The American journal of emergency medicine
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Paraphimosis occurs when the foreskin of the penis is retracted over the glans and cannot be replaced in its normal position. The tight ring of preputial skin constricts the distal penis causing vascular occlusion, much like a tourniquet. ⋯ Irreducible paraphimosis is treated by dorsal slit procedure and subsequent circumcision. We present two cases illustrating the treatment techniques and possible complications of paraphimosis in men.
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Despite widespread use of the Trendelenburg position, its autotransfusion effect remains controversial. Additionally, its adverse effect on cerebral circulation is not generally appreciated. The effects of a 10 degrees head-down tilt on central hemodynamics and flow through the internal jugular vein (IJV) were examined in ten healthy volunteers. ⋯ As a result, calculated IJV blood flow was unchanged throughout the period of tilt. Therefore, the mild trendelenburg position produces a transient autotransfusion effect in normovolemic patients. Our data also suggest that the Trendelenburg produces no adverse effect on cerebral circulation in patients with normal cerebral autoregulation.
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Review Case Reports
Removal of a hardened steel ring from an extremely swollen finger.
For several years various authors have discussed the removal of rings from swollen fingers. Removal normally has involved cutting the ring, but nondestructive methods of removal using string frequently have been recommended as well. A case is reported of a patient who presented with a hardened roller bearing on an extremely swollen index finger, which defied all attempts at removal by previously successful methods. ⋯ The blood pressure cuff, which was used while the elastic band was removed, prevented the refill of the tissue while the finger was examined. Four sessions of compression lasting approximately 10 to 15 minutes each with the elastic band were necessary to eliminate the edema and release the ring. The ring was finally removed utilizing a short piece of string to ease it over a small laceration.
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Comparative Study
Clinical impact of radiograph misinterpretation in a pediatric ED and the effect of physician training level.
Radiograph interpretation in the pediatric emergency department (ED) is commonly performed by pediatric emergency medicine (PEM) attendings or physicians-in-training. This study examines the effect of physician training level on radiograph interpretation and the clinical impact of false-negative radiograph interpretations. Data were collected on 1,471 radiographs of the chest, abdomen, extremity, lateral neck, and cervical spine interpreted by PEM attendings, one PEM fellow, one physician assistant, and emergency medicine, pediatric and family practice residents. ⋯ Twenty (1.4%) radiographs had clinically significant (false-negative) misinterpretations, including 1.7% of physician-in-training and 0.8% of attending interpretations (P = 0.15). No morbidity resulted from the delay in correct interpretation. Radiograph misinterpretation by ED physicians occurs but is unlikely to result in significant morbidity.
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There have been a limited number of studies assessing the impact of attending physician supervision of residents in the emergency department (ED). The objective of this study is to describe the changes in patient care when attending emergency physicians (AEPs) supervise nonemergency medicine residents in a university hospital ED. This was a prospective study including 1,000 patients, 32 second- and third-year nonemergency medicine residents and eight AEPs. ⋯ The most common major changes were ordering laboratory or x-ray tests that showed a clinically significant abnormality, and eliciting important physical exam findings. Potentially limb- or life-threatening errors were averted by the AEP in 17 patients. Supervision of nonemergency medicine residents in the ED resulted in frequent and clinically important changes in patient care.