Publications by authors named "Michael M Neeki"

37 Publications

A Rare Cause of Chest Pain Identified on Point-of-care Echocardiography: A Case Report.

Clin Pract Cases Emerg Med 2022 May;6(2):1-4

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Introduction: Cardiac masses are a rare cause of chest pain. They can often be missed on a chest radiograph performed to evaluate non-specific chest pain and are not readily evaluated with traditional laboratory testing. However, these masses can be visualized with point-of-care ultrasound.

Case Report: We present a case of a 19-year-old female presenting with intermittent chest pain, palpitations, and weakness present for two months. The patient had previously been evaluated at our emergency department one week earlier and was diagnosed with anxiety before being discharged. Besides a tachycardic and labile heart rate, physical examination and laboratory testing were unremarkable. Point-of-care cardiac echocardiography subsequently demonstrated findings concerning for a cardiac mass.

Conclusion: Cardiac masses are a rare cause of chest pain and palpitations that are easily missed. The advent of point-of-care ultrasonography has afforded us the ability to rapidly assess for structural and functional cardiac abnormalities at bedside, and incorporation of this tool into the evaluation of patients with chest pain offers the ability to detect these rare pathologies.
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http://dx.doi.org/10.5811/cpcem.2021.9.53553DOI Listing
May 2022

Comparison of emergency airway management techniques in the performance of emergent Cricothyrotomy.

Int J Emerg Med 2022 May 30;15(1):24. Epub 2022 May 30.

Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave., Colton, CA, 92324, USA.

Introduction: Emergent cricothyrotomy (EC) is a rare and lifesaving procedure to secure a difficult airway when other methods have failed. Many techniques have been discussed in the literature. This study aimed to identify major techniques used to perform EC in a regional trauma center and evaluate outcomes associated with the techniques.

Methods: Patients who underwent EC at Arrowhead Regional Medical Center between 1-1-2009 and 1-1-2019 were reviewed for eligibility for this study. Patients' data were extracted from the trauma database. Chi-square tests were conducted to assess the difference on variables between the techniques.

Results: A total of 51 (0.17%) of these patients required EC and were included in the database. The two most prevalent techniques were the scalpel-bougie-tube (SBT) and the surgical cricothyrotomy technique (SCT). More than half (n = 27, 52.9%) of the cohort received the SBT. There was no statistically significant difference between the two techniques with regards to demographic variables, including age (p = 0.7528), injury severity score (ISS, p = 0.896), gender (p = 0.3709), and race (p = 0.8935). However, the SCT group had a statistically higher Glasgow Coma Scale (GCS) than the SBT group (p = 0.0036). There was no statistically significant difference in mortality or complications between these two groups (p = 0.2172 for mortality).

Discussion: Two techniques of EC were identified as preferred techniques. Both procedures were successful in securing an emergency airway, noting a difference in the time to completion of the two techniques. Given the rarity of the procedure, practitioners may choose the method based on their training and the availability of appropriate instruments.
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http://dx.doi.org/10.1186/s12245-022-00427-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9150303PMC
May 2022

The Role of the Urinary Bladder in the Diagnosis of Abdominal Compartment Syndrome: A Prospective Study in Trauma Patients.

Cureus 2022 Apr 18;14(4):e24238. Epub 2022 Apr 18.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Purpose The aim of this study was to evaluate the accuracy of bladder pressures in the diagnosis and management of abdominal compartment syndrome (ACS). Methods After Institutional Review Board (IRB) approval, nine operative abdominal trauma patients were prospectively studied over an 18-month period. Bladder pressures were compared to pressures obtained from intra-operatively placed electronic transducer located in the pelvis. Statistical analysis was performed using methods described by Bland and Altman. Results A Bland-Altman plot was used to assess the differences between bladder and transducer pressures. There was little agreement between the two methods at low (10-15 mmHg) and high (30-70 mmHg) pressures. At higher pressures, there was a notable difference between these two types of pressure. No patients required repeated operation. One patient died from severe traumatic brain injury. Conclusion Measurements obtained from the urinary bladder did not agree well with those obtained from within the peritoneal cavity. Furthermore, abdominal pressures greater than 20 mmHg did not show signs of ACS in this selected population, raising doubts about the utility of using abdominal pressures alone in the management of ACS.
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http://dx.doi.org/10.7759/cureus.24238DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9116434PMC
April 2022

Pediatric Intussusception Following COVID-19 Infection: A Rare Presentation.

Cureus 2022 Mar 25;14(3):e23488. Epub 2022 Mar 25.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Pediatric intussusception has been reported to be associated with coronavirus disease 2019 (COVID-19) infection in the literature since the start of the pandemic in the past two years. Although this occurrence is exceptionally rare, rapid diagnosis based on recognition of gastrointestinal manifestations, clinical examination, and ultrasound confirmation can expedite appropriate care and prevent delayed complications. Intussusception is the most common cause of intestinal obstruction and acute abdomen in pediatric patients. Without prompt identification, the disease process can lead to necrosis, bowel perforation, shock, and, subsequently, multiorgan failure. Intussusception has previously been associated with viral upper respiratory infections, which can cause mesenteric lymphadenopathy as a lead point to allow the bowel to telescope upon itself. The mechanism of how COVID-19 can contribute to intussusception without respiratory symptoms remains unknown. Here, we present a case of pediatric intussusception associated with COVID-19.
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http://dx.doi.org/10.7759/cureus.23488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9035313PMC
March 2022

Variation in Trauma Team Response Fees in United States Trauma Centers: An Additional Undisclosed Variable Cost in Trauma Care.

Cureus 2022 Jan 31;14(1):e21776. Epub 2022 Jan 31.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Background: The rising costs associated with trauma care in the United States is an important topic in today's healthcare environment. Factors such as innovations in technology, increasing governmental and organizational regulations, and the specialization of care have led to increasing costs to the patient. A component of trauma cost is the one-time trauma team response fee (TTRF). The determination process of the TTRF's dollar amount is elusive as no apparent standardized process exists and the literature is scant regarding this aspect of trauma care.

Methods: A nationwide cross-sectional convenience sample was conducted using SurveyMonkey. Surveys were sent to 525 trauma centers in the continental United States, including Alaska and Hawaii, between October 8, 2019 and March 11, 2020. Additionally, hospital medical directors and trauma medical directors were queried on their knowledge of their facility's TTRF amount.

Results: Only 46 out of 525 trauma centers, or 8.8% of those surveyed shared their scheduled fees. Comparisons of TTRFs among different trauma centers, activation levels, and geographical locations were not statistically significant.

Conclusions: Understanding the true costs of trauma care and fees for patients in the United States remains elusive due to inadequate data and low response rates. Trauma centers struggle to maintain financial viability as regulatory agencies and the public push for transparency of TTRFs. Collaboration between trauma centers and regulatory agencies is needed to ensure a balance between providing quality trauma care with justified associated charges and financial sustainability.
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http://dx.doi.org/10.7759/cureus.21776DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8890606PMC
January 2022

Novel Bedside Utilization of Foley Catheter in the Emergent Removal of Colorectal Foreign Body: A Case Report and Literature Review.

Cureus 2021 Dec 6;13(12):e20217. Epub 2021 Dec 6.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Rectal foreign bodies (RFBs) present unique challenges to the emergency physician. Failure to emergently remove the RFB may lead to additional intraoperative procedures with increased likelihood of complications. We present a case of retained RFB in the emergency department, in which the usual standard approaches to transanal removal had failed. A last-ditch effort by utilizing a Foley catheter inside the object rather than around it led to the successful removal of the RFB. An intense review of the literature highlights the importance of using various novel applications of a Foley catheter to consider cases of RFBs.
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http://dx.doi.org/10.7759/cureus.20217DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8729319PMC
December 2021

Acute Inhalant-Induced Atrial Fibrillation With Severe Hypocalcemia: A Case Report and Review of the Pathophysiology.

Cureus 2021 Nov 25;13(11):e19897. Epub 2021 Nov 25.

Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

The recreational use of inhalants is associated with various detrimental health effects ranging from inebriation to cardiac arrest. It also presents a challenging clinical problem as the diagnosis is made by the presentation and patient's history, which is often difficult to obtain in an intoxicated or obtunded individual. The incidence of inhalant use is relatively high. National surveys have reported that nearly 21.7 million Americans aged 12 and older have used inhaled substances at least once in their lives. There is no reversal agent or antidote for inhalants and supportive care is generally recommended. We present a case of a young patient presenting with acute inhalant toxicity accompanied by atrial fibrillation with a rapid ventricular response and severe hypocalcemia.
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http://dx.doi.org/10.7759/cureus.19897DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8710132PMC
November 2021

Emergent Management of Traumatic Posterior Sternoclavicular Joint Dislocation: A Case Report and Literature Review.

Cureus 2021 Oct 23;13(10):e18996. Epub 2021 Oct 23.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Sternoclavicular joint (SCJ) dislocation is a rare but serious orthopedic injury. Posterior dislocations are more concerning due to the SCJ's proximity to visceral structures such as the trachea, esophagus, subclavian vessels, and brachial plexus. Due to the potential long-term sequelae of missed diagnosis, clinical suspicion should be high when a patient presents with a compression-type injury to the shoulder girdle and pain or deformity to the SCJ.  Here we present a case of a 15-year-old soccer player who presented to the emergency department (ED) after a fall onto his right shoulder with additional compound injuries. A posterior SCJ dislocation diagnosis was suspected and confirmed after a computed tomography scan. A successful closed reduction was done in the ED after consultation with cardiothoracic and orthopedic surgery.  This case adds to the body of literature describing diagnosis and management of posterior SCJ dislocations.
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http://dx.doi.org/10.7759/cureus.18996DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608401PMC
October 2021

Early diagnosis and critical management of wound botulism in the emergency department: a single center experience and literature review.

Int J Emerg Med 2021 Sep 22;14(1):56. Epub 2021 Sep 22.

Department of Emergency Medicine, Arrowhead Regional Medical Center, 400 N. Pepper Ave, Suite # 107, Colton, CA, 92324, USA.

Background: Clostridium botulinum remains a major threat to a select population of subcutaneous and intramuscular drug users. We conducted a retrospective study of patients who were diagnosed with wound botulism and their clinical presentations to the Emergency Department (ED).

Results: A total of 21 patients met the inclusion criteria and all had a confirmed history of heroin use disorder. Initial presentation to the ED included generalized weakness (n = 20, 95%), difficulty swallowing (n = 15, 71%), and speech/voice problems (n = 14, 79%). Sixteen patients (76%) also presented with visible skin wounds and fifteen (71%) required mechanical ventilation (MV). Patients who presented with dysphagia as well as dysarthria and/or dysphonia were more likely to require a percutaneous endoscopic gastrostomy (PEG) tube. Patients who required MV and PEG tubes were noted to have a longer hospital length of stay (LOS) due to the severity of the disease progression.

Conclusions: Emergency physicians should remain vigilant about early recognition of wound botulism, especially in patients who inject drugs.
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http://dx.doi.org/10.1186/s12245-021-00375-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8456643PMC
September 2021

Emergent needle thoracostomy in prehospital trauma patients: a review of procedural execution through computed tomography scans.

Trauma Surg Acute Care Open 2021 27;6(1):e000752. Epub 2021 Aug 27.

Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.

Background: Traumatic tension pneumothoraces (TPT) are among the most serious causes of death in traumatic injuries, requiring immediate treatment with a needle thoracostomy (NT). Improperly placed NT insertion into the pleural cavity may fail to treat a life-threatening TPT. This study aimed to assess the accuracy of prehospital NT placements by paramedics in adult trauma patients.

Methods: A retrospective chart review was performed on 84 consecutive trauma patients who had received NT by prehospital personnel. The primary outcome was the accuracy of NT placement by prehospital personnel. Comparisons of various variables were conducted between those who survived and those who died, and proper versus improper needle insertion separately.

Results: Proper NT placement into the pleural cavity was noted in 27.4% of adult trauma patients. In addition, more than 19% of the procedures performed by the prehospital providers appeared to have not been medically indicated.

Discussion: Long-term strategies may be needed to improve the capabilities and performance of prehospital providers' capabilities in this delicate life-saving procedure.

Level Of Evidence: IV.
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http://dx.doi.org/10.1136/tsaco-2021-000752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8404440PMC
August 2021

Miller-Fisher Syndrome Presenting as Facial Diplegia With COVID-19 Co-Infection.

Cureus 2021 Aug 10;13(8):e17060. Epub 2021 Aug 10.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Coronavirus disease 2019 (COVID-19) has reportedly been associated with various neurological manifestations, including unilateral facial palsy and, very rarely, facial diplegia. We present a unique case of Miller-Fisher Syndrome (MFS), a variant of Guillain-Barré Syndrome (GBS) that was noted in conjunction with a COVID-19 infection. In this case, a patient presented with bilateral facial palsy, dysarthria, right-sided hemiparesis, ataxia, and the confirmation of SARS-CoV-2 infection. His computed tomography (CT) scan of the brain and serology test results did not support alternate etiologies for facial palsy. His cerebrospinal fluid (CSF) studies demonstrated albuminocytologic dissociation, which was consistent with the diagnosis of MFS and further supported by his ataxia and ophthalmoplegia. A five-day course of intravenous immunoglobulin (IVIG) therapy combined with physical, occupational, and speech therapy improved his recovery.
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http://dx.doi.org/10.7759/cureus.17060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8428322PMC
August 2021

Emergent Inpatient Administration of Casirivimab and Imdevimab Antibody Cocktail for the Treatment of COVID-19 Pneumonia.

Cureus 2021 May 27;13(5):e15280. Epub 2021 May 27.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Infection by severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) is known to have the highest mortality rate among the elderly and those with pre-existing medical conditions. Viral load has been directly correlated with increased risk of mortality in hospitalized patients. Once infected, symptoms first arise approximately six to seven days later followed by immunoglobulin M (IgM) antibodies appearing 8-12 days after onset of clinical symptoms. Recent studies have noted that the monoclonal antibody combination of casirivimab and imdevimab (REGN-COV2) effectively reduces viral load in infected seronegative non-hospitalized patients. However, research supporting the use of REGN-COV2 in an inpatient setting is limited. We present the case of a 45-year-old male with confirmed SARS-CoV-2 infection with moderate dyspnea and progressive worsening of his symptoms over a week period. The patient showed drastic improvement of his symptoms after a single low-dose regimen of REGN-COV2 infusion while admitted to the hospital and was subsequently discharged without further medical complications.
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http://dx.doi.org/10.7759/cureus.15280DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8235874PMC
May 2021

The Psychological Impact of COVID-19 on Hospital Staff.

West J Emerg Med 2021 Feb 8;22(2):346-352. Epub 2021 Feb 8.

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Introduction: The coronavirus 2019 (COVID-19) pandemic has created a mental health crisis among hospital staff who have been mentally and physically exhausted by uncertainty and unexpected stressors. However, the mental health challenges and complexities faced by hospital staff in the United States has not been fully elucidated. To address this gap, we conducted this study to examine the prevalence and correlates of depression and anxiety among hospital staff in light of the COVID-19 pandemic.

Methods: The design is a single-center, cross-sectional, online survey evaluating depression and anxiety among all hospital employees (n = 3,500) at a safety-net hospital with a moderate cumulative COVID-19 hospitalization rate between April 30-May 22, 2020. We assessed depression with the Patient Health Questionnaire-9. Anxiety was measured with the Generalized Anxiety Disorder-7 scale. Logistic regression analyses were calculated to identify associations with depression and anxiety.

Results: Of 3,500 hospital employees, 1,246 (36%) responded to the survey. We included 1,232 individuals in the final analysis. Overall, psychological distress was common among the respondents: 21% and 33% of staff reported significant depression and anxiety, respectively, while 46% experienced overwhelming stress due to COVID-19. Notably, staff members overwhelmed by the stress of COVID-19 were seven and nine times more likely to suffer from depression and anxiety, respectively. In addition to stress, individuals with six to nine years of work experience were two times more likely to report moderate or severe depression compared to those with 10 or more years of work experience. Moreover, ancillary staff with direct patient contact (odds ratio [OR] 8.9, confidence interval (CI), 1.46, 173.03) as well as administrative and ancillary staff with indirect patient contact (OR 5.9, CI, 1.06, 111.01) were more likely to be depressed than physicians and advanced providers.

Conclusion: We found that a considerable proportion of staff were suffering from psychological distress. COVID-19-associated depression and anxiety was widespread among hospital staff even in settings with comparatively lower COVID-19 hospitalization rates. Ancillary staff, administrative staff, staff with less job experience, and staff overwhelmed by the stress of COVID-19 are particularly susceptible to negative mental health outcomes. These findings will help inform hospital policymakers on best practices to develop interventions to reduce the mental health burden associated with COVID-19 in vulnerable hospital staff.
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http://dx.doi.org/10.5811/westjem.2020.11.49015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7972387PMC
February 2021

Impact of Obesity on Mortality in Adult Trauma Patients.

Cureus 2021 Feb 15;13(2):e13352. Epub 2021 Feb 15.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Introduction Trauma is a major cause of morbidity and mortality amongst all populations in the United States. With the widespread increase of obesity in the United States, studies have been conducted to compare different body mass index (BMI) groups and their clinical outcomes for traumatic injuries. The goal of this study was to retrospectively compare mortality between adult trauma patients with a high BMI to those with a lower BMI as well as investigate whether the mechanism of trauma had an effect on the outcome. Methods This study was a retrospective review of all adult trauma patients presented to the emergency department at Arrowhead Regional Medical Center (ARMC) between January 2014 and October 2019. The outcome was all-cause mortality. Patients were grouped according to BMI and mechanisms of injury, including blunt trauma, low velocity penetrating trauma, and high velocity penetrating trauma. Patients were also stratified by injury severity scores (ISS). Results Among the 9642 patients assessed in this study, majority (88%) of patients sustained blunt trauma. The number of patients among the three different BMI groups was appropriately equal with 34.4% of normal BMI, 34.6% overweight, and 31.1% obese. The overall mortality of all patients studied was 2.6% (n=248). There was no statistically significant difference in mortality among the three different BMI groups for blunt trauma, penetrating trauma, and subgroup analyses stratified by ISS score (ISS<16 or ISS ≥ 16). Conclusion Our study found no statistically significant differences in mortality among the three BMI groups in regard to mortality, even when stratified by ISS, or mechanism of injury, and traumatic velocities.
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http://dx.doi.org/10.7759/cureus.13352DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968702PMC
February 2021

The Impact of Quality Improvement Measures in the Management of Asthma Patients in Juvenile Detention Facilities.

Cureus 2021 Feb 15;13(2):e13351. Epub 2021 Feb 15.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Asthma is a serious chronic lung disease with a significant economic burden. The population of the San Bernardino County Juvenile Detention and Assessment Centers have higher odds of asthma as compared to the general population. Research has shown that a significant number of patients with a prior history of asthma were misdiagnosed. A protocol using objective testing, along with the detailed patient's history, was successfully implemented to verify the diagnosis and guide more effective medical care. After the implementation of those steps, the prevalence of asthma was found to be lower with the new protocol, from 18.1% in the pre-protocol period to 11.2% in the post-protocol period. This decrease resulted in an associated reduction in both direct and indirect healthcare costs and more efficient medical care.
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http://dx.doi.org/10.7759/cureus.13351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968705PMC
February 2021

Patients' Perception of Telemedicine in a Large Urban Inner-City Emergency Department: A Cross-Sectional Survey.

Cureus 2020 Oct 22;12(10):e11091. Epub 2020 Oct 22.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Introduction Telemedicine has the potential to ease emergency department (ED) overcrowding, improve ED throughput, and decrease the cost of medical care. Much of the current knowledge of telemedicine systems focuses on bringing more specialty care to the ED or improving access in rural areas. Limited research exists on patients' perception of telemedicine in an urban ED. Methods A survey exploring perceptions of telemedicine encounters was distributed to both providers and patients following mirrored encounters between October 2015 and August 2016. Chi-square analysis was conducted to identify associations between factors and openness to telemedicine from the patients' perspective. Results A total of 174 patients were included in the analysis. Factors associated with patient willingness to try telemedicine included: having access to a tablet with internet (p=0.0023), having access to a tablet with camera (p=0.0025), having downloaded apps in the past (p=0.0028), having used an app in the past (p<0.0001), and had frequent video chat in the past (p=0.0142). Conclusion With widespread access to smartphones with internet connectivity and pressing demands for healthcare services, telemedicine may provide a potential solution to low acuity medical care needs.
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http://dx.doi.org/10.7759/cureus.11091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7681748PMC
October 2020

Management of Placental Abruption Following Blunt Abdominal Trauma.

Cureus 2020 Sep 9;12(9):e10337. Epub 2020 Sep 9.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Blunt abdominal trauma during pregnancy poses a significant risk to both the mother and fetus. Here, we review a case of a 21-year-old female at 17 weeks' gestation involved in a motor vehicle accident, who subsequently suffered a placental abruption and fetal demise secondary to the trauma. We present a review of traumatic placental abruptions, including epidemiology, laboratory findings, imaging, and management strategies. Because of associated maternal and fetal morbidity and mortality, it is imperative that health care professionals are well versed in the diagnosis, treatment, and acute care for this rare, yet high-risk scenario.
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http://dx.doi.org/10.7759/cureus.10337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7482995PMC
September 2020

Impact of Healthcare Access Disparities on Initial Diagnosis of Breast Cancer in the Emergency Department.

Cureus 2020 Aug 25;12(8):e10027. Epub 2020 Aug 25.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Breast cancer continues to be the second leading cause of cancer deaths in women in the United States. This is more noticeable in communities with pronounced healthcare disparities. The aim of this study was to investigate the different demographics that might play a role in the detection of breast cancer in a county hospital emergency department (ED). A retrospective study was conducted of female patients diagnosed with breast cancer over a five-year period (1/1/2015 to 12/31/2018). Patients with breast cancer as the primary or secondary diagnosis were identified. This study shows that 66 (73.3%) women diagnosed in the ED were Hispanic or African American. There was a significant delay (a median of 461 days) in the time between the diagnosis of suspected breast cancer in the ED to their follow-up visit with definitive diagnosis in a primary care clinic. These findings suggest that women with a suspected breast cancer diagnosis who are seen in a safety net hospital and have Medicaid funding may have significant delays before final diagnosis is made. Patient demographics could have an impact on the patients' access to screening and regular healthcare visits, hindering an early breast cancer diagnosis by a primary care provider.
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http://dx.doi.org/10.7759/cureus.10027DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451079PMC
August 2020

San Bernardino County Youth Opioid Response: Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder.

Cureus 2020 Aug 16;12(8):e9781. Epub 2020 Aug 16.

Emergency Medicine, Arrowhead Regional Medical Center, Colton, USA.

Opioid use disorder (OUD) and related overdose deaths have become a crisis of epidemic proportions in the United States. In 2018, over 10 million people age 12 years or older misused opioids.Substance use is also correlated with increased physical and mental health disorders, and developmental challenges among youths. Medication-assisted treatment (MAT) has been reported to reduce mortality, opioid use, and human immunodeficiency virus and hepatitis C virus transmission while increasing treatment retention in adults. The San Bernardino County Youth Opioid Response (SBCYOR) program was formed to explore best practices for youths at risk of opioid use disorders and/or overdose. SBCYOR is a coalition of professionals in healthcare, behavioral health, public education, law enforcement, emergency medical services (EMS) agencies, and juvenile detention centers throughout San Bernardino County, California. SBCYOR focuses on high-risk and addicted individuals between the ages of 12 to 24 years in San Bernardino County's correctional system. It utilizes a strategy of collaboration, prevention, risk mitigation, medication, psychological treatment, and community outreach. This study aimed to evaluate the implementation and progress of SBCYOR.
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http://dx.doi.org/10.7759/cureus.9781DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7431298PMC
August 2020

Subacute Presentation of Central Cord Syndrome Resulting from Vertebral Osteomyelitis and Discitis: A Case Report.

Clin Pract Cases Emerg Med 2020 05 23;4(2):267-271. Epub 2020 Apr 23.

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Introduction: Central cord syndrome (CCS) is a clinical syndrome of motor weakness and sensory changes. While CCS is most often associated with traumatic events. There have been few documented cases being caused by abscesses resulting from osteomyelitis.

Case Report: A 56-year-old male presented to a regional trauma center complaining of excruciating neck and bilateral upper extremity pain. Computed tomography of the cervical and thoracic regions revealed severe discitis and osteomyelitis of the fourth and fifth cervical (C4-C5) with near-complete destruction of the C4 vertebral body, as well as anterolisthesis of C4 on C5 causing compression of the central canal. Empiric intravenous (IV) antibiotic therapy with ampicillin/sulbactam and vancomycin was initiated, and drainage of the abscess was scheduled. After the patient refused surgery, he was planned to be transferred to a skilled nursing facility to receive a six-week course of IV vancomycin therapy. A month later, patient returned to emergency department with the same complaint due to non-compliance with antibiotic therapy.

Discussion: Delayed diagnosis and treatment of osteomyelitis can result in devastating neurological sequelae, and literature supports immediate surgical debridement. Although past evidence has suggested surgical intervention in similar patients with presence of abscesses, this case may suggest that antibiotic treatment may be an alternative approach to the management of CCS due to an infectious etiology. However, the patient had been non-compliant with medication, so it is unknown whether there was definite resolution of the condition.

Conclusion: In patients presenting with non-traumatic central cord syndrome, it is vital to identify risk factors for infection in a thoroughly obtained patient history, as well as to maintain a low threshold for diagnostic imaging.
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http://dx.doi.org/10.5811/cpcem.2019.8.44201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7220002PMC
May 2020

Safety and Efficacy of Hospital Utilization of Tranexamic Acid in Civilian Adult Trauma Resuscitation.

West J Emerg Med 2020 Feb 21;21(2):217-225. Epub 2020 Feb 21.

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Introduction: Patients with trauma-induced coagulopathies may benefit from the use of antifibrinolytic agents, such as tranexamic acid (TXA). This study evaluated the safety and efficacy of TXA in civilian adults hospitalized with traumatic hemorrhagic shock.

Methods: Patients who sustained blunt or penetrating trauma with signs of hemorrhagic shock from June 2014 through July 2018 were considered for TXA treatment. A retrospective control group was formed from patients seen in the same past five years who were not administered TXA and matched based on age, gender, Injury Severity Score (ISS), and mechanism of injury (blunt vs penetrating trauma). The primary outcome of this study was mortality measured at 24 hours, 48 hours, and 28 days. Secondary outcomes included total blood products transfused, hospital length of stay (LOS), intensive care unit LOS, and adverse events. We conducted three pre-specified subgroup analyses to assess outcomes of patients, including (1) those who were severely injured (ISS >15), (2) those who sustained significant blood loss (≥10 units of total blood products transfused), and (3) those who sustained blunt vs penetrating trauma.

Results: Propensity matching yielded two cohorts: the hospital TXA group (n = 280) and a control group (n = 280). The hospital TXA group had statistically lower mortality at 28 days (1.1% vs 5%, odds ratio [OR] [0.21], (95% confidence interval [CI], 0.06, 0.72)) and used fewer units of blood products (median = 4 units, interquartile range (IQR) = [1, 10] vs median=7 units, IQR = [2, 12.5] for the hospital TXA and control groups, respectively, (95% CI for the difference in median, -3 to -1). There were no statistically significant differences between groups with regard to 24-hour mortality (1.1% vs 1.1%, OR = 1, 95% CI, 0.20, 5.00), 48-hour mortality (1.1% vs 1.4%, OR [0.74], 95% CI, 0.17, 3.37), hospital LOS (median= 9 days, IQR = (5, 16) vs median =12 days IQR = (6, 22.5) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-5 to 0)), and incidence of thromboembolic events (eg, deep vein thrombosis, pulmonary embolism) during hospital stay (0.7% vs 0.7% for the hospital TXA and control group, respectively, OR [1], 95% CI, 0.14 to 7.15). We conducted subgroup analyses on patients with ISS>15, patients transfused with ≥10 units of blood products, and blunt vs penetrating trauma. The results indicated lower 28-day mortality for ISS>15 (1.8% vs 7.1%, OR [0.23], 95% CI, 0.06 to 0.81) and blunt trauma (0.6% vs 6.3%, OR [0.09], 95% CI, 0.01 to 0.75); fewer units of blood products for penetrating trauma (median = 2 units, IQR = (1, 8) vs median = 8 units, IQR = (5, 15) for the hospital TXA and control groups, respectively, 95% CI for the difference in median = (-6 to -3)), and ISS>15 (median = 7 units, IQR = (2, 14) vs median = 8.5 units, IQR = (4, 16) for the hospital TXA and control groups, respectively, 95% CI for the difference in median, -3 to 0).

Conclusion: The current study demonstrates a statistically significant reduction in mortality after TXA administration at 28 days, but not at 24 and 48 hours, in patients with traumatic hemorrhagic shock.
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http://dx.doi.org/10.5811/westjem.2019.10.43055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7081849PMC
February 2020

Novel Application of Balloon Tamponade in Management of Acute Lower Gastrointestinal Hemorrhage.

Clin Pract Cases Emerg Med 2019 Aug 22;3(3):243-247. Epub 2019 Apr 22.

Arrowhead Regional Medical Center, Department of Surgery, Colton, California.

We present a case of acute lower gastrointestinal (GI) bleeding in the emergency department, in which specialists were not emergently available to render their support. A quick intervention using balloon tamponade technique with a Minnesota tube helped stabilize the patient until intensive care, gastroenterology, and surgical specialists could intervene. We also review previous cases from the literature in which a balloon tamponade method was used to control GI hemorrhage. Our novel application of the Minnesota tube is important for emergency physicians to consider for cases of acute lower GI bleeding, particularly in emergent presentations when specialists are not readily available in-hospital.
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http://dx.doi.org/10.5811/cpcem.2019.3.41772DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6682236PMC
August 2019

Burn Injuries Resulting From Methamphetamine and Honey Oil Explosions: A Retrospective Cohort Study.

J Burn Care Res 2019 10;40(6):828-831

Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, CA.

A high incidence of honey oil and methamphetamine production has led to an increase in burn victims presenting to this regional burn center in California. This study aims to compare patient outcomes resulting from burn injuries associated with honey oil and methamphetamine production. This is a retrospective cohort study using the regional burn registry to identify patients with burn injuries related to honey oil production or methamphetamine purification explosions from January 1, 2008 to December 31, 2017. Patient demographics and clinical outcomes data were abstracted from the burn registry and medical records. A total of 91 patients were included in the final analysis and 59.3% (n = 54) were related to honey oil injury. There was no statistically significant difference between honey oil and methamphetamine burn injuries in regard to clinical outcomes, including mortality (1.9% vs 8.1%, P = .1588), third-degree burn (47.2% vs 59.5%, P = .2508), mechanical ventilator usage (50% vs 69.4%, P = .0714), median hospital length of stay (LOS; 10 vs 11 days, P = .5308), ICU LOS (10 vs 11 days, P = .1903), total burn surface area (26.5% vs 28.3%, P = .8313), and hospital charge (median of US$85,561 vs US$139,028, P = .7215). Honey oil burn injuries are associated with similar hospital LOS, similar ICU LOS, similar total burn surface area, and present a costly public health concern. With the recent legalization of marijuana in California, commercial production of honey oil in addition to increasing education about the risks of illicit honey oil production may alleviate associated risks.
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http://dx.doi.org/10.1093/jbcr/irz093DOI Listing
October 2019

Emergent Treatment of Neuroleptic Malignant Syndrome Induced by Antipsychotic Monotherapy Using Dantrolene.

Clin Pract Cases Emerg Med 2019 Feb 4;3(1):16-23. Epub 2019 Jan 4.

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Neuroleptic malignant syndrome (NMS) is a rare but potentially fatal complication resulting from neuroleptic drug therapy. Presentation of NMS can vary, and diagnosis relies primarily upon medical history and symptomatology. Due to the potential delay in diagnosis, emergency physicians should remain vigilant in recognizing the symptoms of NMS and be prepared to initiate immediate treatment following diagnosis. Dantrolene, which has been used for spasticity and malignant hyperthermia, has been reported as a potential treatment for NMS and led to off-label use for NMS. We report two cases of NMS induced by antipsychotic monotherapy for which dantrolene was administered.
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http://dx.doi.org/10.5811/cpcem.2018.11.39667DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366389PMC
February 2019

Tranexamic Acid in Civilian Trauma Care in the California Prehospital Antifibrinolytic Therapy Study.

West J Emerg Med 2018 Nov 10;19(6):977-986. Epub 2018 Sep 10.

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Introduction: Hemorrhage is one of the leading causes of death in trauma victims. Historically, paramedics have not had access to medications that specifically target the reversal of trauma-induced coagulopathies. The California Prehospital Antifibrinolytic Therapy (Cal-PAT) study seeks to evaluate the safety and efficacy of tranexamic acid (TXA) use in the civilian prehospital setting in cases of traumatic hemorrhagic shock.

Methods: The Cal-PAT study is a multi-centered, prospective, observational cohort study with a retrospective comparison. From March 2015 to July 2017, patients ≥ 18 years-old who sustained blunt or penetrating trauma with signs of hemorrhagic shock identified by first responders in the prehospital setting were considered for TXA treatment. A control group was formed of patients seen in the five years prior to data collection cessation (June 2012 to July 2017) at each receiving center who were not administered TXA. Control group patients were selected through propensity score matching based on gender, age, Injury Severity Scores, and mechanism of injury. The primary outcome assessed was mortality recorded at 24 hours, 48 hours, and 28 days. Additional variables assessed included total blood products transfused, the hospital and intensive care unit length of stay, systolic blood pressure taken prior to TXA administration, Glasgow Coma Score observed prior to TXA administration, and the incidence of known adverse events associated with TXA administration.

Results: We included 724 patients in the final analysis, with 362 patients in the TXA group and 362 in the control group. Reduced mortality was noted at 28 days in the TXA group in comparison to the control group (3.6% vs. 8.3% for TXA and control, respectively, odds ratio [OR]=0.41 with 95% confidence interval [CI] [0.21 to 0.8]). This mortality difference was greatest in severely injured patients with ISS >15 (6% vs 14.5% for TXA and control, respectively, OR=0.37 with 95% CI [0.17 to 0.8]). Furthermore, a significant reduction in total blood product transfused was observed after TXA administration in the total cohort as well as in severely injured patients. No significant increase in known adverse events following TXA administration were observed.

Conclusion: Findings from the Cal-PAT study suggest that TXA use in the civilian prehospital setting may safely improve survival outcomes in patients who have sustained traumatic injury with signs of hemorrhagic shock.
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http://dx.doi.org/10.5811/westjem.2018.8.39336DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6225940PMC
November 2018

Chagas Disease-induced Sudden Cardiac Arrest.

Clin Pract Cases Emerg Med 2017 Nov 9;1(4):354-358. Epub 2017 Oct 9.

Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California.

Sudden cardiac death (SCD) is the most common cause of death in patients with Chagas disease (ChD). There are over 300,000 ChD-infected individuals living in the United States, of whom 10-15% have undiagnosed Chagas cardiomyopathy (CCM). CCM patients have a higher risk of SCD compared to non-CCM patients, although early and appropriate treatment of CCM patients can result in a 95% relative risk reduction of SCD. Emergency physicians have a unique opportunity to improve outcomes among these patients by becoming more vigilant in recognizing the signs and symptoms of CCM in patients who present in sudden cardiac arrest. We report the case of a patient presenting to the emergency department with pulseless ventricular tachycardia and an undiagnosed history of CCM.
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http://dx.doi.org/10.5811/cpcem.2017.5.33626DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5965213PMC
November 2017

Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma.

Trauma Surg Acute Care Open 2017 26;2(1):e000109. Epub 2017 Sep 26.

Department of General Surgery, Arrowhead Regional Medical Center, Colton, California, USA.

Background: A thorough history and physical examination in patients with blunt abdominal trauma (BAT) is important to safely exclude clinically significant intra-abdominal injury (IAI). We seek to evaluate a correlation between self-reported abdominal pain, abdominal tenderness on examination and IAI discovered on CT or during exploratory laparotomy.

Methods: This retrospective analysis assessed patients with BAT ≥13 years old who arrived to the emergency department following BAT during the 23-month study period. Upon arrival, the trauma team examined all patients. Only those who underwent an abdominal and pelvic CT scan were included. Patients were excluded if they were unable to communicate or lacked documentation, had obvious evidence of extra-abdominal distracting injuries, had a positive drug or alcohol screen, had a Glasgow Coma Scale ≤13, or had a positive pregnancy screening. The primary objective was to assess the agreement between self-reported abdominal pain and abdominal tenderness on examination and IAI noted on CT or during exploratory laparotomy.

Results: Among the 594 patients included in the final analysis, 73.1% (n=434) had no self-reported abdominal pain, 64.0% (n=384) had no abdominal tenderness on examination, and 22.2% (n=132) had positive CT findings suggestive of IAI. Among the 352 patients who had no self-reported abdominal pain and no abdominal tenderness on examination, a significant number of positive CT scan results (14%, n=50) were still recorded. Furthermore, a small but clinically significant portion of these 50 patients underwent exploratory laparotomy (1.1%, n=4). All four of these patients ultimately underwent a splenectomy and all were completed on hospital day one.

Conclusion: Lack of abdominal pain and tenderness in patients with BAT with non-distracting injuries was associated with a small portion of patients who underwent a splenectomy. Patients with BAT without abdominal pain or tenderness may need a period of observation or CT scan to rule out IAI prior to discharge home.

Level Of Evidence: Level III, therapeutic/care management.
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http://dx.doi.org/10.1136/tsaco-2017-000109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5877917PMC
September 2017

Evaluation of the effect of methamphetamine on traumatic injury complications and outcomes.

Addict Sci Clin Pract 2018 03 29;13(1):11. Epub 2018 Mar 29.

Department of General Surgery, Arrowhead Regional Medical Center, 400 N Pepper Ave, Colton, CA, 92324, USA.

Background: This study investigates the impact of methamphetamine use on trauma patient outcomes.

Methods: This retrospective study analyzed patients between 18 and 55 years old presenting to a single trauma center in San Bernardino County, CA who sustained traumatic injury during the 10-year study period (January 1st, 2005 to December 31st, 2015). Routine serum ethanol levels and urine drug screens (UDS) were completed on all trauma patients. Exclusion criteria included patients with an elevated serum ethanol level (> 0 mg/dL). Those who screened positive on UDS for only methamphetamine and negative for cocaine and cannabis (MA(+)) were compared to those with a triple negative UDS for methamphetamine, cocaine, and cannabis (MA(-)). The primary outcome studied was the impact of a methamphetamine positive drug screen on hospital mortality. Secondary outcomes included length of stay (LOS), heart rate, systolic and diastolic blood pressure (SBP and DBP, respectively), and total amount of blood products utilized during hospitalization. To analyze the effect of methamphetamine, age, gender, injury severity score, and mechanism of injury (blunt vs. penetrating) were matched between MA(-) and MA(+) through a propensity matching algorithm.

Results: After exclusion, 2538 patients were included in the final analysis; 449 were patients in the MA(+) group and 2089 patients in the MA(-) group. A selection of 449 MA(-) patients were matched with the MA(+) group based on age, gender, injury severity score, and mechanism of injury. This led to a final sample size of 898 patients with 449 patients in each group. No statistically significant change was observed in hospital mortality. Notably, a methamphetamine positive drug screen was associated with a longer LOS (median of 4 vs. 3 days in MA(+) and MA(-), respectively, p < 0.0001), an increased heart rate at the scene (103 vs. 94 bpm for MA(+) and MA(-), respectively, p = 0.0016), and an increased heart rate upon arrival to the trauma center (100 vs. 94 bpm for MA(+) and MA(-), respectively, p < 0.0001). Moreover, the MA(+) group had decreased SBP at the scene compared to the MA(-) group (127 vs. 132 bpm for MA(+) and MA(-), respectively, p = 0.0149), but SBP was no longer statistically different when patients arrived at the trauma center (p = 0.3823). There was no significant difference in DBP or in blood products used.

Conclusion: Methamphetamine positive drug screens in trauma patients were not associated with an increase in hospital mortality; however, a methamphetamine positive drug screen was associated with a longer LOS and an increased heart rate.
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http://dx.doi.org/10.1186/s13722-018-0112-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5874991PMC
March 2018

Alarming increase in electronic nicotine delivery systems-related burn injuries: A serious unregulated public health issue.

Am J Emerg Med 2017 Nov 22;35(11):1781-1782. Epub 2017 May 22.

Department of Emergency Medicine, Arrowhead Regional Medical Center, Medical Office Building Suite 7, 400 N Pepper Ave, Colton, CA 92324, USA; California University of Sciences and Medicine, 400 N Pepper Ave, Colton, CA 92324, USA. Electronic address:

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http://dx.doi.org/10.1016/j.ajem.2017.05.029DOI Listing
November 2017
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