Faculty Bibliography

BACKGROUND:Mass Casualty Events (MCI) which have a direct and persisting impact on the safety and well-being of an emergency department (ED) and its staff, secondary to specific targeting of the healthcare setting, represent a distinct and complex operational challenge. ED physicians may be faced with the prospect of providing ongoing patient care while simultaneously experiencing direct threats to their own health or physical safety. In our study we considered the unique operational challenges encountered, and management strategies adopted, by the ED staff and its leadership to an all-hazard MCI impacting an academic urban emergency department. METHODS:We conducted a retrospective, observational study of data from a tertiary academic medical center of patients arriving to the ED during a protracted MCI lasting from May 11th to May 21st, 2021. No arriving patients were excluded from analysis. Patient demographics, ED resource utilization, throughput, disposition and other pertinent data were considered. Analysis was done of three distinct patient populations including the event-group (EG), a non-event-group (NEG) and a control group (CG). Descriptive statistics were used to evaluating observational findings. RESULTS:We reviewed the records of 8527 total patients presenting to the Shamir Medical Center ED during the event and control periods. Of those, 283 patients were identified as an EG consisting of casualties from the MCI. 3563 patients were identified as the NEG presenting with complaints not related to the event. Our CG consisted of the 4681 patients who presented in the two weeks prior to the MCI. EG patients were noted to have important characteristics including higher relative numbers of men n = 173 (61.6 %), higher CTAS triage acuities [n = 10 (3.8 %), classified as CTAS 1], and an increase utilization of specialty consultation and admission consistent with observed injury patterns, most notably for the orthopedic services [orthopedic consultations: n = 126 (44.5 %) / orthopedic admissions: n = 13 (4.6 %)]. CONCLUSION/CONCLUSIONS:Findings from our observational study suggested that in the absence of larger public health interventions a manmade MCI, with direct threats to an ED and its staff, could force EDs to concurrently address the unique clinical needs of two distinct patient populations while simultaneously needing to take measures to protect hospital staff. Additionally, a higher burden of patient volumes and clinical acuity are likely to be encountered by select specialty consultation services. Further studies could focus on quantitative analysis to better understand the operational impact of these types of events on both patients and staff.

STUDY OBJECTIVE/OBJECTIVE:Prior work has found first-attempt success improves with emergency medicine (EM) postgraduate year (PGY). However, the association between PGY and laryngoscopic view - a key step in successful intubation - is unknown. We examined the relationship among PGY, laryngoscopic view (ie, Cormack-Lehane view), and first-attempt success. METHODS:We performed a retrospective analysis of the National Emergency Airway Registry, including adult intubations by EM PGY 1 to 4 resident physicians. We used inverse probability weighting with propensity scores to balance confounders. We used weighted regression and model comparison to estimate adjusted odds ratios (aOR) with 95% confidence intervals (CIs) between PGY and Cormack-Lehane view, tested the interaction between PGY and Cormack-Lehane view on first-attempt success, and examined the effect modification of Cormack-Lehane view on the association between PGY and first-attempt success. RESULTS:After exclusions, we included 15,453 first attempts. Compared to PGY 1, the aORs for a higher Cormack-Lehane grade did not differ from PGY 2 (1.01; 95% CI 0.49 to 2.07), PGY 3 (0.92; 0.31 to 2.73), or PGY 4 (0.80; 0.31 to 2.04) groups. The interaction between PGY and Cormack-Lehane view was significant (P-interaction<0.001). In patients with Cormack-Lehane grade 3 or 4, the aORs for first-attempt success were higher for PGY 2 (1.80; 95% CI 1.17 to 2.77), PGY 3 (2.96; 1.66 to 5.27) and PGY 4 (3.10; 1.60 to 6.00) groups relative to PGY 1. CONCLUSION/CONCLUSIONS:Compared with PGY 1, PGY 2, 3, and 4 resident physicians obtained similar Cormack-Lehane views but had higher first-attempt success when obtaining a grade 3 or 4 view.

BACKGROUND:In the emergency department (ED), certain anatomical and physiological airway characteristics may predispose patients to tracheal intubation complications and poor outcomes. We hypothesized that both anatomically difficult airways (ADAs) and physiologically difficult airways (PDAs) would have lower first-attempt success than airways with neither in a cohort of ED intubations. METHODS:We performed a retrospective, observational study using the National Emergency Airway Registry (NEAR) to examine the association between anticipated difficult airways (ADA, PDA, and combined ADA and PDA) vs those without difficult airway findings (neither ADA nor PDA) with first-attempt success. We included adult (age ≥14 years) ED intubations performed with sedation and paralysis from January 1, 2016 to December 31, 2018 using either direct or video laryngoscopy. We excluded patients in cardiac arrest. The primary outcome was first-attempt success, while secondary outcomes included first-attempt success without adverse events, peri-intubation cardiac arrest, and the total number of airway attempts. Mixed-effects models were used to obtain adjusted estimates and confidence intervals (CIs) for each outcome. Fixed effects included the presence of a difficult airway type (independent variable) and covariates including laryngoscopy device type, intubator postgraduate year, trauma indication, and patient age as well as the site as a random effect. Multiplicative interaction between ADAs and PDAs was assessed using the likelihood ratio (LR) test. RESULTS:Of the 19,071 subjects intubated during the study period, 13,938 were included in the study. Compared to those without difficult airway findings (neither ADA nor PDA), the adjusted odds ratios (aORs) for first-attempt success were 0.53 (95% CI, 0.40-0.68) for ADAs alone, 0.96 (0.68-1.36) for PDAs alone, and 0.44 (0.34-0.56) for both. The aORs for first-attempt success without adverse events were 0.72 (95% CI, 0.59-0.89) for ADAs alone, 0.79 (0.62-1.01) for PDAs alone, and 0.44 (0.37-0.54) for both. There was no evidence that the interaction between ADAs and PDAs for first-attempt success with or without adverse events was different from additive (ie, not synergistic/multiplicative or antagonistic). CONCLUSIONS:Compared to no difficult airway characteristics, ADAs were inversely associated with first-attempt success, while PDAs were not. Both ADAs and PDAs, as well as their interaction, were inversely associated with first-attempt success without adverse events.

Demands for whole blood (WB) and COVID-19 convalescent plasma (CCP) donations during the SARS-CoV-2 (COVID-19) pandemic presented unprecedented challenges for blood services throughout the world. This study aims to understand the motivating factors that drive WB and CCP donations in the context of the pandemic. This cross-sectional study is based on data extracted from surveys of the two volunteer donor cohorts. The findings reveal that when compared to CCP donors, WB donors were more likely to view donation as a form of social engagement (97.7% vs. 87.1%, p < 0.01), advantageous in the workplace (46.4% vs. 28.6%, p < 0.01), advantageous in their social network (58.6% vs. 47.0%, p = 0.01), and view their donation in the context of positive self-satisfaction (99% vs. 95.1%, p = 0.01). The average age of CCP donors was 7.1 years younger than those who donated WB (p < 0.01). Motivational factors were also analyzed by sex and religiosity. In conclusion, whereas both donor groups showed a high motivation to partake in these life-saving commitments, WB donors were more likely to be motivated by factors that, when better-understood and implemented in policies concerning plasma donations, may help to increase these donations.

BACKGROUND:Cricothyrotomy is a critical technique for rescue of the failed airway in the emergency department (ED). Since the adoption of video laryngoscopy, the incidence of rescue surgical airways (those performed after at least one unsuccessful orotracheal or nasotracheal intubation attempt), and the circumstances where they are attempted, has not been characterized. OBJECTIVE:We report the incidence and indications for rescue surgical airways using a multicenter observational registry. METHODS:We performed a retrospective analysis of rescue surgical airways in subjects ≥14 years of age. We describe patient, clinician, airway management, and outcome variables. RESULTS:Of 19,071 subjects in NEAR, 17,720 (92.9%) were ≥14 years old with at least one initial orotracheal or nasotracheal intubation attempt, 49 received a rescue surgical airway attempt, an incidence of 2.8 cases per 1000 (0.28% [95% confidence interval 0.21 to 0.37]). The median number of airway attempts prior to rescue surgical airways was 2 (interquartile range 1, 2). Twenty-five were in trauma victims (51.0% [36.5 to 65.4]), with neck trauma being the most common traumatic indication (n = 7, 14.3% [6.4 to 27.9]). CONCLUSION:Rescue surgical airways occurred infrequently in the ED (0.28% [0.21 to 0.37]), with approximately half performed due to a trauma indication. These results may have implications for surgical airway skill acquisition, maintenance, and experience.

BACKGROUND:Severe cardiac injury caused by penetrating rib or sternal fractures after blunt chest trauma is a rare clinical entity that has been described in only a few case reports over the last half-century. As a result, questions have arisen about the utility of the cardiac component in the Focused Assessment with Sonography in Trauma (cFAST) examination in evaluating blunt trauma patients. CASE REPORT/METHODS:We present a series of 3 patients who sustained blunt trauma and were discovered on cFAST examination to have developed pericardial tamponade from overlying rib or sternal fractures in the emergency departments of two academic level I trauma hospitals in the United States. Why Should an Emergency Physician Be Aware of This? These cases highlight the need for emergency and trauma physicians to be aware of blunt-induced, penetrating trauma to the heart and mediastinum, and for future trauma care guidelines to consider the importance of the cFAST examination.

Throughout history, earthquakes have caused devastation and loss of life. Emergency medical services (EMS) plays a vital role in the response to any mass-casualty incident or disaster. Magen David Adom, Israel's premier EMS organization, has a unique strategy known as the ABC approach to earthquake response. It involves thousands of salaried workers and trained volunteers who are prepared to respond to an earthquake based on the extent of the disaster. Depending on the amount of destruction, they will be working locally or available to help in other areas. A Level A earthquake causes local destruction and minimal casualties. Any EMS responders in that area as well as in surrounding areas will be available to help. Furthermore, all responders will need to work automatically and autonomously. A Level B earthquake causes extensive destruction, and all responders in the region will be busy caring for the victims. Anyone available outside of the region will come and help. A Level C earthquake is completely devastating, and all workers nationwide will be involved in responding to the catastrophe. The role of EMS responders using the ABC approach to earthquake response, as described here, may be integrated in part or whole in other EMS systems.