Non-Traumatic Urologic Emergencies in Men: A Clinical Review

Although true urologic emergencies are extremely rare, they are a vital part of any emergency physician’s (EP) knowledge base, as delays in treatment lead to permanent damage. The four urologic emergencies discussed are priapism, paraphimosis, testicular torsion, and Fournier’s gangrene. An overview is given for each, including causes, pathophysiology, diagnosis, treatment, and new developments. The focus for priapism is on diagnosis and distinguishing high-flow from low-flow forms, as the latter requires emergent treatment. For paraphimosis, we describe various methods of relieving the stricture, from manual reduction to surgery in extreme cases. For testicular torsion, the most important factor in salvaging the testicle is decreasing time to treatment. This is accomplished through experience and understanding which signs and symptoms strongly suggest it, so that time-consuming tests are avoided. Lastly, Fournier’s gangrene is potentially fatal. While aggressive medical and surgical therapy will improve chances of survival and outcome, it is vital for the emergency department (ED) physician to diagnose Fournier’s. It often presents in the elderly, immunocompromised, or those with depressed mental status. The goal of this paper is to arm EPs with information to recognize urological emergencies and intervene quickly to preserve tissue, fertility, and life

Predicting Patient Patterns in Veterans Administration Emergency Departments

Veteran’s Affairs (VA) hospitals represent a unique patient population within the healthcare system; for example, they have few female and pediatric patients, typically do not see many trauma cases and often do not accept ambulance runs. As such, veteran-specific studies are required to understand the particular needs and stumbling blocks of VA emergency department (ED) care. The purpose of this paper is to analyze the demographics of patients served at VA EDs and compare them to the national ED population at large. Our analysis reveals that the VA population exhibits a similar set of common chief complaints to the national ED population (and in similar proportions) and yet differs from the general population in many ways. For example, the VA treats an older, predominantly male population, and encounters a much lower incidence of trauma. Perhaps most significantly, the incidence of psychiatric disease at the VA is more than double that of the general population (10% vs. 4%) and accounts for a significant proportion of admissions (23%). Furthermore, the overall admission percentage at the VA hospital is nearly three times that of the ED population at large (36% versus 13%). This paper provides valuable insight into the make-up of a veteran’s population and can guide staffing and resource allocation accordingly

In-Training Practice Patterns of Combined Emergency Medicine/Internal Medicine Residents, 2003–2007

<p>Introduction: This study seeks to evaluate the practice patterns of current combined emergency medicine/internal medicine (EM/IM) residents during their training and compare them to the typical practice patterns of EM/IM graduates. We further seek to characterize how these current residents perceive the EM/IM physician’s niche.</p> <p>Methods: This is a multi-institution, cross-sectional, survey-based cohort study. Between June 2008 and July 2008, all 112 residents of the 11 EM/IM programs listed by the Accreditation Council for Graduate Medical Education were contacted and asked to complete a survey concerning plans for certification, fellowship, and practice setting.</p> <p>Results: The adjusted response rate was 71%. All respondents anticipated certifying in both specialties, with 47% intending to pursue fellowships. Most residents (97%) allotted time to both EM and IM, with a median time of 70% and 30%, respectively. Concerning academic medicine, 81% indicated intent to practice academic medicine, and 96% planned to allocate at least 10% of their future time to a university/academic setting. In evaluating satisfaction, 94% were (1) satisfied with their residency choice, (2) believed that a combined residency will advance their career, and (3) would repeat a combined residency if given the opportunity.</p> <p>Conclusion: Current EM/IM residents were very content with their training and the overwhelming majority of residents plan to devote time to the practice of academic medicine. Relative to the practice patterns previously observed in EM/IM graduates, the current residents are more inclined toward pursuing fellowships and practicing both specialties. [West J Emerg Med. 2011;12(4):530–536.]</p

The treatment of cutaneous abscesses: Comparison of emergency medicine providers\u27 practice patterns

INTRODUCTION: Cutaneous abscesses are commonly treated in the emergency department (ED). Although incision and drainage (I&D) remains the standard treatment, there is little high-quality evidence to support additional interventions such as pain control, type of incision, and use of irrigation, wound cultures, and packing. Although guidelines exist to support clinician management of abscesses, they do not clearly specify these additional interventions. This study sought to describe the ED treatments administered to adults with uncomplicated superficial cutaneous abscesses, defined as purulent lesions requiring incision and drainage that could be managed in an ED or outpatient setting. METHODS: Four hundred and seventy-four surveys were distributed to 15 EDs across the United States. Participants were queried about their level of training and practice environment as well as specific questions regarding their management of cutaneous abscesses in the ED. RESULTS: In total, 350 providers responded to the survey (74%). One hundred eighty-nine respondents (54%) were attending physicians, 135 (39%) were residents, and 26 (7%) were midlevel providers. Most providers (76%) used narcotics for pain management, 71% used local anesthetic over the roof of the abscess, and 60% used local anesthetic in a field block for pain control. More than 48% of responders routinely used irrigation after (I&D). Eighty-five percent of responders used a linear incision to drain the abscess and 91% used packing in the wound cavity. Thirty-two percent routinely sent wound cultures and 17% of providers routinely prescribed antibiotics. Most providers (73%) only prescribed antibiotics if certain historical factors or physical findings were present on examination. Antibiotic treatment, if used, favored a combination of 2 or more drugs to cover both Streptococcus and methicillin-resistant Staphylococcus aureus (47%). Follow-up visits were most frequently recommended at 48 hours unless wound was concerning and required closer evaluation. CONCLUSION: Variability exists in the treatment strategies for abscess care. Most providers used narcotic analgesics in addition to local anesthetic, linear incisions, and packing. Most providers did not irrigate, order wound cultures, or routinely prescribe oral antibiotics unless specific risk factors or physical signs were present. Limited evidence is available at this time to guide these treatment strategies

Non-Traumatic Urologic Emergencies in Men: A Clinical Review

Although true urologic emergencies are extremely rare, they are a vital part of any emergency physician’s (EP) knowledge base, as delays in treatment lead to permanent damage. The four urologic emergencies discussed are priapism, paraphimosis, testicular torsion, and Fournier’s gangrene. An overview is given for each, including causes, pathophysiology, diagnosis, treatment, and new developments. The focus for priapism is on diagnosis and distinguishing high-flow from low-flow forms, as the latter requires emergent treatment. For paraphimosis, we describe various methods of relieving the stricture, from manual reduction to surgery in extreme cases. For testicular torsion, the most important factor in salvaging the testicle is decreasing time to treatment. This is accomplished through experience and understanding which signs and symptoms strongly suggest it, so that time-consuming tests are avoided. Lastly, Fournier’s gangrene is potentially fatal. While aggressive medical and surgical therapy will improve chances of survival and outcome, it is vital for the emergency department (ED) physician to diagnose Fournier’s. It often presents in the elderly, immunocompromised, or those with depressed mental status. The goal of this paper is to arm EPs with information to recognize urological emergencies and intervene quickly to preserve tissue, fertility, and life.[West J Emerg Med. 2009;10(4):281-287.

Non-Traumatic Urologic Emergencies in Men: A Clinical Review

Although true urologic emergencies are extremely rare, they are a vital part of any emergency physician’s (EP) knowledge base, as delays in treatment lead to permanent damage. The four urologic emergencies discussed are priapism, paraphimosis, testicular torsion, and Fournier’s gangrene. An overview is given for each, including causes, pathophysiology, diagnosis, treatment, and new developments. The focus for priapism is on diagnosis and distinguishing high-flow from low-flow forms, as the latter requires emergent treatment. For paraphimosis, we describe various methods of relieving the stricture, from manual reduction to surgery in extreme cases. For testicular torsion, the most important factor in salvaging the testicle is decreasing time to treatment. This is accomplished through experience and understanding which signs and symptoms strongly suggest it, so that time-consuming tests are avoided. Lastly, Fournier’s gangrene is potentially fatal. While aggressive medical and surgical therapy will improve chances of survival and outcome, it is vital for the emergency department (ED) physician to diagnose Fournier’s. It often presents in the elderly, immunocompromised, or those with depressed mental status. The goal of this paper is to arm EPs with information to recognize urological emergencies and intervene quickly to preserve tissue, fertility, and life.[West J Emerg Med. 2009;10(4):281-287.

Targeted Needs Assessment of Off Service Residents in Emergency Medicine

Purpose: The purpose of this study is to evaluate the needs of internal medicine residents rotating through the emergency department (ED).Methods: A survey was distributed to 100 internal medicine residents (post-graduate years 2 and 3) from two different residency programs before the start of their emergency medicine (EM) rotation. Residents ranked the level of importance and the level of preparedness for 23 different EM topics, using a Likert-type scale ranging from 1 (least important/least prepared) to 4 (most important/most prepared). We calculated delta values (Δ) from the difference between importance and preparedness and undertook significance testing of this difference.Results: A total of 71 out of 100 surveys were completed properly and returned. Internal medicine residents felt most ill-prepared in the areas of orthopedics, environmental emergencies, otolaryngology, airway management, and ophthalmology. The largest perceived gaps between importance and preparedness lay within the areas of airway management ( Δ=1.30), ophthalmology ( Δ=1.10), environmental emergencies (Δ=0.96), and orthopedics ( Δ=0.96).Conclusion: Our data suggest that internal medicine residents are inadequately prepared for EM topics that they feel are important to their education, specifically airway management, ophthalmology, environmental emergencies and orthopedics. It is quite possible that other specialty residents are also poorly prepared for similar core EM topics. These data will hopefully guide future curricular change for off-service residents in the ED. [West J Emerg Med. 2010;11(5):470-473.

Targeted Needs Assessment of Off Service Residents in Emergency Medicine

Purpose: The purpose of this study is to evaluate the needs of internal medicine residents rotating through the emergency department (ED).Methods: A survey was distributed to 100 internal medicine residents (post-graduate years 2 and 3) from two different residency programs before the start of their emergency medicine (EM) rotation. Residents ranked the level of importance and the level of preparedness for 23 different EM topics, using a Likert-type scale ranging from 1 (least important/least prepared) to 4 (most important/most prepared). We calculated delta values (Δ) from the difference between importance and preparedness and undertook significance testing of this difference.Results: A total of 71 out of 100 surveys were completed properly and returned. Internal medicine residents felt most ill-prepared in the areas of orthopedics, environmental emergencies, otolaryngology, airway management, and ophthalmology. The largest perceived gaps between importance and preparedness lay within the areas of airway management ( Δ=1.30), ophthalmology ( Δ=1.10), environmental emergencies (Δ=0.96), and orthopedics ( Δ=0.96).Conclusion: Our data suggest that internal medicine residents are inadequately prepared for EM topics that they feel are important to their education, specifically airway management, ophthalmology, environmental emergencies and orthopedics. It is quite possible that other specialty residents are also poorly prepared for similar core EM topics. These data will hopefully guide future curricular change for off-service residents in the ED. [West J Emerg Med. 2010;11(5):470-473.