluation Program to Execute a Mass Prophylaxis Exercise in a Rural Community. , Brian K. Smith

Using the Minimum Data Set (MDS) to Triage Long Term Care Facilities’ Residents for a Systematic Evacuation in the Case of Mass Casualty Disaster Events , Zoumana I. Traore

Assessing Change in Baseline Preparedness Knowledge in Long-term Care Facilities , Heidi L. Wheeler

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Examining Employee Knowledge of the Jennie Edmundson Hospital Active Shooter Policy , Mallory W. Darais

The Effects of Severe Weather Warnings on Limited English Proficient (LEP) Hispanics/Latinos in Rural Nebraska , Joan E. Nelson

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Journal Club 6 Which Older Patients Can Safely Forgo CT Head After a Fall? The Falls Decision Rule

The decision of whether or not to order a CT head for an older patient who falls is one I need to make on almost every shift. The Canadian CT Head Rule does not apply to older patients. Does the recently derived Falls Decision Rule give us an answer to the question of which older patients can safely forego a CT head after a fall? Dr. Rohit Mohindra reviews the latest evidence in this EM Cases Journal Club...

EM Quick Hits 56 – Nitroglycerin in SCAPE, REBOA, Diverticulitis Imaging, CRAO, Penicillin Allergy, Physician Personality

In this month's EM Quick Hits podcast: Justin Morgenstern on the first RCT of high dose nitroglycerin in SCAPE, Andrew Neill on Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) indications and evidence, Brit Long on indications for CT in suspected diverticulitis, Tahara Bhate on Central Retinal Artery Occlusion (CRAO) and diagnostic error, Matthew McArthur on penicillin allergy labels, myths and penicillin challenges, and Susan Lu on how ED physician personality influences patient outcomes... Please support EM Cases with a donation: https://emergencymedicinecases.com/donation/

EM Quick Hits 54 Button Battery Ingestion, C. difficile, ECG in Tox, Bed Bugs, Fibrinogen in Trauma, Cold Air for Croup

Olivia Ostrow on the management of button battery ingestions, Brit Long on C difficile infection, Jesse McLaren on an approach to ECG's in the tox patient, Joe Mullally on the identification and treatment of bed bug bites, Andrew Petrosoniak on fibrinogen replacement in bleeding trauma patients, Justin Morganstern on Cold Air for Croup... https://emergencymedicinecases.com/donation/

EM Quick Hits 53 Postpartum Hemorrhage, Serotonin Syndrome, TBI Herniation Syndromes, Ulcerative Colitis, Pediatric C-Spine Immobilization, Global EM

On this month's EM Quick Hits podcast: Anand Swaminathan on update to ED management of postpartum hemorrhage, Nour Khatib on serotonin syndrome and its mimics, Katie Lin on an approach to recognition and management of severe TBI and brain herniation syndromes, Hans Rosenberg on the ED management of ulcerative colitis, Heather Cary on pediatric c-spine immobilization controversies and techniques, Navpreet Sahsi on the difference between humanitarian and development work... Please support EM Cases with a donation: https://emergencymedicinecases.com/donation/

EM Quick Hits 52 Infant Vomiting, Orbital Cellulitis, Prehospital TXA in Trauma, Prevention and Treatment of Delirium, Procedural Skills Decay, Altitude Sickness

In this month's EM Quick Hits podcast: Sarah Reid on an approach to Infant Vomiting, Brit Long on Orbital Cellulitis essentials, Justin Morgenstern on the PATCH trial - Prehospital TXA in Trauma, Christina Shenvi on Prevention and Treatment of Delirium, Jason Hine on Procedural Skills Decay, Aaron Billin on Altitude Sickness... Please support EM Cases with a donation: https://emergencymedicinecases.com/donation/

EM Quick Hits 51 – Methylene Blue in Septic Shock, TMJ Dislocation, Crohn’s Disease, Analgesia for Renal Colic, Inhaled Steroids for Asthma, Hypocalcemia in Bleeding Trauma Patients

On this month's EM Quick Hits podcast: Anand Swaminathan on the role of methylene blue in septic shock, Nour Khatib on jaw dislocation reduction techniques, Hans Rosenberg on a phenotypic approach to Crohn's disease emergencies, Gil Yehudaiff on evidence based analgesics in renal colic, Brit Long on the importance of inhaled steroids for asthma, and Andrew Petrosoniak on the "lethal diamond" in polytrauma patients and the current state of hypocalcemia in bleeding trauma patients... Please support EM Cases with a donation: https://emergencymedicinecases.com/donation/

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EDITORIAL article

Editorial: emergency and critical care of severely injured patients.

• 1 Department of Trauma, Hand and Reconstructive Surgery, Essen University Hospital, Essen, Germany
• 2 Department of Trauma and Reconstructive Surgery, University Hospital RWTH Aachen, Aachen, Germany
• 3 Emergency Intensive Care Unit, First Hospital of Lanzhou University, Lanzhou, Gansu, China

Editorial on the Research Topic Emergency and critical care of severely injured patients

Introduction

Severe trauma is among the leading causes of death and morbidity in many age groups around the world. The chain of survival in critically ill injured patients starts on the scene, continues in the emergency department, and carries on in the first surgical phase and in the intensive care unit. The optimal care of such patients depends on both medical treatment and organizational management. Therefore, it is essential to examine both of these aspects if healthcare systems are to optimize the care of critically ill trauma patients in different parts of the world.

Provision of the best available medical care for severely injured patients might result in suboptimal outcomes if prehospital care, or any link in the path of the patients through the chain of survival, is not of similarly high quality. A close look at the various challenges faced by trauma systems—and their potential solutions—in different regions of the world will enable the identification of existing short-comings and may facilitate the exchange of relevant solutions and possible improvements to processes. Both unmet surgical needs and the cost effectiveness of surgical intervention should be addressed and potential solutions should be suggested, including those related to medical, training, and organizational issues.

In emergency and intensive care, many aspects of care are specific to trauma patients, and so general recommendations and guidelines may not cover the precise needs of injured patients in these settings. Furthermore, many treatment options are currently under scientific discussion. Therefore, new research results and a critical appraisal of the relevant up-to-date knowledge is provided to the readers herein.

Non-technical skills and teamwork

A team of experts does not necessarily make an expert team. Starting from this observation, Alexandrino et al. reviewed some of the most important non-technical skills that are required not only in the emergency department, but also in the operating room, and they proposed ways to improve perioperative communication. Furthermore, they give a short appraisal of existing training courses.

Interhospital transfer

The indication and decision of when to transfer a severely injured patient from one to another hospital are complex. Spering et al. described processes followed for the common, countrywide practice of the interhospital transfer of severely injured patients within a highly developed national network of trauma centers. In addition to their epidemiological overview, they were able to identify major factors that resulted in such a transfer. They also presented data indicating that the introduction of a trauma network resulted in an improved transfer policy.

Anticoagulant and antithrombotic drugs

With an increasingly active aging population, greater numbers of injured patients requiring anticoagulant or antithrombotic treatment are presenting challenges to emergency and surgical teams. One study ( Yamaji et al. ) investigated the impacts of pre-trauma anticoagulant and antithrombotic treatment on mortality in patients with major trauma. They identified differences in outcomes between patients treated with anticoagulant vs. antithrombotic drugs. In this context, a registry study ( Fitschen-Oestern et al. ) focusing on an elderly population analyzed the effects of the application of tranexamic acid on outcomes in patients who were older than 50 years and receiving pre-existing treatment with anticoagulant or antithrombotic medication. In a third study ( Schindler et al. ), a high rate of intracranial bleeding was observed in elderly patients who were receiving anticoagulant or antithrombotic treatment before experiencing a low fall. As this observation was also made in asymptomatic patients, the findings hinted at the necessity of performing a head-CT scan in all such patients.

Bleeding control and fracture management

Endovascular intervention techniques may significantly improve bleeding control and outcomes in severely injured patients. However, they require excellent infrastructure and organization, as delayed processes and other obstacles may diminish their potential benefits. Mizuno et al. analyzed the role of a time delay in transcatheter embolization in patients with pelvic fracture, and their findings substantiated the importance of fast intervention.

The Zürich group of Kalbas et al. presented a review and analysis of registry data that examined the best way to decide on the timing of surgical fracture stabilization in patients with multiple injuries. They discussed the values of different parameters and scores, and they propose the use of a decision tree.

Ventilation and early mobilization

Ventilation and mobilization are central interventions during the intensive care treatment of severely injured patients. Although the general guidelines of ventilatory support do also apply to trauma patients, there may be specific conditions (e.g., pulmonary contusion, inhalation injury) that require more individualized treatment. Meregildo-Rodríguez et al. looked at the ventilation of patients with cervical spinal cord injury who may have specific requirements due to the lack of a primary lung injury and a lack of respiratory-muscle activity. The authors presented a systematic review with a special focus on tidal volumes.

The role and potential advantages of early mobilization in ventilated patients is still a Research Topic under discussion. Wang et al. present another meta-analysis, this time including only randomized controlled trials. They suggested taking a differentiated view with respect to effects on different outcome parameters.

Prediction and quality indicators

Early identification of patients at increased risk of developing complications may help to enable stratification of patients into specific monitoring or treatment pathways, or for potential inclusion in studies trialing novel therapies. In a single-center study ( Xu et al. ), a predictive model for the “Persistent Inflammation, Immunosuppression, and Catabolism Syndrome” was developed and evaluated in trauma patients using parameters that are easily obtained. A nomogram for the calculation of risk was presented.

As has already been stressed in another manuscript on this Research Topic, traumatic brain injuries after low falls in the elderly population is of special interest and concern. It would, therefore, be helpful if specific predictors could be used to indicate the likely treatment courses, outcomes, and resource requirements of such patients. The research group of Forssten et al. identified five predictors of complications and mortality in elderly patients presenting with moderate (Glasgow Coma Scale 9–13) traumatic brain injury after ground-level falls through analyzing information from the database of the American College of Surgeons' Trauma Quality Improvement Program.

Mortality is the primary outcome measure in severely injured trauma victims, with excellent methods available for risk adjustment. However, quality indicators for survivors are rare, and most of those that exist lack validated tools for risk adjustments to improve comparability. Using data from the German Trauma Registry, Lefering et al. developed a model that predicts the length of stay of trauma-injury survivors; after using a dataset describing 108,175 patients, they validated the model in another dataset of more than 72,000 patients. They describe the prediction of patient requirements for ICU treatment (with a duration of more than 1 week) and length of ICU stay for these long-term patients. Their results suggest that this tool may be useful for future benchmarking.

The manuscripts presented on our Research Topic cover a wide range of contributions on subjects that appear to be of general interest for providers of care in the emergency departments, early surgical management, and intensive care treatment in addition to describing prediction models and indicators that may be used for quality control and benchmarking. We hope that readers will gain interesting and helpful information and insights for their own clinical practice and/or stimuli for their own research.

Author contributions

CW: Writing – original draft, Writing – review & editing. FH: Writing – review & editing. LL: Writing – review & editing.

The author(s) declare that no financial support was received for the research, authorship, and/or publication of this article.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Keywords: severe trauma injury, trauma systems, prehospital trauma care, emergency room algorithms, intensive care treatments, first surgical phase, global surgery

Citation: Waydhas C, Hildebrand F and Liu L (2024) Editorial: Emergency and critical care of severely injured patients. Front. Med. 11:1453497. doi: 10.3389/fmed.2024.1453497

Received: 23 June 2024; Accepted: 03 July 2024; Published: 15 July 2024.

Edited and reviewed by: Zhongheng Zhang , Sir Run Run Shaw Hospital, China

Copyright © 2024 Waydhas, Hildebrand and Liu. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Christian Waydhas, christian.waydhas@uni-due.de

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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Catching Up with Honors Alum Nathan Le

• July 23, 2024
• Alumni and Friends

Judy Genshaft Honors College alum Dr. Nathan Le attributes his decision to become a physician to a pivotal Honors experience that inspired his passion for providing compassionate and socially conscious medical care.

A 2019 University of South Florida graduate with a bachelor's in biomedical sciences and a minor in public health, Le was eager to explore the intersection of health, ethics, and medicine during his time at USF. He engaged in activities such as working as a teaching assistant for former Honors professor Dr. Donna Petersen, conducting research in biophysics, and attending the Dominican Republic Beyond the Classroom Program led by Dr. Lindy Davidson to learn about health care access in developing areas.

It's honestly difficult to completely encompass just how grateful I am for my experiences through the Judy Genshaft Honors College. – Dr. Nathan Le

 After graduating from USF, Le attended Florida State University's College of Medicine, where he continued to foster his love for research. He contributed to the publication of a paper titled "Quality Improvement Project: Addressing Recurrent Presentation of Patients with COVID-19 to the Sarasota Memorial Hospital Emergency Care Center from March 2020-March 2021."

After completing medical school in 2023, Le recently wrapped up his first year as an internal medicine resident at the Sarasota Memorial Health Care System and caught up with the Honors College in an interview with Honors News.

Q: Looking back on your time in the Judy Genshaft Honors College, how did your experiences as an Honors student leave a lasting impact on you?

A: My experiences as an Honors student molded me into a more well-rounded individual. During my time at the Judy Genshaft Honors College, I engaged in an array of experiences. These ranged from participating in a biophysics research project and Honors thesis that led to a published article to embarking on a service trip to the Dominican Republic. These experiences and the multitude of Honors courses I took challenged me academically and broadened my perspective on the world around me. This in turn laid the foundation for my career in medicine. Being a part of the Honors College has also cultivated life-long friendships and relationships with people that continue to support me today.

Q: After having now gone on to complete medical school and begin your residency in internal medicine, do you feel that any Honors courses directed or informed your career path?

Dr. Lindy Davidson’s Honors course on service-learning and disability was pivotal in my decision to become a physician. This course and service trip to the Dominican Republic showed me the impact I can have as a physician who is culturally competent, preventative care focused, and sees health care as something influenced by not only medical conditions but also socioeconomic factors.

Because of this experience, I have also learned how important it is for patients to have as much agency in their health care as possible, which goes together with preventative care and patient education. Later on during my time at USF, Dr. Donna Petersen’s Honors course on interprofessionalism in health care, to which I had the pleasure of serving as a TA, gave me more of the tools I would need to eventually practice such patient-centered care that requires a team-based approach. Moreover, Dr. Benjamin Young’s many Honors courses on philosophical topics addressing the human condition have also directed my path in medicine. His courses on bioethics, practical wisdom, and stoicism have strengthened my ability to critically think about a multitude of different obstacles in medicine and life’s many challenges we all go through. Even with all that being said, it is honestly difficult to completely encompass just how grateful I am for my experiences through the Judy Genshaft Honors College.

Nathan Le with Dr. Lindy Davidson and fellow Honors students on the Dominican Republic Beyond the Classroom program.

Q: You just completed your first year of residency with Sarasota-Memorial Health Care System, what do you enjoy about the community that you are doing your residency in?

Sarasota has been a great place to live! I have been in Sarasota since my 3rd and 4th years of medical school since the FSU College of Medicine (FSU CoM) has a regional campus there. I am very grateful to be able to stay with FSU CoM’s Internal Medicine Residency at Sarasota Memorial Hospital! I also have to shout out USF’s Sarasota-Manatee campus of course! I have especially enjoyed the diversity of the community as well as the close-knit and diverse group of co-residents I work with. The beach, weather, and opportunities for many outdoor activities such as kayaking, volleyball, and pickleball really makes it a great place to live and work!

Q: What are your aspirations for the future?

In the future, I am planning on staying in Sarasota to practice primary care!

Q: What are you looking forward to after completing your residency?

I am looking forward to honing my own individual practice of medicine, tackling the primary care shortage, and giving back to the community that helped train me as well as the state of Florida in general.

Q: What advice would you have for current Honors students?

The most important piece of advice I have for current Honors students is to always challenge yourself, get out of your comfort zone, and be open to change. Honestly, at the beginning of my time at USF, I was much more introverted and nervous to venture out of my comfort zone. However, when I finally took that leap of faith and embarked on my first service trip, which also happened to be my first trip outside of the country without my family, I had a life-changing experience that directed me to where I am today.

As Dr. Young emphasized to me during my time at the Honors College, travel and experience are the best teachers since that is when you are really challenged and in turn learn the best about yourself and the world around you. I would also want to emphasize that it is crucial to establish a good work-life balance as early as possible. As Honors students, we often pursue higher level education and set our sights for the next ambitious goal and mountaintop, which often leads us on a rewarding but challenging and long journey.

Always keeping wellness in mind allows for you to continue doing what you love. In the context of health care professions, you can only take care of others effectively when you take care of yourself. Lastly, I just want to remind all the current Honors students to reflect on their journey so far because there is not a shortage of amazing opportunities offered through the Honors College. If I were to go back, I would choose to have my undergraduate journey here every single time!

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Committed to intellectual curiosity, global citizenship, and service across three unique Tampa Bay campuses, Honors News shares the exceptional stories of the Judy Genshaft Honors College.