Ending the Pandemic: Are Rapid COVID-19 Tests a Step Forward or Back?

Some experts have promoted the use of rapid testing for COVID-19. However, with the current technologies available, continuing to replace laboratory-based, real-time reverse transcription polymerase chain reaction tests with rapid (point-of-care) tests may lead to an increased number of false negative tests. Moreover, the more rapid dissemination of false negative results that can occur with the use of rapid tests for COVID-19 may lead to increased spread of the novel coronavirus if patients do not understand the concept of false negative tests. One means of combatting this would be to tell patients who have a “negative” rapid COVID-19 test that their test result was “indeterminate.

Unusual Contents of an Inguinal Hernia

Introduction: Abdominal hernias are commonly seen in the emergency department. One retrospective study involving 330 cases only found two ovarian hernias. Ovarian hernias occur in less than 1% of hernias, given it’s rarity, optimal management is unknown. Case: 56 year old hispanic female with history of c-section presented with one week of constant, sharp LLQ abdominal pain with episodes of increased intensity. Pain was moderate, radiating to the left thigh. Improved with Ibuprofen. Nothing made it worse. Associated with nausea. All reviews of systems otherwise negative. Vitals were within normal ranges. The patient was in no distress, her abdominal exam was limited due to BMI of 41.2 kg/m2, but did have LLQ tenderness with voluntary guarding, no rebound or peritoneal signs. Work-up was negative for UTI, pregnancy, and labs were unremarkable. CT abd/pelvis with IV contrast was performed and demonstrated a left ovary which was herniating through the left inguinal canal. Transvaginal US was subsequently performed to evaluate for ischemia/torsion which demonstrated the ovary within the inguinal canal itself. A bedside hernia reduction was performed by placing the patient in Trendelenburg position. Discussion: Currently there are no standard treatment guidelines for the emergency medicine practitioner. Our bedside reduction followed by surgical repair was similar to the case previously published. While we did proceed with urgent surgery it can likely be performed outpatient. Conclusion: In the setting of an ovary herniating through the inguinal canal, and in the absence of complications, bedside reduction should be strongly considered

Mistakes and Pitfalls Associated with Two-Point Compression Ultrasound for Deep Vein Thrombosis

Introduction: Two-point compression ultrasound is purportedly a simple and accurate means to diagnose proximal lower extremity deep vein thrombosis (DVT), but the pitfalls of this technique have not been fully elucidated. The objective of this study is to determine the accuracy of emergency medicine resident-performed two-point compression ultrasound, and to determine what technical errors are commonly made by novice ultrasonographers using this technique. Methods: This was a prospective diagnostic test assessment of a convenience sample of adult emergency department (ED) patients suspected of having a lower extremity DVT. After brief training on the technique, residents performed two-point compression ultrasounds on enrolled patients. Subsequently a radiology department ultrasound was performed and used as the gold standard. Residents were instructed to save videos of their ultrasounds for technical analysis. Results: Overall, 288 two-point compression ultrasound studies were performed. There were 28 cases that were deemed to be positive for DVT by radiology ultrasound. Among these 28, 16 were identified by the residents with two-point compression. Among the 260 cases deemed to be negative for DVT by radiology ultrasound, 10 were thought to be positive by the residents using two-point compression. This led to a sensitivity of 57.1% (95% CI [38.8-75.5]) and a specificity of 96.1% (95% CI [93.8-98.5]) for resident-performed two-point compression ultrasound. This corresponds to a positive predictive value of 61.5% (95% CI [42.8-80.2]) and a negative predictive value of 95.4% (95% CI [92.9-98.0]). The positive likelihood ratio is 14.9 (95% CI [7.5-29.5]) and the negative likelihood ratio is 0.45 (95% CI [0.29-0.68]). Video analysis revealed that in four cases the resident did not identify a DVT because the thrombus was isolated to the superior femoral vein (SFV), which is not evaluated by two-point compression. Moreover, the video analysis revealed that the most common mistake made by the residents was inadequate visualization of the popliteal vein. Conclusion: Two-point compression ultrasound does not identify isolated SFV thrombi, which reduces its sensitivity. Moreover, this technique may be more difficult than previously reported, in part because novice ultrasonographers have difficulty properly assessing the popliteal vein