Acad Emerg Med Research Articles

In adults in the emergency department with nausea, neither droperidol nor ondansetron improved symptoms.

Source Citation Meek R, Mee MJ, Egerton-Warburton D, et al. Randomized placebo-controlled trial of droperidol and ondansetron for adult emergency department patients with nausea. Acad Emerg Med. 20...

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nausea, isopropanol, rubbing alcohol: nausea, isopropanol, rubbing alcoholFigureFigureNausea is ubiquitous in EDs. Our reflexive treatment is to pop an ondansetron order in the queue and be done with it. Of course, we are often not actually done, and we have to dose again or escalate treatment, sometimes to effect, sometimes not. Occasionally, we belatedly recognize that the most effective nausea therapy is to imprison the patient's shoes and socks in an airtight bag. Some researchers have asserted that EDs fail to administer antiemetics appropriately to a significant proportion of patients with nausea and vomiting and are guilty of oligoantiemesis, a shortcoming of patient care akin to oligoanalgesia, the inadequate treatment of pain. (J Emerg Med 2016;50[6]:818.) The body of evidence, however, would suggest the opposite. Consider a 2015 Cochrane systematic review identifying eight randomized trials of drugs used in the ED to treat nausea and vomiting among adults. It concluded that no definite evidence supports “the superiority of any one drug over any other drug or the superiority of any drug over placebo” for nausea. (Cochrane Database Syst Rev 2015[9]:CD010106; http://bit.ly/2L4MAzM.) Are we wasting time and rapidly-dissolving tablets on our ED patients, and, if so, are there viable alternatives? The New Evidence Does standard ED antiemetic treatment work? The review says the answer is not really, but the evidence doesn't stop there. A multicenter trial of more than 200 adults with nausea from any cause measuring more than 3 on an 11-point verbal rating scale randomized patients to 1.25 mg IV droperidol, 8 mg IV ondansetron, or placebo. All received 1L of normal saline. Most patients (75-80%) in all groups had a clinically meaningful reduction in nausea scores at 30 minutes with similar mean score reductions, but the authors concluded that droperidol and ondansetron were not superior to placebo. (Acad Emerg Med 2018 Oct 11 [Epub ahead of print] doi: 10.1111/acem.13650.) What about isopropyl alcohol wipes? Aromatherapy inhalation of isopropanol treats nausea, but we don't really know how; putative mechanisms include olfactory distraction and controlled breathing. Building on literature from the post-operative arena and a small 2016 randomized controlled trial (Ann Emerg Med 2016;68[1]:1; http://bit.ly/2G3qoaD), a single-center RCT randomized more than 120 patients with nausea of more than 2 on an 11-point verbal scale who did not (yet) have IV access to inhaled isopropyl alcohol (one pad, refreshed every 10 minutes as needed) and 4 mg oral ondansetron, inhaled isopropanol, and oral placebo, or inhaled placebo and oral ondansetron. (Ann Emerg Med 2018;72[2]:184.) The mean decrease in the visual analog scale score at 30 minutes in the two isopropanol arms was 30 mm (95% confidence interval 22-37 mm) and 32 mm (95% CI 25-39 mm), respectively. No adverse events were reported, and pain scores also intriguingly decreased! Not surprisingly, adding ondansetron to inhaled isopropyl alcohol added no benefit. Isopropyl alcohol significantly outperformed oral ondansetron in this well-done trial. The Bedside Trial This practice-changer trial was simple and cheap. We decided to test this, and gave patients without an abdominal complaint or headache a Webcol alcohol prep. Six of eight consecutive assigned patients were enrolled. One patient had abdominal pain and was on his way to an appendicitis diagnosis; he initially reported no change in symptoms, but several minutes later reported relief. The second patient also had a positive result, but was disappointed that the effect lasted only 10 minutes. The next patient had post-concussive vertigo and nausea from taking a header at the skate park. The aromatherapy failed him, consistent with existing evidence (or lack thereof) of antiemetics' effectiveness for vertigo. Two other moderately positive results were seen, and a patient with suspected biliary colic reported that it didn't help with the pain. It had, however, helped with her nausea. Clearly, this case series has more than a few limitations—reporting bias, social desirability bias, small sample size, and lack of a control arm. Nonetheless, the advantages of the therapy—it is quick, cheap, and available without a code to the Pyxis—are sufficient enough for us to keep a stash of wipes in our pockets. In fact, one of us kept a few on hand while flying from Sacramento to Honolulu in case of nausea from turbulence or airline food.? Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

In patients with chest pain, HEART Pathway-guided and usual care did not differ for MACE or health care use.

Source Citation Stopyra JP, Riley RF, Hiestand BC, et al. The HEART Pathway randomized controlled trial one-year outcomes. Acad Emerg Med. 2018. [Epub ahead of print]. 29920834

Topical tranexamic acid for the treatment of epistaxis in patients using antiplatelet agents.

The primary outcome of this randomized controlled trial was the percentage of patients whose epistaxis had stopped at 10 minutes from the time of intervention. Secondary outcomes included the frequency of epistaxis recurrence at both 24 hours and 7 days, emergency department length of stay, and patient satisfaction.

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immunotherapy, cancer: immunotherapy, cancerFigureFigureA 69-year-old man with a history of cancer presented to our ED on day four of taking Ceftin for pneumonia with a fever of 102.5°F and shortness of breath. He had a history of non-small cell lung cancer after a wedge resection and hepatocellular carcinoma after a hepatectomy. His chest film was read as “patchy airspace disease over mid- and lower lung without improvement from prior,” and he was worked up, treated, and admitted for severe sepsis. Sounds like a fairly bread-and-butter emergency department case, right? Of course, there was a twist, which emerged after a CT of the chest and bronchoscopy demonstrated diffuse ground glass opacity and tracheobronchitis, findings that resolved with high-dose prednisone. The diagnosis was not pneumonia but pneumonitis, a complication of the patient's cancer treatment—pembrolizumab (Keytruda), last administered several months before presentation. Pembrolizumab is one of the new-generation cancer treatments that deploys the patient's immune system against cancer cells by removing the malignant cells' ability to disguise themselves rather than killing them directly. These checkpoint inhibitors are revolutionizing oncologic treatment, but are not a risk-free panacea. We all know where these patients are likely to be seen and evaluated when severe side effects emerge. Be on the Lookout Immunotherapy complications have been receiving some attention from scientific journals as well as the lay press this year. Actual data on adverse effect risk, especially for those with a delayed presentation like our patient, remain limited. An Annals of Emergency Medicine study gives us our best sense of the prevalence and nature of side effects in practice, albeit with data from a single and specialized ED setting. (Ann Emerg Med 2018 Jun 4; doi: 10.1016/j.annemergmed.2018.04.019.) The authors retrospectively reviewed records of patients over age 17 on immune checkpoint therapy who visited the University of Texas MD Anderson Cancer Center ED between March 2011 and March 2016. The study's primary goal was to characterize the nature and mortality risks of any adverse reactions to one or more of three immunotherapy medications (pembrolizumab, nivolumab [Opdivo], ipilimumab [Vervoy]). The study identified 1,026 visits among 628 patients, and 257 visits (25%) were related to one or more adverse effects. The list of these starts with diarrhea (12.7%) and continues in descending order of frequency: colitis, pneumonitis, dermatitis, hypophysitis, hepatitis, thyroiditis, pancreatitis, adrenalitis, myocarditis, and vasculitis. Pneumonitis posed the greatest survival risk (hazard ratio 1.72 [95% CI 1.03-2.87] in multivariable Cox regression modeling), and multiple drug therapy made certain specific reactions more likely (e.g., thyroiditis and hypophysitis) than single-drug therapy. We EPs should presume that any patient with active cancer could be on these medications, and we should be on the lookout for their adverse reactions. Fortunately, recent articles in Academic Emergency Medicine and Cureus addressed the physiology, grading, and treatment of checkpoint inhibitor therapies. (Acad Emerg Med 2018 May 5; doi: 10.1111/acem.13443; Cureus 2017;9[10]:e1774; http://bit.ly/2L5zgOk.) The American Society of Clinical Oncology and the National Comprehensive Cancer Network also published guidelines on these. (J Clin Oncol 2018;36[17]:1714; http://bit.ly/2L1RgZV.) Most important are the grading recommendations (1-4) with sensible management ramifications. The skinny is that minor toxicities (Grade 1) can usually be closely monitored without stopping treatment, but Grade 2 and above require immunosuppression (corticosteroid first-line, infliximab second-line) and holding or suspending immunotherapy altogether. The test with this practice-changer will be in the awareness and recall. We must recognize the at-risk patient and remember that delayed symptoms can be common. We penned a limerick to help us remember to add checkpoint inhibitors to the differential diagnosis checklist. (See sidebar.) Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Millenials in Medicine: Tradition and Disruption

Millenials in Medicine: Tradition and Disruption

Brain Trust

Brain Trust

Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

Mindful EM

patient sign-out: patient sign-outFigureFigureOne of the most dangerous procedures we perform is the patient handoff. Every sign-out from emergency physician to emergency physician carries a risk to the patient and liability to the outgoing and incoming care teams. Patient handoff in the emergency department is analogous to passing the baton in a relay race. Transitioning care is passing the baton of responsibility from one physician or team to the next while minimizing distractions and impediments to ED flow. The emergency physician is prone to cognitive errors because of numerous environmental factors, including frequent distractions, interruptions, loud noises, and phone calls, as well as the complexity and diversity of diseases and conditions in our patients. Physician attributes are also associated with errors during sign-out. Physician decision fatigue is more likely to occur at the end of shift, while an incoming physician is more likely to fall into cognitive error traps such as diagnosis momentum. Recent literature highlights the great variability in handoff practices and our assessment of implementing these procedures. It is surprising that not all ED groups and emergency medicine training programs have systems to avoid errors during sign-out given the dangers and risks of sign-out. Most concerning is that a large group of residents is learning this skill informally and with great variability among programs. Would we accept similar training and outcomes for educating our trainees in airway management? A cross-sectional study investigating handoff practices from emergency physician to emergency physician in academic programs found that more than half of the respondents had a standardized system in place for sign-out, which was an improvement from a comparison study in 2011 when only 43 percent did. The authors still concluded that communication still has room for improvement in education and practice. (Acad Emerg Med 2016;23[2]:197.) Most research on handoffs is centered around emergency to inpatient communication. (West J Emerg Med 2017;18[1]:86.) The most common algorithms used are SBAR and IPASS. ACEP has made available a Safer Sign-Out form, which is to be used for EP-to-EP handoffs and provides recommendations for sign-out procedures. (http://bit.ly/2BcKs2r.) These are made up of the five Rs: record, review, round, relay to the nurse/team, and receive feedback. Using the sign-out form, the incoming EPs have the oportunity to record information about results and outcomes that can be followed up by the outgoing team. Less discussed in the literature is physician resistance to implenting effective handoff procedures and the frequent malignant narratives around the sign-out process. Despite the availability of sign-out forms and algorithms, each ED has its own sign-out culture, and each practioner has his own approach. We came up with several recommendations to troubleshoot dangerous transitions that we think can augment the utility and success of an already established handoff process. DO: Recognize the vulnerability to error that occurs during sign-out. Ensure the outgoing doctor introduces the incoming team to the patient and reviews the current workup and plan together, involving the patient. Make sure the incoming and outgoing teams are on the same page. Involve nursing in rounds and the sign-out process. Ensure the incoming doctor arrives early for shifts and becomes familiar with the board prior to receiving sign-out. Be kind to the outgoing doctor; she has worked a long shift and needs to know she is leaving the ED in good hands. DON'T: Don't rush the person giving sign-out. Expect that sign-out will take time. Don't demand the outgoing doctor stay past his shift for trivialities. Don't delay seeing a patient who was endorsed to you. Don't fall into common diagnostic error traps, such as diagnostic momentum that can occur during the sign-out process. In an ideal sign-out, there would be a checklist and overlapping shifts, allowing enough time for the outgoing and incoming physicians to go to the bedside and make sure they are on the same page. During a sign-out, the incoming team should be introduced to the patient and the patient updated on her care plan. This is a good time to involve the patient in his care. Preferably, the entire team would be involved in the sign-out process: physicians, nurses, technicians, residents, pharmacy, and respiratory therapy. Unfortunately, this may not be feasible given the constant influx of new patients and high turnaround. Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website or in our free iPad app, both available at www.EM-News.com. Comments? Write to us at [email protected].

Seizures After Traumatic Brain Injury: Conduct CT

Research Article| September 01 2017 Seizures After Traumatic Brain Injury: Conduct CT AAP Grand Rounds (2017) 38 (3): 32. https://doi.org/10.1542/gr.38-3-32 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Seizures After Traumatic Brain Injury: Conduct CT. AAP Grand Rounds September 2017; 38 (3): 32. https://doi.org/10.1542/gr.38-3-32 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: seizures, traumatic brain injuries Source: Badawy MK, Dayan PS, Tunik MG, et al. Prevalence of brain injuries and recurrence of seizures in children with posttraumatic seizures. Acad Emerg Med. 2017; 24(5): 595– 605; doi: https://doi.org/10.1111/acem.13168Google Scholar Investigators from the Pediatric Emergency Care Applied Research Network (PECARN) conducted a secondary analysis to evaluate the frequency of traumatic brain injuries (TBIs) and short-term seizure recurrence in children with posttraumatic seizures (PTS). Children who were <18 years old and received blunt head trauma that was evaluated at 1 of 25 participating PECARN EDs from 2004 to 2006 were included. All clinical data were obtained via chart review. The main exposure was PTS, defined as a witnessed seizure episode that occurred after the traumatic event. PTS timing was categorized as immediate (on impact), within 30 minutes, or >30 minutes after the traumatic event. PTS duration was categorized as <1 minute, 1 to <5 minutes, 5–15 minutes, and >15 minutes. The main outcome measures were (a) the presence of TBIs on CT images, defined as the presence of any intracranial hemorrhage, cerebral edema, pneumocephalus, or skull fracture; (b) the need for neurosurgical intervention; and (c) recurrent seizures within 1 week of the ED visit. Investigators calculated the frequencies of each outcome, the type of TBIs identified, the association of PTS timing and duration with presence of TBI, and the frequencies of neurosurgical intervention and recurrent seizures in those with PTS but no TBI. There were 42,424 participants included in the analysis, with 536 (1.3%) having PTS. Of those with PTS who had CT results (n = 466), 72 had TBIs (15.4%). The most common TBIs identified were cerebral contusion (5.6%) and subarachnoid hemorrhage (5.4%). The frequency of TBI increased as the timing and duration of PTS increased. Of the 72 patients with PTS who had TBIs on CT images, 20 (27.8%) underwent neurosurgery, and 15 (20.8%) had recurrent seizures. Of those with no TBI on CT images or no CT performed (n = 457), 5 (1.1%) had recurrent seizures, and none required neurosurgical intervention. The investigators conclude that children with PTS have a high likelihood of TBI on CT images, and a high proportion of those with TBI on CT images require neurosurgical interventions and have recurrent seizures. Dr Bratton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. TBIs are known to cause early and late PTS. Risk factors for “early” PTS (occurring within 7 days of injury) include severe and/or penetrating brain injuries, subdural hematoma, cerebral contusions, depressed skull fractures, retained bone or metal fragments, focal neurological deficits, loss of consciousness, Glasgow Coma Scale (GCS) score <10, prolonged posttraumatic amnesia, and age <2 years.1 The incidence and prognosis of early PTS have been more closely evaluated for pediatric severe TBI (GCS 3–8) when compared to moderate (GCS 9–12) or mild (13–15) TBI. The results of the current... You do not currently have access to this content.

Point-of-Care US and Nonangulated Forearm Fractures

Research Article| August 01 2017 Point-of-Care US and Nonangulated Forearm Fractures AAP Grand Rounds (2017) 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Point-of-Care US and Nonangulated Forearm Fractures. AAP Grand Rounds August 2017; 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: diagnostic radiologic examination, forearm fractures, point-of-care ultrasonography, pain Source: Poonai N, Myslik F, Joubert G, et al. Point-of-care ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med. 2017; 24(5): 607– 616; doi: https://doi.org/10.1111/acem.13146Google Scholar Researchers from multiple Canadian institutions conducted a cross-sectional study to determine the utility of point-of-care ultrasonography (POCUS) in children with suspected nonangulated distal forearm fractures. Children were eligible if they were 4–17 years old and presented to the study emergency department (ED) with a suspected nonangulated distal forearm fracture, defined as maximal pain and tenderness at the distal third of the forearm after an acute fall on an outstretched hand. Each participant underwent radiography and POCUS of the distal ulna and radius. POCUS was performed and interpreted by 4 POCUS-certified pediatric ED physicians with at least 2 years of POCUS experience who were not involved in the patient’s care. POCUS evaluators were blinded to the radiographs, and radiography technicians and radiologists were blinded to POCUS interpretations. Each study child was classified as having a fracture or not on the basis of a radiologist’s interpretation of the patient’s radiographs. The primary outcome was the sensitivity and specificity of the POCUS evaluation by the ED physician (fracture or no fracture) when compared to radiograph interpretation. Secondary outcomes included (a) patient self-reported pain immediately after radiography and POCUS by using Faces Pain Scale–Revised scores, (b) caregiver satisfaction with each imaging procedure by using a single-item question and a 5-point Likert scale, and (c) duration of POCUS and radiography procedures. Of 169 children enrolled, 76 had a fracture on radiographs. The most common type was a buckle fracture (80%). The sensitivity and specificity of POCUS were 94.7% (95% confidence interval [CI], 89.7%–99.8%) and 93.5% (95% CI, 88.6%–98.5%), respectively. There were 4 fractures missed with POCUS (1 distal radius buckle fracture and 3 ulnar styloid factures). There were 6 nonfractures that were interpreted as fractures at POCUS. POCUS was associated with a significantly lower median pain score when compared with radiography. There was no significant difference in median caregiver satisfaction scores with POCUS and radiographic procedures. POCUS was associated with a significantly lower median procedure duration than radiography (1.5 vs 27 minutes, respectively; P < .001). The researchers conclude that using POCUS to assess distal forearm injuries in children is accurate, timely, and associated with low levels of pain. Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. POCUS is a useful tool in the pediatric ED setting. The current study is 1 of several published in recent years to evaluate its use in forearm fractures in children. A recent meta-analysis of these studies supports the high sensitivity and specificity reported in the present study,1 which excluded children with obvious forearm deformities and thereby reduced the potential for inflated test performance. Few prior studies have been conducted to evaluate pain... You do not currently have access to this content.

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Mindful EM

Mindful EM

Diversity Matters

Diversity Matters

Commentary: Death by Distraction

Distraction is something that emergency medical personnel are intimately familiar with. We’re used to being distracted on our shifts. Observational studies have shown that interruptions during ED shifts occur as frequently as every 6 to 9 minutes. We tell ourselves that it’s okay because we’re excellent multitaskers; then we try to remember what we were doing and get back to it. In the meantime, studies demonstrating our multitasking effectiveness—or the lack thereof—are beginning to accumulate, and they suggest we’re not as facile with distractions as perhaps we’d like to be. A study of residents performing virtual surgery showed worse outcomes with pagers beeping and sign-out list questions being asked compared with that in a quiet environment. It’s widely accepted that interrupting nurses during medication preparation and administration is detrimental to patient safety. Yet, as providers, we often continue to believe that we’re immune to this effect. Language: en

A Child's Last Hours'Multidisciplinary Training in End-of-Life Care in Children's Hospitals: Adolescent With Cystic Fibrosis

Abstract Introduction This resource is one of a three-module workshop using a case-based approach to teach interprofessional learners about end-of-life (EOL) care in dying hospitalized patients. Th...

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Which “ROMI” Patients Can Be Sent Home After Two Hours?

Several attempts have been made to develop decision aids for chest pain patients (NEJM JW Emerg Med Sep 2012 and Acad Emerg Med 2012; 19:837; NEJM JW

The Case Files

A 59-year-old woman presented to the emergency department complaining of worsening abdominal pain and distension as well as four episodes of syncope and lightheadedness. The patient reported a past medical history of hypertension and hypothyroidism, but denied other comorbidities. The patient reported that she was walking her dog the previous night when the dog bolted forward, causing her to lose her balance and fall forward. The patient reported that she was able to tuck into a ball and roll, sustaining minor trauma only to her right side. She denied any head trauma or loss of control after falling. She was able to walk home, and she felt fine apart from some bruising on her right lower ribs. Over the course of the evening, however, the patient's pain began to worsen. She had several episodes of nausea and non-bloody, non-bilious emesis. The next morning she began to feel short of breath, and her abdominal pain continued to worsen. She reported two episodes of syncope, which she attributed to the severity of her pain or because she was breathing too quickly.FigureFigureThe patient's systolic blood pressure was in the 80s when she arrived in the ED, and her heart rate was 130 bpm. Her respiratory rate was 26 bpm, and her SPO2 was 85% on room air. The patient was in distress and started on oxygen, intravenous access was obtained, and she was resuscitated with normal saline. She had significant abdominal pain that seemed to localize to the right upper quadrant, and a bedside FAST exam was positive for intra-abdominal fluid. The patient was expeditiously transferred to a trauma center where she underwent a CT with IV contrast for the abdomen and pelvis. A large smoothly marginated cystic lesion was noted on the dome of the right hepatic lobe measuring 13.1 x 8.6 cm. A grade 3 liver laceration was noted at the base of the hepatic cysts with a surrounding large hematoma. Moderate amounts of fluid were noted in Morrison's pouch, the surrounding paracolic gutter, and the pelvis. A fracture was also noted in the right eighth rib that was not displaced. The patient's hemoglobin levels continued to drop, and she was taken to interventional radiology, where she was noted to have a small pseudoanuerysm of a segmental branch of the right hepatic artery within the hepatic cyst, with evidence of active intraperitoneal extravasation. The patient then underwent an embolization of the segmental branch of the right hepatic artery, and hemostasis was successfully obtained. The patient's hemoglobin levels stabilized after the embolization, and she was able to resume a regular diet. She was discharged on hospital day six with the plan to follow up with trauma surgery.FigureFigureFigureUnintended falls are the most common cause of injury in the United States. They lead to 7.9 million emergency department visits per year and 860,000 hospitalizations. (Acad Emerg Med 1998;5[11]:1064.) In our particular case, what appeared to be a benign mechanism resulted in a serious injury because of the presence of a benign hepatic cyst that the patient didn't know about. Simple hepatic cysts are believed to be present in five to 10 percent of the population, with increasing incidence with age. (J Clin Ultrasound 1996;21[2]:115.) Common complications of hepatic cysts include rupture, contained hemorrhage, and obstructive jaundice. (J Nippon Med Sch 2010;77[3]:181; West J Med 1982;136[3]:246; Am J Gastroenterol 1988;83[1]:93.) Multiple cases of traumatic rupture of hepatic cysts are reported, but these are typically contained within the cyst. Few reports exist suggesting hemoperitoneum after cyst rupture. In our case, the rupture of the hepatic cyst was accompanied by a liver laceration, which led to extravasation of blood leading to hemoperitoneum. (HPB Surg 1988;1[1]:81; South Med J 1989;82[5]:667.) Focused bedside ultrasonography and strong clinical suspicion assisted in expediting a transfer to a trauma center where intervention corrected the problem.

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FigureFigureFigureFigureWhat do eggs, peppercorns, wooden skewers, and dental picks have in common with embedded corneal foreign bodies? Far more than you might think. The most practical way to teach removal of such a foreign body is with a simulation device, but that is easier said than done. A review of the published medical literature revealed two models: One used glass spheres coated with paraffin; another used polyvinyl and gelatin. (Acad Emerg Med 1995;2[9]:831; Emerg Med J 2014;31[4]:329.) These simulation models were objectively assessed to be adequate, but we felt they had inherent limitations that restricted their day-to-day use. Both required significant time to develop, prepare, and execute, and we deemed the cost too high to permit routine usage. Instead, we developed a model that incorporated the use of the slit lamp with the actual removal process. This technique was specifically chosen to teach optimal control and maximize patient safety. All medical, nursing, pharmacy, physician assistant, EMS, and public health students at the University of Toledo are part of the Emergency Medicine Docent Program, a structured, multidisciplinary educational endeavor. Students enrolled in the month-long emergency medicine clerkship rotation not only participate in patient care activities, but also receive formalized didactic training, simulated clinical education with human simulators, and skills training with simulation models.FigureFigureIt wasn't long before these students mastered the slit lamp, and began asking how to remove an embedded corneal foreign body. This is not an unusual query because many of the health care students in the program intend to specialize in emergency medicine. The opportunity to see the technique in actual practice is pure serendipity, actually attempting it even less so. That is usually the domain of the junior EM resident. These considerations led us to conceive a novel simulation that was easy to construct, quick to deploy, and inexpensive. Enter the egg, peppercorns, dental picks, and skewer. You will need to hard boil an egg to mimic the eye, and roll it on a bed of crushed peppercorns to mimic foreign bodies. Insert one skewer through the egg, and temporarily attach it onto the chin and forehead rest of the slit lamp. Adjust the chin rest to ensure that the egg and peppercorns are within the visual axis of the viewer, and secure the device with tape. Use a dental pick to demonstrate removal of a peppercorn fragment. This simulation model takes only minutes to assemble, and is constructed so that multiple students can participate at one educational setting. The dental pick was chosen instead of a needle or burr to minimize expense and the risk of an accidental stick. We trialed the technique on medical and nonmedical faculty and students, and found it to be an efficacious educational device. It takes less than half an hour for a student to learn how to use the slit lamp and the technique for removing an embedded corneal foreign body. It also reassures educators that students are actually using the slit lamp correctly by being able to see and remove a peppercorn fragment from the egg's surface. The method was viewed positively by faculty and students even when compared with the gelatin simulation model that was described in the medical literature.FigureWe have been so heartened by our findings that we have encouraged public health, nursing, and pharmacy students to participate in our slit lamp and foreign body removal education. This is especially important in times of catastrophe or pandemic when physicians, nurses, and midlevel providers are in short supply and health care delivery may be in the hands of nontraditional responders. We are at the feasibility stage with the model and technique. A research study is planned to assess whether learning from the model would improve the emergency medicine resident's comfort level and prowess when dealing with an actual patient.