Faculty Bibliography

Introduction: Disconjugate eye movements have been associated with traumatic brain injury since ancient times. Ocular motility dysfunction may be present in up to 90% of patients with concussion or blast injury. Methods: We developed an algorithm for eye tracking in which the Cartesian coordinates of the right and left pupils are tracked over 200 seconds and compared to each other as a subject watches a short film clip moving inside an aperture on a computer screen. We prospectively eye tracked 64 normal healthy non-injured control subjects and compared findings to 75 trauma subjects with either a positive head CT (n=13), negative head CT (n=39) or non-head injury (n=23) to determine whether eye tracking would reveal the disconjugate gaze associated with both structural brain injury and concussion. Tracking metrics were then correlated to the clinical concussion measure SCAT3 in trauma patients. Results: Five out of five measures of horizontal disconjugacy were increased in positive and negative head CT patients relative to non-injured control subjects. Only one of five vertical disconjugacy measures was significantly increased in brain injured patients relative to controls. Linear regression analysis of all 75 trauma patients demonstrated that three metrics for horizontal disconjugacy negatively correlated with SCAT3 symptom severity score and positively correlated with total Standardized Assessment of Concussion (SAC) score. Abnormal eye tracking metrics improved over time towards baseline in brain injured subjects seen in follow-up. Conclusions: Eye tracking may help quantify the severity of ocular motility disruption associated with concussion and structural brain injury.

Background: Due to mortality and morbidity from prescription opioids,the New York City Department of Health, in concert with local physicians, developed guidelines for prescription of opioids in NYC EDs. The largest adopter, Health and Hospitals Corporations (HHC), reviewed it's changes in prescribing after introduction of the guidelines. Objectives: To review if voluntary guidelines change opioid prescribing by ED providers in a public hospital system. Methods: A computerized database was retrospectively reviewed for all adults presenting to an ED in the corporation's acute care hospitals. (~1.1 million ED visits/year) Data were abstracted from 9 of 11 hospitals. Two were excluded for IT issues. All adults discharged from one of the EDs with prescriptions containing oxycodone, hydrocodone, methadone, or codeine were included. We compared differences in opioid prescriptions of ED providers (attending physicians, mid-level providers, and EM residents) for a 6 month time frame pre and post guidelines in 2012 vs 2013. Variables: 1) Opioid prescriptions per 1000 ED visits, 2) total prescriptions, 3) percent of prescriptions with 20 pills or less, 4) total pills prescribed, 5) and 30-day patient return rate (percent of visits where patients received an opioid prescription AND returned (in multiple defined time frames) and received another prescription). Results: The rate of prescriptions given by ED providers per 1000 ED visits fell 18.8% (62.6 to 50.8). The percent of prescriptions with <20 pills dispensed increased by 10.3% from 77.6% to 87.9% (p 3500 (18753 vs 15042). There was a reduction of pills dispensed by more than 100,000 (363226 vs 246520). There was no significant change in return rate. ED visits decreased <2% during the study period. Conclusion: The introduction of guidelines combatting a public health problem can be deployed successfully in a very large public health system. In 6 months, metrics related to the number of pills prescribed had improved without evidence of significant unde!

A freestanding, 911-receiving emergency department was implemented at Bellevue Hospital Center during the recovery efforts after Hurricane Sandy to compensate for the increased volume experienced at nearby hospitals. Because inpatient services at several hospitals remained closed for months, emergency volume increased significantly. Thus, in collaboration with the New York State Department of Health and other partners, the Health and Hospitals Corporation and Bellevue Hospital Center opened a freestanding emergency department without on-site inpatient care. The successful operation of this facility hinged on key partnerships with emergency medical services and nearby hospitals. Also essential was the establishment of an emergency critical care ward and a system to monitor emergency department utilization at affected hospitals. The results of this experience, we believe, can provide a model for future efforts to rebuild emergency care capacity after a natural disaster such as Hurricane Sandy. (Disaster Med Public Health Preparedness. 2014;0:1-4).

BACKGROUND: Flexion-extension radiographs are often used to assess for removal of the cervical collar in the setting of trauma. The objective of this study was to evaluate their adequacy. We hypothesized that a significant proportion is inadequate. METHODS: This was a retrospective review of C-spine clearance at a level 1 trauma center. A trauma-trained radiologist interpreted all flexion-extension radiographs for adequacy. Studies performed within 7 days of injury were considered acute. RESULTS: Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30 degrees of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate. CONCLUSIONS: Injury to the C-spine may harbor significant consequences; therefore, its proper evaluation is critical. The majority of flexion-extension films are inadequate. As such, they should not be included in the algorithm for removal of the cervical collar. If used, adequacy must be verified and supplemental radiographic studies obtained as indicated.

To provide guidance to clinicians about best practices, the Wilderness Medical Society convened an expert panel to develop evidence-based guidelines for the treatment and prevention of lightning injuries. These guidelines include a review of the epidemiology of lightning strikes and recommendations for the prevention of lightning strikes, along with treatment recommendations organized by organ system. Recommendations are graded based on the quality of supporting evidence according to criteria put forth by the American College of Chest Physicians.

Background: In NYC, pediatric pedestrians struck by motor vehicles account for thousands of visits to pediatric emergency departments. In 2007, approximately 60 children were killed due to this mechanism of injury. Currently, NY State collects retrospective information of admitted pediatric pedestrians injured. Objectives: Our goal is to collect comprehensive information prospectively of all children injured as a pedestrian or cyclist vs. motor vehicle. This novel project will allow better delineation of risk factors to target injury prevention. Methods: We have developed a prospective database of all pedestrians/cyclists injured or killed by motor vehicles from December 22, 2008 until present. A pediatric patient is defined as age < 18 years. Information regarding circumstances of incident, injury information, and hospital course were obtained from patient, guardian, emergency responders (paramedics, police, fire officers), and other sources (witnesses and medical record). Results: of 1000 patients, 116 (12%) were pediatric patients. The mean age was 11 years, with 40% of patients in the 6-12 age range. There was a male predominance. Eighty-five percent were pedestrians. One quarter of the cyclists were wearing a helmet. Fifty-two percent did not have adult supervision at the time of the incident. Five percent of incidents occurred within two blocks of school. Forty-two percent of patients were struck mid-block, 25% were darting out into the street, and two patients were boarding a bus. Eleven percent of patients were using an electronic device at time of injury. One patient reported cocaine and one patient was ethanol intoxicated. Twenty percent of patients had loss of consciousness and 6% had a GCS < 15 upon arrival. The injury severity score was greater than 10 in 9% of patients. Twenty-eight percent of patients were admitted. There were no mortalities. Conclusion: Pediatric pedestrians and cyclists struck by motor vehicles are a public health hazard. The majority of injuries are low acuity and result in few hospitalizations. Injury prevention strategies should focus on improving traffic safety knowledge and safety gear wearing in children. (Table Presented)

Patients presenting to the emergency department (ED) with behavioral disturbances account for approximately 6% of all ED visits. Emergency physicians are often responsible for the initial assessment of these patients' psychiatric complaints, which might include homicidal and suicidal behavior and acute psychosis. The emergency physician might be asked to provide medical clearance before transfer to definitive psychiatric care. The purpose of the medical screening is to identify medical conditions that might be causing or contributing to the psychiatric emergency or that might be dangerous or inappropriate to treat in a psychiatric facility. Appropriate treatment in the ED is essential to avoid morbidity and mortality resulting from misdiagnosis of medical conditions as psychiatric illnesses and from mismanagement of psychiatric illnesses

BACKGROUND: Hollow viscus injuries are uncommon and occur in approximately 1% of all blunt trauma patients. DISCUSSION: These injuries are often not suspected and are difficult to diagnosis. Morbidity and mortality are high, and a negative abdominal computed tomography is not sufficient to rule out these injuries in certain clinical scenarios. CONCLUSION: Using a case-based approach, the epidemiology and diagnostic pathways to manage hollow viscus injuries are reviewed