Leff, Rebecca

Abstract Background: Milk-alkali syndrome (MAS) resulting in hypercalcemic crisis represents a life-threatening medical emergency in the setting of excessive calcium and absorbable alkali ingestion. While an uncommon cause of altered mental status and acute renal failure in the emergency department, emergency medicine clinicians should be aware of this syndrome due to significant morbidity and mortality if left undiagnosed. Case presentation: A 63-year-old woman with history of familial hypoparathyroidism presented to our emergency department with worsening confusion, slurred speech, generalized weakness, and failure to thrive over the course of one month. Review of systems was positive for tachypnea, polydipsia, diffuse musculoskeletal pain, dehydration, poor oral intake, nausea with nonbilious nonbloody emesis, and severe fatigue. Family reported increasing difficulties with completing activities of daily living including ambulation and medication compliance. Physical examination yielded no focal neurologic deficits concerning for ischemic stroke. Laboratory investigations revealed acute renal injury, metabolic alkalosis, and severe hypercalcemia. CT imaging of the head revealed no acute intracranial abnormalities. During evaluation, the patient revealed that she had been taking 15 calcium carbonate (tums) tablets daily, along with vitamin-D and calcitriol, as a result of increased symptoms of gastroesophageal reflux disease. The patient received aggressive fluid and subcutaneous calcitonin in the emergency department. She was admitted to the hospital, where she continued to receive aggressive intravenous fluids. Calcium supplementation was withheld and chlorthalidone discontinued. After a thorough negative workup, the etiology of her hypercalcemia was deemed most likely secondary to milk-alkali syndrome. She was discharged home in stable condition on hospital day 6 without receiving hemodialysis. Conclusions: Emergency physicians should be vigilant of MAS given the potential for high morbidity if left undiagnosed. Emergency clinicians should ask about calcium supplements, as these often won't be listed on the patient's medication list and can be purchased over the counter.

Abstract Background Pulmonary embolism (PE) in the pediatric population is uncommon, and due to a silent presentation often unrecognized entity that remains one of the most challenging medical conditions in the emergency department (ED). Risk factors for PE in children include nephrotic syndrome, immobility, obesity, congenital heart disease, and malignancy. In patients with PE, thromboembolism has been reported to occur at unusual venous sites including the veins within the central nervous system and abdomen. Although penile pain is a rare presenting symptom in the ED, in patients with hypercoagulability, it can herald a life threating event such as PE prompting further evaluation. Case presentation A 15-year-old male with a history of B-cell acute lymphoblastic leukemia who presented to the ED with an 18-hour history of penile pain. In the ED, the patient was in acute distress and rated his pain as 9/10. Initial vital signs were within normal limits, except mild tachypnea. On physical examination, his penile shaft was erythematous, indurated, and tender to palpation. He received fentanyl and morphine for pain. A complete blood cell count revealed pancytopenia with a platelet count of 73 x 109/L (139–320 x 109/L). A work-up for sexually transmitted diseases, urolithiasis, urinary tract infection, deep venous thrombosis (DVT), and priapism was negative. Approximately two hours after morphine administration, his saturations started dropping to mid-70’s. A computed tomography pulmonary angiogram (CTPA) revealed bilateral segmental acute pulmonary embolism involving multiple segmental right and left lower lobe pulmonary arteries. Penile pain and hypoxia have resolved with heparin. Conclusions PE is easily missed diagnosis among children who present to the ED and can be potentially fatal. A high index of suspicion is required in asymptomatic and oligo-symptomatic children with prothrombotic risk factors who develop thromboembolism-related symptoms at unusual sites as well as hypoxia in the ED setting.

Background Individuals with non-English language preferences (NELP) represent a growing proportion of the USA population. Prior studies demonstrate disparate health outcomes related to NELP status; however, this patient population is often excluded from medical research. There is a paucity of literature describing the impact of NELP status on trauma, specifically injury and outcomes related to vehicle occupants injured during motor vehicle collisions (MVCs). The goal of this study was to evaluate the representation of patients with NELP in both emergency medicine and trauma literature. Methods We conducted a systematic search of US-based publications from 2010 to 2021. Titles, abstracts and full texts of eligible articles were evaluated. Data were extracted using an a priori determined standardised reporting tool to evaluate language as study inclusion/exclusion criteria, manuscript reporting of language, assessment of language as a primary variable and consideration of language in study methodology. Results A total of 82 studies met inclusion criteria. Twenty-three studies (28%) excluded NELP populations and only one study explicitly included the NELP population. None of the studies evaluated language as a primary outcome of the study or included language as a variable in the analysis. Over half of the studies (53.6%) used a public data set or registry. Conclusion NELP populations are routinely excluded from and are difficult to identify in MVC trauma research. Without appropriate inclusion and identification, it will be difficult to understand the prevalence and outcomes of traumatic injury in NELP patients and to develop culturally and linguistically appropriate interventions.

Objectives To assess the association between emergency medicine physician supervision and 3-day mortality for patients receiving care from non-physician clinicians in a task-sharing model of emergency care in rural Uganda. Design Retrospective cohort analysis with multivariable logistic regression. Setting Single rural Ugandan emergency unit. Participants All patients presenting for care from 2009 to 2019. Interventions Three cohorts of patients receiving care from non-physician clinicians had three different levels of physician supervision: ‘Direct Supervision’ (2009–2010) emergency medicine physicians directly supervised all care; ‘Indirect Supervision’ (2010–2015) emergency medicine physicians were consulted as needed; ‘Independent Care’ (2015–2019) no emergency medicine physician supervision. Primary outcome measure Three-day mortality. Results 38 033 ED visits met inclusion criteria. Overall mortality decreased significantly across supervision cohorts (‘Direct’ 3.8%, ‘Indirect’ 3.3%, ‘Independent’ 2.6%, p<0.001), but so too did the rates of patients who presented with ≥3 abnormal vitals (‘Direct’ 32%, ‘Indirect’ 19%, ‘Independent’ 13%, p<0.001). After controlling for vital sign abnormalities, ‘Direct’ and ‘Indirect’ supervision were both significantly associated with reduced OR for mortality (‘Direct’: 0.57 (0.37 to 0.90), ‘Indirect’: 0.71 (0.55 to 0.92)) when compared with ‘Independent Care’. Sensitivity analysis showed that this mortality benefit was significant for the minority of patients (17.2%) with ≥3 abnormal vitals (‘Direct’: 0.44 (0.22 to 0.85), ‘Indirect’: 0.60 (0.41 to 0.88)), but not for the majority (82.8%) with two or fewer abnormal vitals (‘Direct’: 0.81 (0.44 to 1.49), ‘Indirect’: 0.82 (0.58 to 1.16)). Conclusions Emergency medicine physician supervision of emergency care non-physician clinicians is independently associated with reduced overall mortality. This benefit appears restricted to the highest risk patients based on abnormal vitals. With over 80% of patients having equivalent mortality outcomes with independent non-physician clinician emergency care, a synergistic model providing variable levels of emergency medicine physician supervision or care based on patient acuity could safely address staffing shortages.