The American journal of emergency medicine
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Despite projections of an oversupply of residency-trained emergency medicine physicians by 2030 and amidst intensifying national debate over Nurse Practitioner (NP) qualifications to practice independently and unsupervised, NPs are increasingly staffing Emergency Departments (EDs) as hospitals seek to contain costs while simultaneously expanding services. We sought to characterize NP practice in the ED by examining NP independent billing by level of severity of illness, and relationship to practice authority, State Medicaid expansion status, and rurality. ⋯ As a proportion of the providers independently billing in the ED, NPs are increasingly managing higher acuity patients as evidenced by billing percentage of the highest acuity CPT codes (99284 and 99285). During the same time period, ED MDs decreased their billing in the same categories. Current employment of NPs in the ED may not be fulfilling its original vision to care for the lower acuity patients in order to allow MDs to care for the more acutely and critically ill patients, and to increase the services for underserved populations in rural areas, those over age 65, and those with limited English language proficiency. Future research should investigate ED policies resulting in NPs as opposed to MDs seeing patients with greater severity codes.
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Case Reports
A case of intracranial hemorrhage after a single dose of Yohimbine in a chronic user of clonidine.
Yohimbine, an alpha-2 adrenoreceptor antagonist found in a variety of supplements, has been historically used to treat libido, erectile dysfunction, xerostomia, and as a weight loss enhancement. Yohimbine toxicity causes a sympathomimetic syndrome as demonstrated by the case below of a female who developed an intracranial hemorrhage (ICH) following an ingestion of yohimbine. ⋯ Dietary supplements are not required by the FDA to undergo efficacy or safety testing, necessitating clear post-marketing communication regarding potential adverse events from various supplements. Users should be aware of yohimbine-containing products and the possible side effects of toxicity. It is crucial that physicians and patients be aware of possible drug-supplement interactions of yohimbine and the presentation of sympathomimetic syndromes.
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To investigate the accuracy and total assessment time (TAT) of the "All-in-one" (AIO)-window/level setting for whole-body computed tomography (CT) image compared to multiple tissue-specific window/level settings conventionally used for detection of traumatic injuries. ⋯ In a time-delimited image review, similar diagnostic accuracy was reached faster using the AIO vs the conventional window/level settings. When providing a "wet read" at the CT console, the ability to identify traumatic injury using a single AIO-window/level may help expedite patient management.
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Obstructive shock is often associated with poor right ventricular (RV) output and requires rapid obstruction release. A 54-year-old man was brought to our emergency department, presenting with shock. He had previously undergone esophagectomy with gastric interposition through the retrosternal route, after which he could not eat solid foods. ⋯ Anatomically, the retrosternal route is located directly in front of the RV. Thus, it is thought that the massively dilated gastric tube externally compressed the RV, preventing adequate RV filling and causing the obstructive shock. In such cases, the patient's position should be changed immediately to release the RV compression.
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This case demonstrates a complex patient presenting with diagnosis of pulmonary embolism. He received heparin therapy, then subsequently found to have an intracranial hemorrhage, which rapidly progressed, leading to patient demise. Through this case, the reader should better understand the therapeutic conundrums in critical PE patients and complications of anticoagulation.