J Emerg Med
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Tactical emergency medicine services (TEMS) has emerged as a specialized niche within the field of emergency medicine. With increasing demand for physician participation in civilian tactical teams, there will be efforts by residents to become involved at earlier points in their clinical training. ⋯ Tactical emergency medicine is a specialty that utilizes the full array of the emergency physician's skill set. It is also a field that is ripe for continued expansion, but the resident looking to become involved with a team should be aware of the requirements necessary to do so and the obstacles likely to be encountered along the way.
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Admitted and discharged patients with prolonged emergency department (ED) stays may contribute to crowding by utilizing beds and staff time that would otherwise be used for new patients. ⋯ In our ED, having both admitted and discharged patients staying > 6 h is associated with crowding.
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Combined computed tomography and cerebrospinal fluid (CSF) analysis has been shown to be 100% sensitive for detecting subarachnoid hemorrhage (SAH) when CSF is obtained between 12 h and 2 weeks from time of headache onset and spectrophotometry is used to evaluate CSF for xanthochromia. Because most hospitals do not use spectrophotometry, we sought to evaluate the sensitivity of CSF analysis for xanthochromia by visual inspection. We retrospectively identified all patients seen in the Emergency Department (ED) with an ED discharge diagnosis of SAH from June 1993 to November 2005. ⋯ By predetermined protocol, 35 were excluded for lack of a report of CSF color, 1 was excluded because the time from headache onset to CSF collection was < 12 h, and 26 were excluded for lack of documentation of a definitive imaging study. Of the remaining 19, 9 were found to have xanthochromic CSF and 10 were found to have colorless CSF, resulting in a sensitivity for visual inspection of CSF of 47.3% (95% confidence interval 24.4-71.1%). Visual inspection of CSF supernatant for xanthochromia lacks the sensitivity necessary to reliably exclude the diagnosis of SAH.
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We present the case of a 57-year-old woman who suffered a delayed presentation of a traumatic diaphragmatic rupture (TDR). Because TDR is frequently missed on initial presentation, a delay between trauma and diagnosis can present a unique diagnostic dilemma for the emergency physician. Important historical clues and physical examination findings are the keys to making this diagnosis.
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The GlideScope Video Laryngoscope (Verathon, Bothell, WA) is a video laryngoscopy system that can be used for routine intubation, but is also commonly used as an alternative for difficult or failed airways. Previous reports have identified a very high incidence of grade 1 and grade 2 Cormack-Lehane glottic views, but despite these high-grade views, intubation is sometimes difficult due to the angle of insertion and shape of the endotracheal tube. Several maneuvers have been reported to increase the likelihood of successful endotracheal tube placement in these uncommon cases of failure. ⋯ We believe that this maneuver may be useful in other cases of failed GlideScope intubation, when a high-grade laryngeal view is obtained but tube passage is not possible due to a sharp posterior angulation of the trachea.