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  Improving Substance Use Disorder Care in the Emergency Department through Process Changes and Education

  Tiffany Morelli and Cynthia Seferian

  Publication Date: 5-2025

  Corewell Health Beaumont Troy Hospital emergency department is a Level II trauma center that had an annual volume of 108,311 in 2023. In 2023 our team was consulted on 570 opioid use disorder (OUD) patients, provided 371 free take-home intranasal Narcan Kits, and connected 237 of them. In 2022, we saw 531 OUD patients, provided 311 free take-home intranasal Narcan Kits, and connected 271 of them. In July of 2022 we started to track patients here for other substances outside of OUD. This added an additional 1,956 patients to our consult list for 2022 and 2023. Our program was initiated in 2019, as we identified a need for additional resources for this population. We currently have a team that consists of an ER Physician, APP, and 3 RNs. We see patients 6 days a week, from 7am-7pm. This program is currently funded through a grant. Our goal is to identify, treat and connect with resources those at risk for or suffering from OUD/SUD. We also focus on educating our staff on decreasing the stigma associated with addiction. We provide free Narcan Kits, and offer initiation of medication assisted treatment (MAT).

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  Gluteal Compartment Syndrome as the Underlying Cause of Rhabdomyolsis: Case Report

  Omar Alazem, Harjinderpal Singh, and Haidar Al-Saadi

  Publication Date: 5-9-2024

  Gluteal compartment syndrome (GCS) is a rare and easily-missed diagnosis that can cause significant morbidity and mortality.

  It is an important diagnosis to consider in the ED for “found down” patients, prompting thorough physical examination. It should also be in the differential diagnosis of causes of rhabdomyolysis.

  Awareness of this largely clinical diagnosis is critical, as early intervention with emergent fasciotomy leads to better outcomes.

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  A Fatal Cause of Weakness: Bilateral Lower Extremity Weakness in Aortic Dissection

  Yasmine Ankouny, Gina M. Ruggirello, and Adam Vieder

  Publication Date: 5-9-2024

  Aortic dissection is characterized by the tearing of the aortic wall, creating a false lumen between the intima and media, that can compromise blood flow to vital organs. This tear most commonly occurs in the ascending aorta, specifically in the right lateral wall where shear forces are greater.3Aortic dissection is relatively uncommon and most often presents with severe tearing chest or back pain. Early diagnosis is critical for survival.2,3.

  The incidence of acute aortic dissection is estimated to be 2.6-3.5 per 100,000 person-years.1.

  In a study from the International Registry of Acute Aortic Dissection (IRAD), 66% were males with the mean age of 63 years old.2.

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  Myasthenia Gravis Seronegative

  Ryan Brown and Avery Cheap

  Publication Date: 5-9-2024

  Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterized by fluctuating weakness involving ocular, bulbar, limb, and/or respiratory muscles.

  Antibodies found in MG = (anti-AChR), (anti-MuSK), (anti-LRP4), antiagrin, anti-titin, (anti-RyR), anti-collagen Q, and (anti-KV1.4) antibodies.

  MG is relatively uncommon with annual incidence 7-30 cases per million.

  Can occur at any age but has bimodal distribution of 2nd and 3rd decade for females to 6th to 8th decade of life for males.

  Myasthenia gravis can be precipitated by recent surgeries, illness or immunizations.

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  Encephalitis: Acyclovir Toxicity or Varicella Zoster Virus?

  Christine Carline, David Hess, and Diane Paratore

  Publication Date: 5-9-2024

  • Varicella zoster virus (VZV) encephalitis can cause headache, vomiting, fever, altered mental status (AMS), ataxia, visual hallucinations and seizures

  • Acyclovir toxicity has similar symptoms such as hallucinations, confusion, AMS and dysphasia

  • Therefore, it can be difficult to distinguish acyclovir toxicity from VZV encephalitis.

  • We will discuss a patient with symptoms concerning for these diagnoses.

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  Emergency Department Treatment of Elevated Blood Pressure in the Headache Patient

  Lauren Eberhardt, Michelle Jankowski, and Brett Todd

  Publication Date: 5-2024

  • Headache is an extremely common emergency department (ED) chief complaint, accounting for 1-3% of emergency department (ED) visits per year globally.
  • Headache is often associated with elevated blood pressure and the most frequent clinical manifestation of hypertensive urgency, occurring in 35.9% of patients.5
  • First line treatments used for acute headache management in the ED include intravenous fluid (IVF), anti-dopaminergic agents, aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and ketorolac.6
  • Rescue analgesia is needed for pain management in 16% to 18.1% of patients.8,9.
  • Rescue analgesia includes: additional doses of first line analgesia or initiation of a second line medication1,6,10,11 such as magnesium sulfate, anti-epileptics, nerve blocks, and ketamine.6
  • It is unclear if the headache is the cause of elevated blood pressure or if elevated blood pressure results in pain and distress.
  • An improved understanding of this relationship could provide guidance to ED physicians managing headache patients with elevated blood pressure.

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  Characterizing the Effectiveness of Prehospital Pediatric Pain Management in Children with Long Bone Fractures

  Revelle Gappy, Ashima Goyal, John Frawley, Sariely Sandoval, Nai-Wei Chen, Remle Crowe, and Robert Swor

  Publication Date: 5-2024

  Prehospital pediatric pain management has been poorly understood and sub-optimally treated.1-3 Pain scales for children differ from adult pain scales and it is unclear if pain assessments are well documented, particularly in infants and toddlers.4-6 Surveys of emergency medical services (EMS) personnel identify barriers to pain management including discomfort with emergency care of injured children, concern for allergic reactions, additional pain from intravenous catheter insertion, parental influence, as well as lack of knowledge and experience secondary to the relatively infrequent treatment of acutely injured children.7-9

  The effectiveness of prehospital pain medication administration for children is unknown, as is the efficacy of basic, non-pharmacological measures such as splinting and icing for pain management. Historically, opioids for pediatric pain management have been in widespread use.10 The American Academy of Pediatrics (AAP 11) and several other national organizations created a joint policy statement in 2009 that reaffirms the importance of pain assessment and treatment, including sedation and analgesia, as a potential development topic for pediatric care and professional performance.

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  Cardiac Arrest in Setting of Thyroid Storm

  Jacob Hague, Eric Litman, Kyle Smola, and Amy Wallace

  Publication Date: 5-9-2024

  Thyroid storm is a true endocrine emergency resulting from the vast overproduction of thyroid hormone leading to markedly increased metabolic demands affecting all organ systems. [1] This condition can be precipitated by medication non-compliance, prior illnesses, surgery and contracture of underlying infections. The cardiovascular implications include high output heart failure, dilated cardiomyopathy and acute tachy-arrhythmias, which serve as the leading cause of mortality in thyroid storm. Burch-Wartofsky Point Score (BWPS) is frequently used to diagnose thyroid storm [2]. Early treatment in the emergency department has been shown to mitigate acute compromise of left ventricular function and augment clinical outcomes.

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  Purr-Ils of the Liver: A Case of Mash Cirrhosis Complicated by Disseminated Pasteurella

  Joanna Henry, Alaa Abujame, Cameron Hubbard, Angela Shermetaro, James Hebden, Hussein Bazzy, Jared Grodman, Katie Sumnicht, and Christopher Cooley Cooley

  Publication Date: 5-9-2024

  Pasteurella Multicoda is a gram-negative coccobacillus that is commensal to mammals such as domesticated pets and transmitted to humans by scratches or bites. The extent of infection is often limited to soft tissue, bone, and joint.

  Disseminated infection by P. multicoda infrequently is typically associated with peritoneal dialysis.

  We present a case of disseminated P. multocida infection with bacteremia and peritonitis in a patient with NASH Cirrhosis.

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  Vesicant Infusates Are Not Associated with Ultrasound-Guided Peripheral Intravenous Catheter Failure: A Secondary Analysis of Existing Data

  Mahmoud Hijazi, Amit Bahl, and Nai-Wei Chen

  Publication Date: 5-2024

  With over 300 million used annually in the United States, peripheral intravenous catheters (PIVC) are the most commonly used invasive device in the acute care setting1,2. Unfortunately, PIVCs have high failure rates with up to 63% failing prematurely3,4.

  Certain intravenous medications categorized as vesicants and irritants are known to cause vein and local tissue injury. The Infusion Nursing Society (INS) created this list based on infusate osmolarity thresholds that increase the likelihood of these complications5.

  It is perceived the impact of these medications on larger proximal veins with higher flow rates and improved hemodilution diminishes the likelihood of these complications. Thus, guidelines support the use of the vesicants and most irritants via central venous lines6

  Some recent studies have shown that these medications may be safely infused in smaller distal peripheral veins with lower flow rates, particularly many irritants7-9

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  A Case of Spontaneous Coronary Artery Dissection in a Postpartum Woman

  John Kruszewski, Alaa Abujame, and Amy Wallace

  Publication Date: 5-9-2024

  Spontaneous coronary artery dissection (SCAD) is a nontraumatic, noniatrogenic separation of the coronary arterial wall and is an infrequent cause of acute myocardial infarction. The underlying mechanism of SCAD is not fully understood. Proposed mechanisms likely include intimal tear and bleeding of the vasa vasorum, inflammation of the adventitia and tortuosity of the coronary artery. SCAD should be considered in any young patient who presents with an acute myocardial infarction or cardiac arrest, especially in females without risk factors or history of coronary heart disease. Diagnosis is confirmed with coronary angiography. Management strategies include medical management, revascularization, mechanical support and cardiac transplantation

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  Mounjaro Mediated Drug-Induced Immune Thrombocytopenia

  Barbara Senger, Zachary Howarth, Ali Baydoun, and Benjamin Rossi

  Publication Date: 5-9-2024

  Thrombocytopenia is a condition in which a person has low platelets or thrombocytes in the blood.

  Symptoms of thrombocytopenia vary based on severity.

  Mild: asymptomatic.

  Moderate: prolonged bleeding following trauma, easy ecchymosis, petechiae and purpura.

  Severe: spontaneous ecchymosis/petechiae/purpura, spontaneous mucosal bleeding, life threatening internal bleeding.

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  Stress Induced Electrical Storm with Recurrent ICD Defibrillation

  Joshua M. Smith and Frank Schell

  Publication Date: 5-9-2024

  Electrical storm is a life-threatening condition where a patient may experience frequent episodes or persistent ventricular arrythmias. With improved medical treatment of advanced heart failure patients, patients with electrical storm are presenting more commonly to emergency centers. Patients with implantable cardiac defibrillators experiencing multiple appropriate defibrillations need emergent evaluation and a systematic approach by Emergency Physicians.

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  Rapid Response Team Codes Following Transition-of-Care from the Emergency Department to an Inpatient Medicine Unit

  Kerrin Bersani and Brett Todd

  Publication Date: 5-2023

  Transitions-of-care from the emergency department (ED) to an inpatient unit have been identified as a high-risk period for medical error due to multiple causes, such as communication mishaps, excessive workload, variability in patient flow, and unclear assignment of responsibility. Patients who experience a diagnostic error are also at increased risk for poor outcomes, including increased length-of-stay and mortality. Rapid Response Teams (RRTs) are frequently utilized by hospitals to address a sudden deterioration in clinical status, often after a transition-of-care. We investigated the occurrence of RRT in patients shortly after a transition-of-care from the ED to a medicine unit. Further, we analyzed the rates of RRT across various demographic groups.

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  Beyond COVID-19: The Impact of Recent Pandemics on Medical Students and their Education: A Scoping Review

  Moneb Bughrara, Stephanie Swanberg, Victoria Lucia, Keaton Schmitz, Dawn Jung, and Tracy Wunderlich-Barillas

  Publication Date: 5-2023

  Over the past two years, COVID-19 has greatly altered undergraduate medical education (UME) as well as daily life. Medical schools across the world were disrupted and had to immediately adapt the educational experience to the online environment in order to continue the delivery of quality UME. However, COVID-19 was not the only recent pandemic. This posed the question, were similar disruptions and adaptations also seen in recent past pandemics such as Severe Acute Respiratory Syndrome (SARS) or Middle East Respiratory Syndrome (MERS) that could have prepared UME for COVID-19? This scoping review investigated the educational and personal impact of recent pandemics on UME and medical students.

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  Encephalitis: Acyclovir Toxicity or Varicella Zoster Virus?

  Christine Carline, David Hess, and Diane Paratore

  Publication Date: 5-4-2023

  Varicella zoster virus (VZV) encephalitis can cause headache, vomiting, fever, altered mental status (AMS), ataxia, visual hallucinations and seizures1

  ▪ Acyclovir toxicity has similar symptoms such as hallucinations, confusion, AMS and dysphasia2 .

  ▪ Therefore, it can be difficult to distinguish acyclovir toxicity from VZV encephalitis.

  ▪We will discuss a patient with symptoms concerning for these diagnoses.

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  Purr-Ils of the Liver: A Case of Mash Cirrhosis Complicated by Disseminated Pasteurella

  Joanna Henry, Alaa Abujame, Cameron Hubbard, Angela Shermetaro, James Hebden, Hussein Bazzy, Jared Grodman, Katie Sumnicht, and Christopher Cooley

  Publication Date: 5-4-2023

  Pasteurella Multicoda is a gram-negative coccobacillus that is commensal to mammals such as domesticated pets and transmitted to humans by scratches or bites. The extent of infection is often limited to soft tissue, bone, and joint.

  Disseminated infection by P. multicoda infrequently is typically associated with peritoneal dialysis.

  We present a case of disseminated P. multocida infection with bacteremia and peritonitis in a patient with NASH Cirrhosis

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  Impact of Earlier Ophthalmology Clerkships on Medical Student Match Rates in Ophthalmology

  Andrew Lee and Steven Joseph

  Publication Date: 5-2023

  The purpose of this study is to analyze the association between earlier clerkship exposure and match success, specifically in ophthalmology. Medical schools are constantly changing their clinical curriculums to provide a stronger foundational education to their students. The structure of each medical school’s clerkship curriculum varies in timing, length and availability of certain core and elective rotations. Gaining a better understanding of the factors that affect student match rates in certain specialties can influence changes in clinical curricula to maximize future match success.

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  A Prospective Sonographic Evaluation of Peripheral Intravenous Catheter Associated Thrombophlebitis

  Nicholas Mielke, Steven Johnson, Patrick Karabon, and Amit Bahl

  Publication Date: 5-2023

  Thrombophlebitis associated with peripheral intravenous catheters (PIVCs) is a poorly described complication in the literature. Given limited accuracy of current assessment tools and poor documentation in the medical record, the true incidence and relevance of this complication is misrepresented. We aimed to identify risk factors in the development of thrombophlebitis using an objective methodology coupling serial diagnostic ultrasound and clinical assessment.

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  Family/Decision maker Perception of Patient Care and Withdrawal of Life Sustaining Treatment

  Joshua Paul, Revelle Gappy, Tracy Wunderlich-Barillas, and Robert A. Swor

  Publication Date: 5-2023

  Withdrawal of life sustaining treatment (WLST) is the process by which a patient has life supporting measures removed when a decision is reached that further care if futile. This process is a complex interplay of medical science, the healthcare teams’ past experiences, and communication with the patient’s family/decision maker Family members are commonly called upon to make critical decisions regarding the provision or withdrawal of patient care. Our objective was to describe the perceptions and experiences of the family members of patients who were admitted to an intensive care unit after resuscitation from an Out of Hospital Cardiac Arrest (OHCA).

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  Stress Induced Electrical Storm with Recurrent ICD Defibrillation

  Joshua M. Smith and Frank Schell

  Publication Date: 5-4-2023

  Electrical storm is a life-threatening condition where a patient may experience frequent episodes or persistent ventricular arrythmias. With improved medical treatment of advanced heart failure patients, patients with electrical storm are presenting more commonly to emergency centers. Patients with implantable cardiac defibrillators experiencing multiple appropriate defibrillations need emergent evaluation and a systematic approach by Emergency Physicians.

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  Evaluation of online patient information regarding emergency center utilization

  Rachel Truland and Steven Joseph

  Publication Date: 5-2023

  The decision a patient makes when seeking emergency medical care comes with risks and ambiguity if the right decision is not made. The internet is increasingly accessible to patients, and they often consult an internet search prior to seeking healthcare. The aim of this study is to assess the readability and reliability of online information regarding a patient’s decision to seek emergency care.

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  Differences within a health system: imaging use for suspected pediatric appendicitis

  Nafisa Bhuiyan, Ryan Nierstedt, Michelle Jankowski, Shanna Jones, and Aveh Bastani

  Publication Date: 5-2-2022

  INTRODUCTION
  Ultrasound (US) is the first line imaging used for suspected pediatric appendicitis. However, following equivocal US findings and its lower negative predictive value for ruling out appendicitis, Computed Tomography (CT) imaging is often performed in children. This study investigates the differences in imaging utilization between a community hospital (Beaumont Troy) and a children’s ED hospital (Beaumont Royal Oak), making it the first study to evaluate suspected pediatric appendicitis in Beaumont Health System. It also aims to further characterize differences in patient outcomes such as surgery, length of hospital stay, complications of appendicitis, and highlight the need to reduce unnecessary CT use due to its radiation exposure.

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  A Case Report of a Rare COVID-19 Complication: a Subdural Empyema in a Pediatric Female

  Christine Carline, Scott Klein, Christopher Cooley, and Daniel Zoller

  Publication Date: 5-2022

  • There have been few reported cases of intracranial complications in patients with COVID-19 and even fewer cases in children.

  • A subdural empyema (SDE) is an intracranial abscess between the dura and arachnoid mater.

  • A SDE usually occurs due to sinusitis, most commonly the frontal sinus, or acute otitis media

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  Evaluation of Implementing ‘Team Strategies and Tools to Enhance Performance and Patient Safety’ in a Community Emergency Department

  Bryson Caskey, Shanna Jones, Sarah Berry, Heather Harris, David Donaldson, and Aveh Bastani

  Publication Date: 5-2-2022

  This study sought to provide an initial evaluation of implementing the program ‘Team Strategies and Tools to Enhance Performance and Patient Safety’ (TeamSTEPPS) in the William Beaumont Troy Emergency Department (ED). TeamSTEPPS integrates teamwork into medical practice by developing tools and strategies within leadership, situation monitoring, mutual support, and communication to increase team performance in order to improve quality, safety, and efficiency of healthcare1,2 (figure 1). It was implemented in the Troy Beaumont ED in 2017. This study was designed to determine if the program is achieving desired outcomes, identify areas for improvement, and add to the limited fund of data on the effectiveness of TeamSTEPPS in community ED’s3-5.