Validity of Triage Performed by Nurses Educated by Train-of-Trainer‬ Workshop Participants; a Cross-sectional Study for Assessment of Cascade Training System

Introduction: In 2010, a national triage train-of-trainer (TOT) workshop was held in Tehran, Iran. Objective: The present study aimed to assess the validity of the triage performed by the nurses educated by those who participated in TOT workshop. Method: This cross-sectional study was carried out in 6 teaching hospitals from 4 universities in Iran. Inter-rater and intra-rater reliability of performed triage by participations was measured. Thirteen nurses were randomly selected. Thereafter, at the end of each working shift, patient data recorded in the daily data registry forms were collected. Then, duration of hospital stay, number of cases admitted to general wards or intensive care units, number of cases discharged from the ED within 12 hours and mortality rate were compared with the triage level determined by the nurse. Results: In total, 30 nurses with a mean age of 28.4 ± 3.7 years were enrolled. In this study, 1491 triage cases (61.6% male) were evaluated, of which 4.2% were triaged as level 1, 18.3% as level 2, 37.1% as level 3, 20.4% as level 4 and 20.0% as level 5. The following outcome was observed: 3.64% were discharged, 6.29% were hospitalized, 3% died and 2.3% were discharged against medical advice without completing treatment. The correlation of determined triage level and patients’ duration of hospitalization was significant based on one-way ANOVA test (p = 0.000). The outcome of the patients significantly correlated with the level of triage determined by the study nurses (p = 0.000). Conclusion: Based on the findings, it appears that triage performed by the study nurses educated by those who participated in TOT workshop through cascade training system had perfect validity

Pain Relieving Effect of Sublingual Glycerol Trinitrate in Renal Colic: a Randomized Placebo-Controlled Trial

Introduction: Renal colic is caused by colicky spasms of ureters. As has been shown in previous experiments, glycerol trinitrate (TNG) can inhibit these muscular spasms. Objective: This study was performed to assess the pain relieving effect of TNG among patients referred due to renal colic pain to the emergency department (ED). Methods: This study is a randomized, placebo-controlled study on 60 patients with renal colic who were referred to the ED, who were diagnosed clinically to have renal colic, and their pain was more than 5 based on a visual analogue scale (VAS). The patient's pain was recorded at the moment of clinical diagnosis, and each one received one capsule, either 0.4 mg TNG or placebo, plus a 100 mg indomethacin suppository. The pain score was re-assessed after 5 and 30 min. The values were recorded and compared using SPSS-16 software. Results: Sixty patients with a mean age of 35.75 ± 11.99 years were enrolled (73.3% male). Patients in the two groups were matched for age (p = 0.290), sex (p = 0.559), and the presence of microscopic hematuria (p = 0.292). Pain relief from the start point until the end of the intervention was statistical different in all studied patients (p < 0.05); but the comparison between the two groups showed no significant difference in this regard (p = 0.440). Conclusion: It is likely that adding TNG to an indomethacin suppository had no significant effects on better pain management of patients referred with renal colic to the ED

Validity of Triage Performed by Nurses Educated by Train-of-Trainer‬ Workshop Participants; a Cross-sectional Study for Assessment of Cascade Training System

Introduction: In 2010, a national triage train-of-trainer (TOT) workshop was held in Tehran, Iran. Objective: The present study aimed to assess the validity of the triage performed by the nurses educated by those who participated in TOT workshop. Method: This cross-sectional study was carried out in 6 teaching hospitals from 4 universities in Iran. Inter-rater and intra-rater reliability of performed triage by participations was measured. Thirteen nurses were randomly selected. Thereafter, at the end of each working shift, patient data recorded in the daily data registry forms were collected. Then, duration of hospital stay, number of cases admitted to general wards or intensive care units, number of cases discharged from the ED within 12 hours and mortality rate were compared with the triage level determined by the nurse. Results: In total, 30 nurses with a mean age of 28.4 ± 3.7 years were enrolled. In this study, 1491 triage cases (61.6% male) were evaluated, of which 4.2% were triaged as level 1, 18.3% as level 2, 37.1% as level 3, 20.4% as level 4 and 20.0% as level 5. The following outcome was observed: 3.64% were discharged, 6.29% were hospitalized, 3% died and 2.3% were discharged against medical advice without completing treatment. The correlation of determined triage level and patients’ duration of hospitalization was significant based on one-way ANOVA test (p = 0.000). The outcome of the patients significantly correlated with the level of triage determined by the study nurses (p = 0.000). Conclusion: Based on the findings, it appears that triage performed by the study nurses educated by those who participated in TOT workshop through cascade training system had perfect validity

The Effect of Language Barrier and Non-professional Interpreters on the Accuracy of Patient-physician Communication in Emergency department

Introduction: Patients’ relatives commonly play the role of interpreters in medical interviews. These non-professional interpreters are prone to potentially-dangerous translation errors. Objective: The present study was conducted to evaluate these errors in the emergency department (ED). Method: Twenty interviews with Azeri patients were recorded. They were unable of speaking Persian and therefore accompanied by a relative as a Persian interpreter. These records were presented to two physicians as native Azeri speakers to determine the clinical importance of the interpreters' errors according to their medical expertise. Results: The total omission and addition errors observed in Azeri to Persian translation were significantly more than in Persian to Azeri translation, while mistranslation errors were almost the same. The relatives with higher levels of education made fewer errors, and those living with the patients made significantly more addition errors. Conclusion: Non-professional interpreters cannot effectively facilitate patient-physician communication, as their translation is error-prone, especially in terms of translating their native language into official languages. These errors can have important clinical ramifications

Accuracy of Ultrasonography in Diagnosis of Shoulder Dislocation: A Systematic Review

Context: This meta-analysis of clinical trials was conducted to compare the diagnostic accuracy of ultrasound in comparison to plain radiography in shoulder dislocation. Evidence acquisition: MEDLINE, Cochrane Database of Systematic Reviews, clinicaltrials.gov, Google scholar, and Scopus were searched for clinical trials. Diagnosis of shoulder dislocation and confirmation of shoulder reduction were the outcomes of interest. Sensitivity, specificity, positive predictive value and negative predictive value of included clinical trials were calculated.  Results: Seven studies met our inclusion criteria and were analyzed. All included studies except two had a sensitivity and specificity of 100% for ultrasound (one with a sensitivity of 54% and one with a specificity of 60%). Conclusion: It can be suggested that ultrasound can be used as a reliable alternative diagnostic method for detection of both dislocation and reduction in shoulder joint. This may decrease the delay in treatment, cost, radiation exposure, and need for repeated sedation

Two Different Endotracheal Tube Securing Techniques: Fixing Bandage vs. Adhesive Tape

Introduction: Emergency physicians should secure Endotracheal tubes (ETT) properly in order to prevent unplanned extubation (UE) and its complications. Despite various available endotracheal tube holders, using bandages or tape are still the most common methods used in this regards. Objective: This study aimed to compare adhesive tape (AT) versus fixing bandage (FB) method in terms of properly securing ETT. Methods: This was an observational longitudinal trial. All patients older than 15-years-old admitted to the ED who had indication for ETT insertion were eligible. Patients were randomly assigned to one of the two groups in which AT or FB was applied. All patients were observed thoroughly in the first 24 hours after intubation. Using a pre-prepared checklist, encountered UE rate and other data were recorded. Results: Seventy-two patients with the mean age of 55.98 ± 18.39 years were finally evaluated of which 38 cases (52.8%) were male. In total, 12% of patients in our study experienced unplanned extubation. Less than 12% of the patients experienced complete UE; there was no statistically significant difference between the two groups (p = 0.24). Comparison of UE with age showed no significant difference (p = 0.89). Male patients experienced more UE, but this was not statistically significant (p = 0.44). Conclusion: It is likely that whether the AT method or FB was applied for securing the ETT in emergency departments, there was no significant difference in rates of unplanned extubation

Emergency Overcrowding Impact on the Quality of Care of Patients Presenting with Acute Stroke

Introduction: Emergency overcrowding is defined as when the amount of care required for patients overcomes the available amount. This can cause delays in delivering critical care in situations like stroke. Objective: The aim of this study was to assess the possible impact of emergency department (ED) crowding on the quality of care for acute stroke patients. Methods: In this cross-sectional prospective study, all patients with symptoms of acute stroke presenting to the ED of educational hospitals were enrolled. All patients were assessed and examined by the emergency medicine (EM) residents on shift and a questionnaire was filled out for them. The amount of time that passed from the first triage to performing the required interventions and delivering health services were recorded by the triage nurse. ED crowding was measured by the occupancy rate. Then, the correlation between all of the variables and ED crowding level were calculated. Results: The average daily bed occupancy rate was 184.9 ± 54.3%. The median time passed from the first triage to performing the interventions were as follows: the first EM resident visit after 34 min, the first neurologic visit after 138 min, head CT after 134 min, ECG after 104 min and ASA administration after 210 min. There was no statistically significant relationship between the ED occupancy rate and the time elapsed before different required health services in the management of stroke patients either throughout an entire day or during each 8-hour interval (p > 0.05). Conclusion: In the current study, the ED occupancy rate was not significantly correlated with the time frame associated with management of admitted acute stroke patients

Association of Lymphopenia with Short Term Outcomes of Sepsis Patients; a Brief Report

Introduction: Studies have claimed that low lymphocyte count is independently correlated with 28-day survival of sepsis patients. Therefore, this study aimed to evaluate the value of lymphopenia in predicting the short-term outcome of sepsis patients. Methods: This cross-sectional study was performed on sepsis patients referred to the emergency department during an 8-month period and relationship of lymphopenia with 28-day mortality and probability of septic shock and readmission due to sepsis was assessed. Results: 124 cases with the mean age of 66.12 ± 15.82 (21-90) years were studied (54.8% male). 81 (65.3%) cases had lymphopenia (59.3% male). Lymphopenic patients had a significantly higher mean age (p = 0.003), higher need for ICU admission (p < 0.001), higher prevalence of 28-day septic shock (p < 0.001), higher 28-day mortality (p < 0.001), higher probability of readmission due to sepsis (p = 0.048), and higher SOFA score (p < 0.001). During 28 days of follow up, 57 (46%) patients were expired. They had a higher prevalence of septic shock (p < 0.001) and higher SOFA score (p < 0.001). Multivariate analysis showed that septic shock (OR=364.6; 95% CI: 26.3 to 5051.7; p = 0.001) and lymphopenia (OR=19.2; 95% CI: 1.7 to 211.3; p = 0.016) were the independent predictors of 28-day mortality. Conclusions: Based on the findings, lymphopenia was independently associated with higher 28-day mortality and lymphopenic patients were older than the control group and had a significantly higher need for ICU admission, higher probability of 28-day septic shock and readmission due to sepsis, and higher SOFA score

Attitude toward end-of-life care in emergency medicine residents- can a short workshop make a difference?

Background There is a growing demand for palliative care (PC) in Emergency departments (ED) as the number of patients who need end-of-life (EOL) care is increasing. Despite significant variability amongst residency programs, there is a lack of structured core curriculum for PC/EOL care in most emergency medicine (EM) training programs, which often do not meet the needs of EM physicians. In this study, we evaluate the effect of a short EOL care workshop on changing the attitude of Iranian EM residents towards EOL care in ED. Method In this prospective before/after educational study at Tehran University of medical science, we enrolled 40 EM residents using a random sampling method. We obtained demographic and practice background information, and participants underwent a half-day PC training workshop designed by an expert panel. We administered a translated and validated Standard PEAS (physician End of Life Care Attitude Scale) questionnaire before and four weeks after an educational intervention. Baseline and differences in attitude were reported and compared by paired t-test, repeated measure ANOVA, and ANOVA. Results None of the participants had prior experience of formal PC training. All of the 40 participants completed the follow-up questionnaire. Baseline attitude was not different among demographic groups. The mean (SD) PEAS score before and four weeks after the workshop was 86.9 (5.8) versus 89(6.9), respectively (P = 0.023). Residents with no previous close exposure to a terminal illness in their family members had significantly more attitude change than those with such an experience (P = 0.045). Conclusion A brief educational intervention improved EM residents’ attitudes toward EOL care. The optimal design and characteristics of this educational intervention yet remain to be defined by further studies

Lidocaine induced seizure during rapid sequence intubation, a case report

به دلیل تاثیر مناسب و شروع اثر سریع، لیدوکائین به طور معمول برای ساپرس تغییرات همودینامیک ناشی از لوله گذاری داخل تراشه مورد استفاده قرار می گیرد. از جمله عوارض جانبی این دارو تشنج می باشد که متعاقب تجویز موضعی و وریدی آن به صورت موردی گزارش شده است. در این مقاله به معرفی بیماری می پردازیم که با شکایت از تنگی نفس شدید و پیشرونده به بخش اورژانس ارجاع گردید و در حین انجام لوله گذاری داخل تراشه با توالی سریع و به دنبال تجویز لیدوکائین وریدی دچار تشنج تونیک کلونیک جنرالیزه شد.The best choice for Patients who need intubation in the emergency ward is rapid sequence intubation in order to reduce laryngoscopic adverse effect and to have better condition for intubation. Lidocaine is one of the drugs used in premedication before induction and paralysis to attenuate laryngoscopic sympathetic reflex. We present a patient that had an episode of seizure immediately after administering lidocaine intravenously during rapid sequence intubation, not reported before