Frontiers in Emergency Medicine (E-Journal)
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Abdominal pain with oral pigmentations as a clue for Peutz-Jeghers syndrome
Get PDFA 33-year-old woman presented to the emergency department with colicky abdominal pain, nausea and vomiting, constipation, obstipation, and rectorragia. She had a history of similar abdominal pain from a few months ago. She had no history of any specific disease and taking any medication. She had no history of surgery and specific family diseases. Her vital signs on admission were heart rate 90/minute, respiratory rate 18/minute, blood pressure 110/70 mmHg, and temperature of 37.1°C. There were several brown spots on her lips and inside her mouth. On abdominal examination, she had a generalized tenderness, especially in the LLQ. In the digital rectal examination, the rectum was empty. Lab tests showed the following results: leukocyte count 4000/mm3 with 80.9% neutrophils, hemoglobin 12.1 g/dl, platelet 320000/µl, and creatinine 0.6 mg/dl, BUN 14 mg/dl, glucose 152 mg/dl, sodium 137 mEq/L, potassium 4.5 mEq/L. Chest and abdominal radiographs were performed on the patient (Figure 1). No subdiaphragmatic free air was seen in the chest x-ray. The abdominal x-ray showed no air-fluid levels as well as any gas in the rectum. On abdominal and pelvic ultrasound, a moderate amount of free fluid was seen in the abdomen along with jejunoileal intussusception in the LLQ with an intestinal loops thickness increase
Central retinal artery occlusion presenting with headache and sudden painless blurring of vision
Get PDFThe patient was a 61-year-old smoker male, who presented to emergency department (ED) with complaints of sudden onset of headache followed by painless blurring of vision of the right eye that was started 10 hours prior to the admission. Due to blood pressure of 190/104 mmHg at home, the patient had taken amlodipine 10mg orally. The patient reported some episodes of transient ischemic attacks in his past medical history, for which he did not take any advice from physicians. The patient was also found to be hypertensive with deranged cholesterol. On examination in ED, the patient was afebrile, and had pulse rate= 88/min, blood pressure (BP)= 130/90 mmHg, respiratory rate=22/min, and O2 Saturation=99% in room air. There was not any positive finding in systemic examination. Patient was admitted for further evaluation and management. Paraclinical lab tests were all reported in normal range. Echocardiography revealed left ventricular ejection fraction (LVEF) of 60%, with no regional wall motion abnormality (RWMA), mild concentric left ventricular hypertrophy (LVH) and normal cardiac chambers. In view of Headache, brain computed tomography (CT) scan was performed, in which, there was prominence of sulci, basal cistern, sylvian fissure and ventricular system suggestive of age-related diffuse cerebral atrophy. Ill-defined hypodensities were seen in bilateral periventricular white matter, suggestive of chronic ischemic changes. Later, brain magnetic resonance imaging (MRI) was also performed, which revealed multiple discrete and confluent areas of hyperintensity scattered in subcortical deep and periventricular white matter of both cerebral hemispheres, suggestive of nonspecific small vessel ischemic changes, likely a combination of ischemic demyelination chronic lacunar infarcts and prominent perivascular space. The ventricular system and subarachnoid space were prominent, suggestive of age-related cerebral atrophy. In the next step, cervical and brain MRI angiography was performed, which revealed 100% occlusion of right internal carotid artery at its origin, with no distal reformation of the artery in the neck and intracranial part. The right middle and anterior cerebral artery were filling via circle of Willis and were severely diffusely narrowed in calibre. There were mild atheromatous changes in the left common carotid artery and carotid bulb causing mild narrowing. Bilateral vertebral arteries were normal. There was evidence of diffuse severe narrowing and poor visualization of entire left anterior cerebral artery. Ophthalmology reference was taken and fundus examination was done. On examination, the patient was found to have finger counting close to face with no improvement with glasses. In the right eye, anterior segment examination showed relative afferent pupillary defect (RAPD), while fundus examination revealed retinal background pale white with cherry red spot in macula and absent venous pulsation in the right eye, suggestive of Central Artery Retinal Obstruction (CRAO), and thread like blood vessels and Grade II Hypertensive retinopathy. After starting the low molecular weight heparin, antiplatelet and steroid, vision improved from finger counting close to face to finger counting at 3 feet distance. Patient was later discharged under follow-up for further recovery
Relationship between seizures and metabolic acidosis: a prospective observational study
Get PDFObjective: To assess changes in blood gas parameters, such as pH, partial carbon dioxide pressure (PaCO2), bicarbonate (HCO3), base deficit, and lactate values, in patients who present to the emergency care unit after aseizure. Methods: This is a prospective study on patients who suffered a generalized tonic-clonic seizure. The demographic and biochemical data of the patients and their blood gas parameters were recorded both at the time of presentation to the emergency department and during the follow-up examination. Results: A total of 68 patients were included in the study. Among the patients, 60.3% (41) were male. The median age of the patients was 43 years (IQR: 29-65.25). The median initial lactate value was 5.7 mmol/L (25th and 75th percentiles: 3.5–8.5 mmol/L). The median follow-up lactate value was 1.8 mmol/L (25th and 75th percentiles: 1.1–2.8 mmol/L). The statistical analysis of the blood gas parameters revealed a statistically significant difference in the pH, PaCO2, base deficit, and lactate values between the initial and follow-up evaluations (P<0.001). Conclusion: The results of our study suggest that metabolic acidosis with high anion gap may develop due to the increase in the lactate levels as a result of a tonic-clonic seizur
The severity of mental health problems in healthcare professionals and its associated risk factors during COVID-19 pandemic
Get PDFObjective: This study assesses the severity of mental health problems in healthcare professionals (HCPs) and its associated risk factors during COVID-19 pandemic at a tertiary hospital in Harar, Eastern Ethiopia. Methods: An institutional-based cross-sectional study was done from November 01 to 15, 2020. Data was collected by using a web-based self-administered questionnaire. Descriptive statistical analysis, cross tabs, and logistic regressions were utilized. Results: Out of 238 HCPs, 54.6% of them had a mental health problem. The prevalence of depression, anxiety, and stress was 44.1%, 48.3%, and 29.0%, respectively. Cigarette smoking was the only factor associated with depression. Being female, a cigarette smoker, and previously diagnosed with COVID-19 were associated with anxiety, while cigarette smoking and previous COVID-19 suspect had a significant association with stress. Conclusion: The burden of mental health problems among HCPs is high. The Federal Ministry of Health should incorporate psychosocial support for healthcare professionals during pandemics. This study highlights the need for developing policies to decrease mental health problems among HCPs during the COVID-19 pandemic
Telemedicine and natural disasters: various services, requirements, challenges, and general framework
Get PDFProviding early health care services in natural disaster is one of the essential applications of telemedicine. This narrative review aims to investigate the applications, advantages and challenges of telemedicine in natural disaster-stricken areas. Medline (through PubMed), Web of Science (WOS), and Scopus databases were searched for related articles published from beginning to 2022. The keywords used for the search included "telemedicine" and "natural disaster." After removing duplicate papers, irrelevant review articles and letters to editors, 44 relevant papers were selected and reviewed. Information sharing through audio, visual, and data-oriented services is among critical approaches that telemedicine services mainly use. Teleconsultation, tele-education, remote interpretation, tele-psychiatry, and tele-surgery are among measures that can be implemented in emergencies like earthquakes, fires, floods, storms, and drought. The fundamental requirements of a telemedicine-oriented system for providing emergency services in natural disasters include wireless scales, conversation tools, blood pressure monitor, respiratory rate monitor, spo2 sensor, glucometer, portable ultrasound unit, wearable thermometers, virtual stethoscopes, portable three leads electrocardiograph monitor, and digital otoscopes. Simple telemedicine systems can have many advantages in the natural disasters. However, the main challenge in this regard is to adapt the necessary communication systems to a telemedicine paradigm. Another critical challenge is to interpret and apply the summary of acquired information and the inevitable interaction outcomes at the required time and place
General medicine interns’ attitude in continuing their education in emergency medicine residency programs
Get PDFIntroduction: Emergency medicine (EM) is a relatively new medical specialty, which concerns patients who need vital and urgent medical care. This study aimed to evaluate the general medicine interns’ attitude in continuing their education in EM residency programs. Methods: This study is a prospective cross-sectional study, which was performed on 180 medical students during their internship using convenience sampling. Data were collected using a valid and reliable researcher-made questionnaire and analyzed using SPSS 26 software. Results: One hundred and eighty medical students in the internship period with the mean of 25.65 ± 2.72 (23 – 46) years were studied (53.3% male; 76.7% single). Only 33 (18.3%) interns indicated their interest in continuing their education in EM residency programs. 30 (16.66) cases were not interested in continuing their education in any residency program (61.1% of whom cited migration as the reason, 13% cited not working as a specialist, 14.8% indicated lack of economic justification, and 11.1% cited other reasons for not wanting to enter residency programs). The mean overall interest score to EM residency program was 59.61 ± 12.66 % (20 – 96.41%). The lowest and highest interest scores obtained in the economic status (47.91 ± 21.13%) and education status (70.59 ± 15.77%) of EM specialty, respectively. The mean overall interest score was not statistically different between male and female students (p = 0.366). There was a significant statistical correlation between gender and type of discipline chosen, and female mostly chose non-surgical disciplines (p = 0.001). Conclusion: The interest of general medicine interns in continuing their education in EM residency program was average. The economic field of EM has been one of the best factors in attracting students to continue their studies in this field
Frequency and types of workplace violence against emergency medical technicians: a cross-sectional study in Tehran, Iran
Get PDFObjective: This study was implemented to assess various types of violent incidents involving emergency medical technicians (EMTs) working in Tehran, Iran. Furthermore, the characteristics of violent people and possible causes of their violence were assessed. Methods: In this cross-sectional study, 500 EMTs working in the capital city of Tehran were randomly invited. The participants were asked to fill out a questionnaire of workplace violence. Univariate and multivariate logistic regression were also performed for identifying the possible risk factors of violence. In addition, the distribution and association of violence patterns were also analyzed considering demographic features and characteristics of violent people. Results: In total, 320 EMTs with the mean age of 31.8 ± 6.7 years participated, 315 (98.4%) of whom were men. Overall, 279 (87.2%) out of the 320 participants experienced 654 episodes of violence, mostly bullying, in the last 4 months. The relationship between the level of education and experiencing violent incidents was statistically significant (p=0.035). Also, non-Persian EMTs had experienced significantly more violent behaviors than Persian EMTs [171 (91.0%) vs. 108 (81.8%); p=0.016]. Nonetheless, the prevalence of violent incidents was not significantly correlated with marital status, years of work experience, employment situation, and working hours. The odds of facing violent behavior among EMTs with associate degree was 2.9 times higher than those with technical diploma (p=0.048). Furthermore, the odds of experiencing violence among non-Persian EMTs was 2.2 times higher than Persian EMTs (p=0.039). Conclusion: We found that EMTs had faced numerous episodes of violence in their workplace, especially verbal threats, which were more prevalently committed by patients’ relatives during night shifts
Severity assessment of impairment in spinal cord injury; a systematic review on challenging points about International Standards for Neurological Classification of Spinal Cord Injury
Get PDFObjective: Assessment of spinal cord injuries (SCI) severity is usually done according to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). However, a limitation of ISNCSCI has not been thoroughly evaluate; therefore, a systematic review was performed to gather current evidence on the limitations of the ISNCSCI for assessing SCI. Methods: An extensive literature search was performed using Medline, Embase, Web of Science, Cochrane library, and Scopus for all articles up until the end of 2017 and then was updated to the end of 2020. Data was summarized by two independent reviewers and limitations of the ISNCSCI was further categorized. Results: 31 studies were included in the analysis. The limitations of ISNCSCI were classified into 6 domains: 1) lack of assessment of autonomic nervous system; 2) low value in assessing severity of SCI severity in children; 3) confounding factors which impact outcome are not accounted for by ISNCSCI; 4) lack of an established optimal cut off time point for administering the ISNCSCI; 5) low predictive and diagnostic value for assessing incomplete motor injuries; 6) poor classification and predictive value of the ISNCSCI. Conclusion: Although the ISNCSCI is a commonly used tool to assess the severity of SCI, there are several limitations
An atypical case of Guillain-Barré: overlap of Miller Fisher syndrome with pharyngeal-cervical-brachial variant
Get PDFThe patient was a 30-year-old female. She had developed dysphagia three days prior to admission. Initially, she only had problem swallowing solids but later the problem progressed to liquids, and after that dysphonia was added. She was visited by a first-level doctor who diagnosed her problem as pharyngotonsillitis and treated her with amoxicillin + clavulanate without improvement. Two days later, diplopia was added, which led her to come to our hospital. Upon arrival, the vital signs were recorded as blood pressure 120/70 mmHg, respiratory rate 18 breaths per minute, temperature 35.7 °C, and O2 saturation 98% in room air. She was alert, oriented in three spheres, normoreflexic, had isochoric pupils with ptosis when making a pathetic look, and had preserved motor and sensory function of the facial nerve. She also had dysphonia, inability to swallow, with difficulty to manage secretions. She had normal thorax with adequate ventilatory mechanics, lung fields with adequate air entry and exit, rhythmic precordium without aggregated auscultator phenomena, globular abdomen at the expense of panniculus adiposus, preserved peristalsis, pelvic limbs with 1/5 bilateral loss of strength, preserved sensitivity, bilateral areflexia, thoracic limbs strength 3/5 bilateral, and ataxic gait
Factors affecting simulators of the hospital emergency department during emergencies and disasters in Iran: a qualitative study
Get PDFObjective: The simulation strategy is so important for appropriate responses and preparedness of hospital emergency department staff in emergencies to strengthen team building and care focused on the interdisciplinary community. Therefore, this study aimed to identify the factors affecting the hospital emergency department's simulators during emergencies and disasters. Methods: This conventional content analysis study was conducted in 2021. Participants were selected from Iranian experts using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis. Results: Analysis of the data results through semi-structured interviews showed 4 main categories and 11 subcategories including management and leadership (the structure, casualty management, command, interactions and coordination, communications and information, as well as human resources), and increasing the capacity (resources (physical resources, and financial resources)), modern technology approaches (information technology), laws and policies (policies, guidelines, and rules). Conclusion: The simulation technology use can be effective in preparing the hospital emergency department in the event of disasters, strengthening management and leadership, proper planning, appropriate organizational culture, organizational learning, interactions and coordination, casualty management, as well as providing resources, equipment, items, processes, and instructions. So, the use of these new technological training is recommended to improve responses in times of emergencies and disasters