Frontiers in Emergency Medicine (E-Journal)
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Frontiers in Emergency Medicine: A work overview for 2022
Get PDFIn 2022, Frontiers in Emergency Medicine published 60 papers in four distinct issues with authors from various nationalities, including Mexico, Turkey, Egypt, India, Yemen, the USA, Palestine, Poland, Saudi Arabia, the Netherlands, the UAE, Algeria, Ethiopia, Jordan, Cameroon, the UK, and Iran. As we did last year, we decided to review and evaluate various aspects of our work in the previous year. In the year 2022, despite the not-yet-ended pandemic, COVID-19 apparently missed its priority as the hottest topic of research and it seems that researchers took time to focus on their main research lines. Therefore, we were able to publish articles in different fields and cover more topics; however, we still received so many papers on COVID-19 and published some of them, not only on treatment but also on other aspects of the disease, and also some case reports. We also published a letter in which the authors pointed to increased prevalence of bloodstream infection with Klebsiella species in patients with recent COVID-19 infection, which may be an interesting issue for further investigations. We had two other papers that were published as “Letter to the Editor”. One was related to blunt abdominal injuries in the National Trauma Registry of Iran, and the other was concerned with Eye emergencies during wars, which was published around the beginning of Russia's war against Ukraine. There were 25 published papers in 2022 that fulfilled the criteria of an original article. Of these, only 7 were focused on COVID-19, and the rest covered other topics including critical care, neurological emergencies, experimental studies, point of care ultrasound, cardiovascular emergencies, emergency department management topics, trauma, and prehospital emergency care. Interestingly, the most viewed article was the one in which a series of oleander poisoning cases were reported by a group of authors from India. In addition to original articles, there were also one umbrella review, one systematic review, and some other types of reviews that have their own value and specific audiences, in which some recommendations were reviewed by experts in the fields. Case presentation maybe the most popular part of the journals. We have various structures in this regard, so that we can respond to the passion of our addressees. We published 5 Case reports, and also 5 papers categorized as “case-based learning points”. However, there are some other structures available for those interested in sharing their experience with their patients, which we regularly suggest to the authors in the peer review process of their submissions. We are honored to have published a series of educational papers on “electrocardiogram interpretation”, all written by Jerry W. Jones as an invited author, and we are very grateful for his participation and companionship. We also intend to introduce historical aspects of emergency medicine in various countries; therefore, an editorial paper written by Ozgur Karcioglu was published, which points to the emergency medicine journey in Turkey. We are very eager to have this type of papers from other countries and we will certainly invite other experts in this regard
Ups and down of emergency medicine in Iran: an urgent agenda
Get PDFA startling high number emergency medicine (EM) residency positions in Iran remained unfilled in this year’s National Residency Examination. In fact, the unprecedented numbers of unoccupied EM residency training positions over the past few years had already shocked the specialty, but this year’s statistics are alarming. Working as an emergency physician has never been an easy task, yet, since its establishment as a specialty in Iran in the year 2000 (1,2), EM continued to attract applicants over years. The trend of disfavoring EM, which started a few years ago, has important implications for nationwide residency programs, applicants, and most importantly our patients. It has also contributed to a state of general anxiety within the EM community, who feel that EM is a “profession in peril”, perpetuating the situation and starting a vicious cycle. EM departments are struggling to find a solution to ensure that delivery of quality care amid staffing shortages, and the authorities in the Ministry of Health and Medical Education (MOHME) are trying to solve the problem by “supplemental offer”, in the hope of recruiting applicants for unclaimed spots. However, besides these temporizing measures, it is imperative to deep dive into the factors contributing to this unprecedented national trend in order to shed light on the factors behind it and the solutions ahead of us. The problem is multifaceted and influenced by a myriad of interconnected factors. It is partly driven by the current landscape of the healthcare system and the changes to specialty preferences by students (3) in general. Moreover, the trend seems to be present in other parts of the world as well (3). Yet, there are aspects that are unique or more significant for EM in Iran: As a specialty driven by the needs of the society, its existence requires constant support and recognition by the society (mainly represented in the health sector by MOHME). It seems that the current authorities have forgotten what the emergency rooms were like in the era before EM, and have taken the current situation of emergency healthcare for granted. This is represented not only in their speeches and statements, but also in their decisions regarding regulations for compensation. Establishment of EM as a specialty was a fundamental action toward improving emergency care (4,5), but it was too optimistic to think that it can solve the entire problem. More actions were needed including training other related providers and ancillary staff, restructuring the design of the departments, and changing the employment structure of ED healthcare providers. Eluded by the drastic changes created just by the introduction of competent and energetic EM physicians, the authorities neglected many of these crucial actions. In an effort to solve quickly a problem that existed for a long time, MOHME created a surge in EM positions, jeopardizing the quality of EM training programs and ignoring the supply-demand dynamics of the discipline. They even failed to consider the advice of the National Board of Emergency Medicine, who repeatedly warned them against the dangers of expanding the number of residency programs and training sites without enough quality assurance system in place. This mass production of emergency physicians with inconsistent qualities, considered by many as the main trigger of the shift in the situation of EM, require a detailed exploration in its own right. Surprisingly, the number of EM residency positions has increased in recent years, while the number of applicants continued to decline. High levels of burnout (resulting from poor compensation and financial reward mechanisms, high prevalence of violence (6,7), overcrowding of the EDs with extended boarding of the patients, and exacerbated by the COVID pandemic) has disappointed many EM practitioners who selected this specialty with great enthusiasm. Some of these people role model burnout explicitly during their shifts and fail to interact positively with medical students, who are potential applicants of EM residency. This atmosphere of despair reassure the hesitant applicants not to opt this field as the future of their carriers. As emergency physicians, we are accustomed to dealing with unanticipated, unfavorable events and we have been trained to handle these conditions calmly and efficiently. In this case, too, we must take this situation as an opportunity to shape the future of our specialty. Convincing those who are responsible for healthcare workforce planning to work in tandem with the authorities in charge of graduate medical training in order to find logical and feasible solutions including an organized approach to a balanced workforce is a first step. This requires diplomacy and tactfulness of the EM community, and perhaps more importantly, an open mind and a listening ear on the administration side. 
Veganism and hypercoagulable state-hyperhomocysteinemia presenting as pulmonary thrombo-embolism in a vegetarian living at high altitude
Get PDFHyperhomocysteinemia as a hypercoagulable state has been debatable, but when associated with other highriskfactors like severe vitamin B12 and folate deficiency, smoking, high altitude, and antiphospholipid syndromecan present with thromboembolism. Vegans are at high risk of severe B12 deficiency as the primary source isanimal products. Right now, the total number of vegans, vegetarians, and all related categories, is close to 14per cent of the world population. We here present a young vegan with severe B12 deficiency presenting withsub-massive thromboembolism
The effect of propranolol on post-accident stress and clinical outcomes of burn patients: a clinical trial
Get PDFObjective: The hypermetabolic response has undoubtedly evolved to help survive burns, but this physiological response has inconsistent consequences and increases the clinical consequences, such as increased heart work and ultimately its decline, decreased immune system function, risk of sepsis, increased long-term hospitalization, which increases the mortality of patients. This study aims to examine the effect of propranolol on post-traumatic stress disorder and clinical outcomes in burn patients. Methods: This was an open-labeled randomized clinical trial in a single center with two parallel groups without placebo control. Propranolol was given 48 hours after starting of resuscitation. Results: In this study, the burn wound of the patients who used propranolol healed faster. In addition, the administration of propranolol reduced the size of the burning surface, the size of the tissue required skin graft, the rejection rate of skin grafts, and also the length of stay in the hospital. Conclusion: Using propranolol in treating burns can play an influential role in the recovery of burn patients, and reduce the post-traumatic stress disorder
Endometriosis as a rare cause of small bowel obstruction
Get PDFA 30-year-old married woman with a history of infertility was referred to the general surgery department with complaints of occasional and intermittent left lower abdominal and left inguinal pain. Abdominal examination was normal and there was no obvious bulging in the left inguinal region. Routine laboratory tests were normal. Abdominal and pelvic ultrasonography revealed a left inguinal hernia with a defect of 15 millimeters (mm) and did not report any other pathological points. The patient was a candidate for laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair. During the operation, pneumoperitoneum was performed through the umbilical region using a Veress needle, and after inserting a 10 mm umbilical port and exploring the abdomen, blood was seen in the pelvis. It was determined that the bleeding was from the mesentery of the small intestine (a known iatrogenic complication caused by Trocar or Veress needle). Two more 5 mm ports were inserted, the mesenteric bleeding was ligated using a ligature, and it was decided to continue the surgery laparoscopically. No obvious hernia was seen in the exploration of the inguinal area. After intra-abdominal blood suction, it was determined that there was a retroperitoneal hematoma in zone one. The patient's vital signs were still stable. After some patience, it became clear that the hematoma was expanding, so a decision was made to perform a laparotomy. Zone one was explored, and it was found that there was a perforation in front of the inferior vena cava, and there was heavy bleeding, so after controlling the proximal and distal vein, the perforation site was repaired using Prolen threads. In pelvic exploration, there was extensive adhesion in the region of the ovaries, fallopian tubes, and uterus, but there was no mass in the ovaries. Full abdominal exploration was performed. There was a mass in the small intestine 15 centimeters (cm) from the ileocecal valve, which caused an almost complete obstruction. Considering the patient's stable vital signs, a decision was made to resect the mass, and anastomose of the small intestine. At the end of the surgery and after washing the abdomen, the opened peritoneum was repaired on the vein, and two drains were placed in the pelvis. On the third day of surgery and after bowel habits returned, a liquid diet was started. On the fifth day, the patient had a good general condition, so the drains were removed and she was discharged. The histopathology examination of the small intestine mass showed endometriosis. The patient was referred to a gynecologist for consultation and treatment
The effects of forced air warming system on the hemodynamic status, pain intensity, tremors, nausea and vomiting in candidates of emergency laparotomy patients: a double-blind randomized clinical trial
Get PDFObjective: During emergency laparotomy surgeries, a wide incision is usually created in the abdomen causing the exposure of visceral organs to cold temperatures in the operation room. Other factors such as excessive stress, intra-operation blood transfusion, and prolonged anesthesia increase the risk of hypothermia in these patients. In this study, we studied the effects of forced air warming systems on the hemodynamic status, pain intensity, tremors, nausea and vomiting in emergency laparotomy patients. Methods: In the present double-blinded clinical trial, 80 candidates for emergency laparotomy were randomized into two groups: intervention (patients receiving forced air warming during anesthesia) and control (patients without an active warming system). Patients’ hemodynamic status (during anesthesia and at post anesthesia care unit (PACU), pain intensity, opioids received, tremors, nausea, vomiting, and antiemetics administration were compared between the two groups. Results: The amounts of opioids (P=0.041) and relaxants (P=0.039) received by the patients were significantly lower in the intervention group than in the control group. The hemodynamic status was more stable in the patients of the intervention group than those in the control group at all times measured. Pain intensity (per minute) at the PACU was significantly higher in the control group than in the intervention group (P=0.041). Among the patients admitted to the PACU, participants with no tremors (P=0.005) or nausea (P=0.005) were significantly higher in the intervention group than in the control group. Also, in the recovery unit, patients in the intervention group received significantly lower amounts of opioids (i.e., mg of pethidine, P=0.036) and antiemetics (P=0.011) compared to the control group. Conclusion: The use of a forced air warming system in the operation room stabilizes the hemodynamic status and reduces the pain intensity, tremors, nausea and vomiting in emergency laparotomy patients. As a non-pharmacological strategy, this method was observed to have satisfactory safety
Pulmonary hydatid cyst in pregnancy
Get PDFA 26-year-old pregnant lady was referred from a private hospital to the emergency department with a cough, shortness of breath, decreased oxygen saturation, and repeated vomiting. She went to the private hospital for obstetrics and gynecology follow-up for her pregnancy. The patient is 21 weeks pregnant with no known comorbidities. She is gravida three and para two. The patient claimed that since 3 days, the shortness of breath (SOB) and cough have been worsening, and she has been inducing herself to vomit more frequently, however, there is no associated dysphagia. She denied fever, headache, dizziness, abdominal pain, or a change in bowel habits
Flash pulmonary edema in the cardiac catheterization laboratory: a case report
Get PDFFlash pulmonary edema is a potentially fatal condition that can suddenly deteriorate a patient's status in a variety of settings, including the catheterization laboratory. We describe a 51-year-old woman with a history of hypertension who was admitted for a second valve operation for degenerated aortic bioprosthesis. Before undergoing coronary angiography, she looked a little worried, she experienced respiratory distress and a significant increase in blood pressure in favor of acute flash pulmonary edema, which was immediately and successfully managed by respiratory support and administration of high-dose intravenous nitroglycerine and loop diuretic therapy. The present scenario highlights the significance of being aware of the warning signs of acute flash pulmonary edema to make a prompt diagnosis and initiate the appropriate treatment to prevent catastrophic consequences
Once in a lifetime experience
No full textTo the editor-in-chief
Emergency medicine (EM) is one of the most difficult fields of medicine, and specialists in this field should handle different tasks, simultaneously. According to some reports, this group has the highest burnout level among different medical specialities. It is necessary for the professionals in this field to zoom out once in a while. Sabbaticals are good opportunity for this purpose among academics. This period not only provides a time window to get away from work stress, it also helps to broaden people's view via learning new materials. Over one year, September 2022 – August 2023, I completed my Master of Science in epidemiology degree at the University of Ottawa. In addition, the work at the Ottawa hospital research institute (OHRI) which is well known across the world for its excellence in EM research provided me a unique opportunity to participate in some research studies. I detail a few observations below
Relationship of the systemic immuno-inflammation index and hematological inflammatory index with mortality and hospitalization in acute pancreatitis: a cross-sectional study
Get PDFObjective: This study was conducted to reveal the relationship of the hematological inflammatory index (HII) and systemic immuno-inflammation index (SII) with short-term and prolonged hospitalization in cases of acute pancreatitis. Methods: This single-center cross-sectional study was conducted in the emergency department (ED) of an educational hospital. The study population contained cases who untaken to the ED with acute pancreatitis between August 15, 2021, and May 15, 2022. Cases discharged from the ED, those referred to another center for hospitalization, and those with absent information were excluded from the study. The patients were grouped according to the length of hospital stay (expected and prolonged) and short-term mortality (survivor and died). We constructed a receiver operating characteristic (ROC) curve for short-term mortality and prolonged hospitalization and obtained the area under the curve (AUC) values for SII and HII. Results: One hundred seventy-seven patients were included in the study. There was no significant difference between the expected and prolonged hospitalization groups in the terms of SII and HII (P=0.649 and P=0.084, respectively). There was also no significant difference between the survivor and died groups in the terms of these indexes (P=0.070 for HII and P=0.138 for SII). The AUC values for the SII and HII in the prediction of 30-day mortality were 0.616 and 0.642, respectively. The AUC values for the SII and HII in the prediction of prolonged hospitalization were 0.580 and 0.642, respectively. Conclusion: The outcomes of the present study showed no significant difference among the expected and prolonged hospitalization groups or the survivor and died groups in the terms of SII and HII. We recommend the validation of our results in multicenter studies with larger samples