In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

Over the past 5 to 10 years, electronic dance music (EDM) festivals have grown in popularity in the United States, developing into massive, multiday events drawing crowds of tens of thousands of attendees.¹ The nature of these events—ie, long outdoor performances attended by a primarily youthful audience in sometimes austere environments¹—presents several unique challenges to local EDs, including the ability to effectively manage mass cases of polysubstance abuse, exposure to extremes of weather, and dehydration.

Since 2011, Orlando, Florida has been host to a popular annual EDM festival—one that has nearly doubled in size since its inception. In 2015, both the volume of 911 calls related to this event and number of attendees seeking care at the city’s first aid stations located at the festival overwhelmed our local emergency medical services (EMS) system and the nearest ED. The acuity of these patient interactions ranged from cases that could have been treated and released on-site to several critical care cases, including two fatalities.

In advance of the November 2016 festival, event staff, EMS, and hospital planners worked together to improve attendee safety and to avoid unnecessary admissions to the area receiving hospital, Orlando Regional Medical Center (ORMC). This cooperative endeavor resulted in the creation of a unique, fully staffed field hospital that was seamlessly integrated with EMS personnel and in constant communication with ORMC. The implementation of a field hospital on-site at the event decreased mortality and provided a reasonable and manageable way to safely treat and release patients who would have otherwise required transportation to the receiving center.

The 2016 Festival: Background

Location and Setup

In November 2016, the EDM festival was held at its usual location in the fields and areas surrounding a large stadium near downtown Orlando. Although the fall season in Florida can be unpredictable, the weather during the day is typically hot and humid, with temperatures averaging 80°F to 90°F. The festival took place over a 2-day period between noon and midnight each day. Unlike similar multiday festivals that run over a consecutive period of 24 to 48 hours, there were no overnight activities at this event.

Whereas other similar festivals often take place in more remote, austere environments such as deserts or forests, the Orlando EDM festival was held within the city but did not have on-site overnight accommodations. While this location eased some of our concerns, overnight closure of the field hospital altered our approach to patient management. When the facility closed, many patients who may have been observed overnight and subsequently released, required transport to the hospital for further observation and monitoring.

Attendees and Layout

The festival drew approximately 30,000 to 40,000 attendees each day, with multiple stages and fairground-type attractions spread over approximately 45 acres. The area was transformed by massive stages and production equipment, including complex lighting, pyrotechnics, expansive sound systems, and carnival rides. There were also dozens of on-site kiosks and pop-up structures selling food, merchandise, and alcoholic and nonalcoholic beverages.

Substance Abuse and Elemental Exposures

Although festival planners expressly prohibit illicit drug use at EDM events, substance use has been and continues to be prevalent at these types of festivals—particularly the use of alcohol, amphetamines such as 3,4-methylenedioxymethamphetamine (MDMA, also known as “ecstasy” and “Molly”), lysergic acid diethylamide (LSD), cocaine, and marijuana (Table).²

Lessons From the 2015 Festival

The 2015 EDM festival in Orlando had taken place without significant coordination between local EMS medical directors and ORMC, and was treated in a similar manner to other mass gatherings held in the area—ie, with extra EMS personnel on-site as well as several first aid stations. However, over the course of the 2015 event, the medics on-site were overwhelmed by the number of attendees seeking care, and felt obligated to transport a large number of these patients to ORMC (many of whom did not require hospital care), or to treat and release patients in a manner that was not in accordance with existing protocol.

As a result, the online medical control doctors at ORMC were overwhelmed by the sudden influx of calls for treat-and-release orders or intravenous (IV) hydration—not a common occurrence at this institution. This resulted in dozens of patient transports to the ED. Many of these patients did not require emergent care but simply needed shelter from the elements, rest because of sleep deprivation, or a place to recover from the effects of alcohol or drugs. Some patients, however, presented to ORMC in critical condition, two of whom died from suspected drug-related causes and/or severe hyperthermia.

After-Action Review

An after-action review of the 2015 EDM festival conducted by the Orlando Fire Department (OFD) concluded that significantly more medical support was needed for this and similar large-scale events in the future. Together with OFD, we examined how other regions in the United States handled similar festivals, and it became clear that a multidisciplinary approach, including a field hospital, EMS, ORMC, and festival planners, would be necessary for the 2016 festival.

Collaborative Planning for the 2016 Festival

Festival planners and promoters worked closely with the City of Orlando and EMS medical directors for months leading up to the 2016 EDM festival. The complexities of stage set-up alone required significant coordination, including the closure of several roads. To set up the field hospital, we first tried to acquire “real estate” on festival grounds. When this proved not to be feasible, we worked with city officials to create a field hospital on a street just outside the festival’s side gate.

Resources

Throughout the process, we worked closely with the festival’s planners, as well as a medical team designated by its parent company, to coordinate shared resources. The medical team provided a significant amount of medical supplies to our field hospital. In addition, the festival obtained and paid for an insurance rider extending coverage to our medical staff while working at the event.

Ground Control Staff

The planners and promoters of the EDM festival host several other festivals each year, including some that are larger and longer than the annual event held in Orlando. A small team from Orlando visited their set-up at a larger festival in Nevada several months prior to the 2016 EDM festival, gathering information on how we could best execute our plans. In addition to equipment and support, the festival also designated ground controllers (GCs) stationed throughout the festival area. These were individuals without medical training who could be easily identified and could guide those in need of medical attention to the nearest first aid station or to the field hospital, or contact us when someone was in need of immediate or emergent care.

Access and Communications

Several areas identified for improvement from 2015 included better ambulance access, radio communication (especially with physicians), and appropriate staffing. To provide additional medical staff for the 2016 EDM festival, the Office of the Medical Director (OMD) and the Central Florida Disaster Coalition (CFDC), a regional nonprofit organization that assists with disaster-health response in the area, utilized this event as a drill for a large-scale disaster that would require a self-sufficient field hospital. Part of this initiative included radio transmission equipment that would allow the routing of all 911 and other emergency calls from the festival grounds directly to on-site medical personnel.

In addition to the CFDC resources, we had dedicated medical control on the radio to answer questions from the paramedics staffing the outer first aid stations. This was separate from our normal medical control base-station process, and allowed our traditional EMS operating structure to continue outside the event without any confusion or added burden from within.

Field Hospital and First Aid Stations

Created just beyond the fencing that surrounded the event, the field hospital was a 3,200-square-foot, enclosed, air-conditioned structure powered by generators. In addition to the field hospital, three first aid stations were strategically placed around the festival grounds, and groups of medical personnel were assigned to walk the grounds.

The field hospital was staffed by physicians, nurses, paramedics, respiratory therapists, administrative staff, and pharmacists, and was divided into three separate color-coded sections based on patient acuity—a “green” section with 16 beds for low-acuity patients; a “yellow” section with 10 beds for medium-acuity patients; and a “red” section with four beds for critical care patients. The critical care area, which was set up as a free-standing ED, had ventilators, ultrasound equipment, an ice bath, and advanced life support equipment. Board-certified emergency physicians were present in each area at all times throughout the event, in addition to several emergency medicine residents and medical students. The field hospital also housed a fully stocked pharmacy.

To direct and manage patients, a registration section was set up in front of the field hospital; intake/triage took place in a separate 15-chair, low-acuity area located beyond the front door. Charting was performed on CFDC charts and maintained for records; however, no patients were billed for care.

Separate command vehicles were set up for operations, radio communication, and storage of the staff’s personal belongings. The festival organizers provided meals to all medical personnel.

Access, Communications, and Transportation

A designated road was closed off to all nonemergency traffic leading from the field hospital to an open access point. Our closed communication system meant that 911 calls inside the event would be dispatched to our personnel stationed on-site.

The field hospital served as a single casualty collection point for the entire event, so any patient transported out would first go to the field hospital for evaluation, then move to a waiting transport vehicle, if necessary. This arrangement not only allowed the on-scene staff to evaluate and, when necessary, stabilize patients before transport, but also permitted us to identify and care for those who could be treated on-scene instead of sending them to the hospital. Routing all patients through one location also allowed the EMS staff to appropriately monitor the exact number of patients being treated. The first aid stations were staffed by paramedics and emergency medical technicians, and stocked with advanced life support and first aid equipment.

Motorized golf carts, “gators,” and hand-held carts were used to convey patients from first aid stations and other parts of the festival grounds to the field hospital. On several occasions, physicians accompanied paramedics responding to calls on the festival grounds.

The 2016 Festival: First-Person Report

An hour before the event began, we arrived at the scene, familiarized ourselves with the layout, and met with incident command, EMS, medical directors, and festival staff to discuss plans and divide the teams up. Prior to the event, a medical toxicologist reviewed with participating medical staff several priority resuscitation measures for patients presenting with drug intoxication. These priorities included control of hyperthermia, management of drug-related arrhythmias, seizures, and agitation, all of which permitted smooth transition of care and mutual understanding about which patients ultimately required transfer to the hospital.

Unexpected Needs

The medical needs were not great during the daytime hours. However, by sunset, a constant stream of attendees visited our field hospital, bringing their own prescription medications, including some requiring refrigeration, and requested that we store these on their behalf. We quickly created a process for safe storage and accountability of these medications.

In addition to requesting an unanticipated storage facility, attendees presented with more expected and typical “urgent care needs,” including headaches, rashes, and blisters. By the late afternoon, we began seeing patients who had been vomiting after riding fair attractions and those with heat-related syncope.

As evening descended, our triage area became busy with a wave of agitated, intoxicated patients presenting via EMS, friends, and GCs. When indicated, benzodiazepines (lorazepam and midazolam) were administered to mild-to-moderately agitated patients after verbal de-escalation attempts were unsuccessful. Severely agitated patients required sedative treatment with an antipsychotic (haloperidol or ziprasidone).

In the low-acuity (green) section, arousable patients whose vital signs were stable rested on cots, as did those requiring oral ondansetron for vomiting and who were able to tolerate oral hydration. The moderate-­acuity (yellow) section housed a large number of dehydrated and/or intoxicated patients who required IV fluid therapy. Patients in the critical care (red) area suffered primarily from behavioral issues and altered mental status requiring chemical or physical restraint; many of these patients were transported to the hospital once they could be safely moved. Other critical care patients with medical emergencies were also housed in this area, including an overdose victim for whom endotracheal intubation was needed for airway protection.

As the evening progressed, we saw more severe overdoses and intoxications, including several cases of alcohol- and drug-induced seizures. Any seizure that occurred on the festival grounds was considered a potential cardiac arrest, requiring physician response. Some of our most difficult patient encounters included seizing or postictal patients presenting in an agitated fashion among crowds of intoxicated people who were attempting to help. We also treated a middle-aged festival employee with cardiac disease who presented with chest pain and acute electrocardiogram changes.

One festival attendee with a history of shoulder dislocation presented with a recurrent dislocation. Without needing to sedate the patient, we successfully reduced the dislocated shoulder at the field hospital. Afterward, the patient refused transport to the hospital and insisted on returning to the festival in a sling. Several patients were seen for complaints of eye pain or irritation attributed to vigorous wind and pyrotechnic displays around the large stages—two underwent ophthalmologic evaluation with a small eye kit (topical anesthetic, fluorescein stain, and a Woods lamp) and were diagnosed with corneal abrasions.

Multiple patients with histories of asthma presented with respiratory complaints ranging from mild to severe. Most of these patients were successfully treated with albuterol, though some required supplemental oxygen and corticosteroid therapy. One patient required transport to ORMC for additional care and treatment.

Nonmedical Presentations

The location of the field hospital beyond the perimeter fence of the event created a slight “disconnect” from the crowds and lights—but not from the sound. Several attendees presented to the field hospital, asking for a place to “chill out.” To accommodate these presentations, several chairs were set up under the cover of a pop-up tent for a place to rest and drink a bottle of water. Some individuals remained in this tent for nearly the entire event—refusing care, but feeling more comfortable being in proximity of the field hospital. Although many of these individuals appeared to be intoxicated, the area remained calm throughout the event. This makeshift rest area also served as cover during a brief rain storm in the late afternoon on day 1, as well as for those seeking shelter from the hot afternoon.

Emergency Medical Services

The OFD contributed substantial resources to the 2016 festival, and their support continued throughout the event. Operations were based on the National Incident Management System’s framework, which was developed in coordination with the OMD, OFD, and other stakeholders within ORMC. Logistics and medical groups were created, and the event was divided geographically into “northern,” “southern,” and “eastern” divisions. The unified command structure included a fire department deputy chief and a liaison officer (the OFD off-duty coordinator) who maintained face-to-face communications with festival operators throughout the event. The medical group was coordinated by the OFD EMS chief in collaboration with the OMD. A communications plan was created and used effectively throughout the event to coordinate patient movement, transfers, and transports to the field hospital and ORMC. Briefings were conducted for each operational period and included all personnel involved in the event.

At least one EMS medical director was on-site at all times, in constant communication with the EMS chief on scene, who functioned primarily at the field hospital to guide throughput of patients. The OFD staffed three first aid stations with advanced and basic life support providers, and had personnel roving the festival grounds. In addition to having advanced life support capabilities, the first aid stations dispensed acetaminophen, adhesive bandages, ear plugs, and bottled water, and responded to nearby calls for help and transported patients to the field hospital as needed.

The OFD was also the primary transport agency. Ambulances were dedicated to the event and stationed at the field hospital to transport patients to ORMC. In total, 32 EMS personnel were on scene, including ambulance personnel, staffing at first aid stations, and personnel circulating among the crowd.

The Orlando Police Department (OPD) was also a constant presence at the event, providing security for both festivalgoers and staff at the field hospital. We did not have our own security personnel at the field hospital, and OPD provided a comfort level for the medical staff as the number of agitated, intoxicated patients increased.

Orlando Regional Medical Center

During the 2015 EDM festival, ORMC had been inundated with festivalgoers. Many required only minor care, but some were in need of critical care, including two cardiac arrest patients. Based on this festival experience, hospital administration at ORMC ensured adequate staffing for the 2016 festival, including nursing, medical technicians, radiology technicians, and respiratory therapists. Communication between familiar colleagues, operating under mutually understood protocols, and the ability to communicate with the field hospital, allowed for very smooth transitions of care throughout the 2016 event.

There was a direct correlation between the time of day and number and severity of patients transported to the hospital. Early in the day, patients presented with heat illness and altered mental status, syncope, and confusion; all were easily managed. By late evening, patients with possible arrhythmias, seizures, hyperthermia, chest pain, and altered mental status began to arrive. While the number of patients with the clinical presentation of intoxication and agitation was not surprising, the outcomes were occasionally unexpected—including several elevated troponin levels and occasional arrhythmias.

The hospital received 68 patients directly from the field hospital at the festival. More than 100 presented to the field hospital with altered mental status, of which dozens resolved with observation and close monitoring. Thirty patients had transient arrhythmias ranging from tachycardia and a slightly widened QRS complex. Six had seizures which responded to benzodiazepine treatment. One patient suffered respiratory failure; he was managed by mechanical ventilation, which was performed at the field hospital, and afterward transported to ORMC with a resident physician. Five patients had hyponatremia, which may have been dilutional from excess free-water intake or mediated by syndrome of inappropriate antidiuretic hormone secretion secondary to MDMA use. Hyperthermic patients were managed with active cooling.

Laboratory evaluation revealed elevated troponin levels in six patients, though none of the patients required emergent cardiac intervention. The elevated troponin levels were possibly secondary to demand ischemia from sympathomimetic toxidromes.

Although many patients admitted to using recreational drugs, few specified the type or amount of drug taken, either because they were too altered to communicate, were unfamiliar with what they ingested, or feared legal repercussions. Ethanol, marijuana, and MDMA were the most commonly reported drugs.

Lessons Learned

Over the 2-day 2016 EDM festival, 235 patients were treated at the field hospital, and 68 were transported to ORMC—almost 100 fewer hospital transports than during the 2015 EDM festival, which lacked a field hospital. Although two attendees at the 2016 event required intensive care at ORMC, there were no deaths. Overall, the field hospital and cooperative approach provided a safer method for treating patients and without overwhelming hospital or EMS resources. 
Successful utilization of a field hospital at the 2016 EDM festival required the coordinated efforts of multiple organizations, including the EMS system, ORMC, festival organizers, and disaster response groups. The deployment of this strategy required a great deal of planning, coordination, and efforts months before the actual event, and included a sufficient number of trained emergency and medical personnel, support staff for equipment set-up, operation, and takedown, and insurance coverage.

In reviewing the medical care model provided for the 2016 EDM festival, we concluded that a more effective and efficient staffing model would have deployed more nurses and fewer physicians. Utilizing the event as training for residents and medical students resulted in a large number of providers on-site, but inadequate support staff.

When planning for this event, we did not anticipate the extent of the primary care and urgent care concerns encountered during the event, though we did anticipate that the most critical medical concerns were sympathomimetic and hallucinogenic toxidromes requiring restraint, benzodiazepines, and antipsychotics.

Over the past 5 to 10 years, electronic dance music (EDM) festivals have grown in popularity in the United States, developing into massive, multiday events drawing crowds of tens of thousands of attendees.¹ The nature of these events—ie, long outdoor performances attended by a primarily youthful audience in sometimes austere environments¹—presents several unique challenges to local EDs, including the ability to effectively manage mass cases of polysubstance abuse, exposure to extremes of weather, and dehydration.

Since 2011, Orlando, Florida has been host to a popular annual EDM festival—one that has nearly doubled in size since its inception. In 2015, both the volume of 911 calls related to this event and number of attendees seeking care at the city’s first aid stations located at the festival overwhelmed our local emergency medical services (EMS) system and the nearest ED. The acuity of these patient interactions ranged from cases that could have been treated and released on-site to several critical care cases, including two fatalities.

In advance of the November 2016 festival, event staff, EMS, and hospital planners worked together to improve attendee safety and to avoid unnecessary admissions to the area receiving hospital, Orlando Regional Medical Center (ORMC). This cooperative endeavor resulted in the creation of a unique, fully staffed field hospital that was seamlessly integrated with EMS personnel and in constant communication with ORMC. The implementation of a field hospital on-site at the event decreased mortality and provided a reasonable and manageable way to safely treat and release patients who would have otherwise required transportation to the receiving center.

The 2016 Festival: Background

Location and Setup

In November 2016, the EDM festival was held at its usual location in the fields and areas surrounding a large stadium near downtown Orlando. Although the fall season in Florida can be unpredictable, the weather during the day is typically hot and humid, with temperatures averaging 80°F to 90°F. The festival took place over a 2-day period between noon and midnight each day. Unlike similar multiday festivals that run over a consecutive period of 24 to 48 hours, there were no overnight activities at this event.

Whereas other similar festivals often take place in more remote, austere environments such as deserts or forests, the Orlando EDM festival was held within the city but did not have on-site overnight accommodations. While this location eased some of our concerns, overnight closure of the field hospital altered our approach to patient management. When the facility closed, many patients who may have been observed overnight and subsequently released, required transport to the hospital for further observation and monitoring.

Attendees and Layout

The festival drew approximately 30,000 to 40,000 attendees each day, with multiple stages and fairground-type attractions spread over approximately 45 acres. The area was transformed by massive stages and production equipment, including complex lighting, pyrotechnics, expansive sound systems, and carnival rides. There were also dozens of on-site kiosks and pop-up structures selling food, merchandise, and alcoholic and nonalcoholic beverages.

Substance Abuse and Elemental Exposures

Although festival planners expressly prohibit illicit drug use at EDM events, substance use has been and continues to be prevalent at these types of festivals—particularly the use of alcohol, amphetamines such as 3,4-methylenedioxymethamphetamine (MDMA, also known as “ecstasy” and “Molly”), lysergic acid diethylamide (LSD), cocaine, and marijuana (Table).²

Lessons From the 2015 Festival

The 2015 EDM festival in Orlando had taken place without significant coordination between local EMS medical directors and ORMC, and was treated in a similar manner to other mass gatherings held in the area—ie, with extra EMS personnel on-site as well as several first aid stations. However, over the course of the 2015 event, the medics on-site were overwhelmed by the number of attendees seeking care, and felt obligated to transport a large number of these patients to ORMC (many of whom did not require hospital care), or to treat and release patients in a manner that was not in accordance with existing protocol.

As a result, the online medical control doctors at ORMC were overwhelmed by the sudden influx of calls for treat-and-release orders or intravenous (IV) hydration—not a common occurrence at this institution. This resulted in dozens of patient transports to the ED. Many of these patients did not require emergent care but simply needed shelter from the elements, rest because of sleep deprivation, or a place to recover from the effects of alcohol or drugs. Some patients, however, presented to ORMC in critical condition, two of whom died from suspected drug-related causes and/or severe hyperthermia.

After-Action Review

An after-action review of the 2015 EDM festival conducted by the Orlando Fire Department (OFD) concluded that significantly more medical support was needed for this and similar large-scale events in the future. Together with OFD, we examined how other regions in the United States handled similar festivals, and it became clear that a multidisciplinary approach, including a field hospital, EMS, ORMC, and festival planners, would be necessary for the 2016 festival.

Collaborative Planning for the 2016 Festival

Festival planners and promoters worked closely with the City of Orlando and EMS medical directors for months leading up to the 2016 EDM festival. The complexities of stage set-up alone required significant coordination, including the closure of several roads. To set up the field hospital, we first tried to acquire “real estate” on festival grounds. When this proved not to be feasible, we worked with city officials to create a field hospital on a street just outside the festival’s side gate.

Resources

Throughout the process, we worked closely with the festival’s planners, as well as a medical team designated by its parent company, to coordinate shared resources. The medical team provided a significant amount of medical supplies to our field hospital. In addition, the festival obtained and paid for an insurance rider extending coverage to our medical staff while working at the event.

Ground Control Staff

The planners and promoters of the EDM festival host several other festivals each year, including some that are larger and longer than the annual event held in Orlando. A small team from Orlando visited their set-up at a larger festival in Nevada several months prior to the 2016 EDM festival, gathering information on how we could best execute our plans. In addition to equipment and support, the festival also designated ground controllers (GCs) stationed throughout the festival area. These were individuals without medical training who could be easily identified and could guide those in need of medical attention to the nearest first aid station or to the field hospital, or contact us when someone was in need of immediate or emergent care.

Access and Communications

Several areas identified for improvement from 2015 included better ambulance access, radio communication (especially with physicians), and appropriate staffing. To provide additional medical staff for the 2016 EDM festival, the Office of the Medical Director (OMD) and the Central Florida Disaster Coalition (CFDC), a regional nonprofit organization that assists with disaster-health response in the area, utilized this event as a drill for a large-scale disaster that would require a self-sufficient field hospital. Part of this initiative included radio transmission equipment that would allow the routing of all 911 and other emergency calls from the festival grounds directly to on-site medical personnel.

In addition to the CFDC resources, we had dedicated medical control on the radio to answer questions from the paramedics staffing the outer first aid stations. This was separate from our normal medical control base-station process, and allowed our traditional EMS operating structure to continue outside the event without any confusion or added burden from within.

Field Hospital and First Aid Stations

Created just beyond the fencing that surrounded the event, the field hospital was a 3,200-square-foot, enclosed, air-conditioned structure powered by generators. In addition to the field hospital, three first aid stations were strategically placed around the festival grounds, and groups of medical personnel were assigned to walk the grounds.

The field hospital was staffed by physicians, nurses, paramedics, respiratory therapists, administrative staff, and pharmacists, and was divided into three separate color-coded sections based on patient acuity—a “green” section with 16 beds for low-acuity patients; a “yellow” section with 10 beds for medium-acuity patients; and a “red” section with four beds for critical care patients. The critical care area, which was set up as a free-standing ED, had ventilators, ultrasound equipment, an ice bath, and advanced life support equipment. Board-certified emergency physicians were present in each area at all times throughout the event, in addition to several emergency medicine residents and medical students. The field hospital also housed a fully stocked pharmacy.

To direct and manage patients, a registration section was set up in front of the field hospital; intake/triage took place in a separate 15-chair, low-acuity area located beyond the front door. Charting was performed on CFDC charts and maintained for records; however, no patients were billed for care.

Separate command vehicles were set up for operations, radio communication, and storage of the staff’s personal belongings. The festival organizers provided meals to all medical personnel.

Access, Communications, and Transportation

A designated road was closed off to all nonemergency traffic leading from the field hospital to an open access point. Our closed communication system meant that 911 calls inside the event would be dispatched to our personnel stationed on-site.

The field hospital served as a single casualty collection point for the entire event, so any patient transported out would first go to the field hospital for evaluation, then move to a waiting transport vehicle, if necessary. This arrangement not only allowed the on-scene staff to evaluate and, when necessary, stabilize patients before transport, but also permitted us to identify and care for those who could be treated on-scene instead of sending them to the hospital. Routing all patients through one location also allowed the EMS staff to appropriately monitor the exact number of patients being treated. The first aid stations were staffed by paramedics and emergency medical technicians, and stocked with advanced life support and first aid equipment.

Motorized golf carts, “gators,” and hand-held carts were used to convey patients from first aid stations and other parts of the festival grounds to the field hospital. On several occasions, physicians accompanied paramedics responding to calls on the festival grounds.

The 2016 Festival: First-Person Report

An hour before the event began, we arrived at the scene, familiarized ourselves with the layout, and met with incident command, EMS, medical directors, and festival staff to discuss plans and divide the teams up. Prior to the event, a medical toxicologist reviewed with participating medical staff several priority resuscitation measures for patients presenting with drug intoxication. These priorities included control of hyperthermia, management of drug-related arrhythmias, seizures, and agitation, all of which permitted smooth transition of care and mutual understanding about which patients ultimately required transfer to the hospital.

Unexpected Needs

The medical needs were not great during the daytime hours. However, by sunset, a constant stream of attendees visited our field hospital, bringing their own prescription medications, including some requiring refrigeration, and requested that we store these on their behalf. We quickly created a process for safe storage and accountability of these medications.

In addition to requesting an unanticipated storage facility, attendees presented with more expected and typical “urgent care needs,” including headaches, rashes, and blisters. By the late afternoon, we began seeing patients who had been vomiting after riding fair attractions and those with heat-related syncope.

As evening descended, our triage area became busy with a wave of agitated, intoxicated patients presenting via EMS, friends, and GCs. When indicated, benzodiazepines (lorazepam and midazolam) were administered to mild-to-moderately agitated patients after verbal de-escalation attempts were unsuccessful. Severely agitated patients required sedative treatment with an antipsychotic (haloperidol or ziprasidone).

In the low-acuity (green) section, arousable patients whose vital signs were stable rested on cots, as did those requiring oral ondansetron for vomiting and who were able to tolerate oral hydration. The moderate-­acuity (yellow) section housed a large number of dehydrated and/or intoxicated patients who required IV fluid therapy. Patients in the critical care (red) area suffered primarily from behavioral issues and altered mental status requiring chemical or physical restraint; many of these patients were transported to the hospital once they could be safely moved. Other critical care patients with medical emergencies were also housed in this area, including an overdose victim for whom endotracheal intubation was needed for airway protection.

As the evening progressed, we saw more severe overdoses and intoxications, including several cases of alcohol- and drug-induced seizures. Any seizure that occurred on the festival grounds was considered a potential cardiac arrest, requiring physician response. Some of our most difficult patient encounters included seizing or postictal patients presenting in an agitated fashion among crowds of intoxicated people who were attempting to help. We also treated a middle-aged festival employee with cardiac disease who presented with chest pain and acute electrocardiogram changes.

One festival attendee with a history of shoulder dislocation presented with a recurrent dislocation. Without needing to sedate the patient, we successfully reduced the dislocated shoulder at the field hospital. Afterward, the patient refused transport to the hospital and insisted on returning to the festival in a sling. Several patients were seen for complaints of eye pain or irritation attributed to vigorous wind and pyrotechnic displays around the large stages—two underwent ophthalmologic evaluation with a small eye kit (topical anesthetic, fluorescein stain, and a Woods lamp) and were diagnosed with corneal abrasions.

Multiple patients with histories of asthma presented with respiratory complaints ranging from mild to severe. Most of these patients were successfully treated with albuterol, though some required supplemental oxygen and corticosteroid therapy. One patient required transport to ORMC for additional care and treatment.

Nonmedical Presentations

The location of the field hospital beyond the perimeter fence of the event created a slight “disconnect” from the crowds and lights—but not from the sound. Several attendees presented to the field hospital, asking for a place to “chill out.” To accommodate these presentations, several chairs were set up under the cover of a pop-up tent for a place to rest and drink a bottle of water. Some individuals remained in this tent for nearly the entire event—refusing care, but feeling more comfortable being in proximity of the field hospital. Although many of these individuals appeared to be intoxicated, the area remained calm throughout the event. This makeshift rest area also served as cover during a brief rain storm in the late afternoon on day 1, as well as for those seeking shelter from the hot afternoon.

Emergency Medical Services

The OFD contributed substantial resources to the 2016 festival, and their support continued throughout the event. Operations were based on the National Incident Management System’s framework, which was developed in coordination with the OMD, OFD, and other stakeholders within ORMC. Logistics and medical groups were created, and the event was divided geographically into “northern,” “southern,” and “eastern” divisions. The unified command structure included a fire department deputy chief and a liaison officer (the OFD off-duty coordinator) who maintained face-to-face communications with festival operators throughout the event. The medical group was coordinated by the OFD EMS chief in collaboration with the OMD. A communications plan was created and used effectively throughout the event to coordinate patient movement, transfers, and transports to the field hospital and ORMC. Briefings were conducted for each operational period and included all personnel involved in the event.

At least one EMS medical director was on-site at all times, in constant communication with the EMS chief on scene, who functioned primarily at the field hospital to guide throughput of patients. The OFD staffed three first aid stations with advanced and basic life support providers, and had personnel roving the festival grounds. In addition to having advanced life support capabilities, the first aid stations dispensed acetaminophen, adhesive bandages, ear plugs, and bottled water, and responded to nearby calls for help and transported patients to the field hospital as needed.

The OFD was also the primary transport agency. Ambulances were dedicated to the event and stationed at the field hospital to transport patients to ORMC. In total, 32 EMS personnel were on scene, including ambulance personnel, staffing at first aid stations, and personnel circulating among the crowd.

The Orlando Police Department (OPD) was also a constant presence at the event, providing security for both festivalgoers and staff at the field hospital. We did not have our own security personnel at the field hospital, and OPD provided a comfort level for the medical staff as the number of agitated, intoxicated patients increased.

Orlando Regional Medical Center

During the 2015 EDM festival, ORMC had been inundated with festivalgoers. Many required only minor care, but some were in need of critical care, including two cardiac arrest patients. Based on this festival experience, hospital administration at ORMC ensured adequate staffing for the 2016 festival, including nursing, medical technicians, radiology technicians, and respiratory therapists. Communication between familiar colleagues, operating under mutually understood protocols, and the ability to communicate with the field hospital, allowed for very smooth transitions of care throughout the 2016 event.

There was a direct correlation between the time of day and number and severity of patients transported to the hospital. Early in the day, patients presented with heat illness and altered mental status, syncope, and confusion; all were easily managed. By late evening, patients with possible arrhythmias, seizures, hyperthermia, chest pain, and altered mental status began to arrive. While the number of patients with the clinical presentation of intoxication and agitation was not surprising, the outcomes were occasionally unexpected—including several elevated troponin levels and occasional arrhythmias.

The hospital received 68 patients directly from the field hospital at the festival. More than 100 presented to the field hospital with altered mental status, of which dozens resolved with observation and close monitoring. Thirty patients had transient arrhythmias ranging from tachycardia and a slightly widened QRS complex. Six had seizures which responded to benzodiazepine treatment. One patient suffered respiratory failure; he was managed by mechanical ventilation, which was performed at the field hospital, and afterward transported to ORMC with a resident physician. Five patients had hyponatremia, which may have been dilutional from excess free-water intake or mediated by syndrome of inappropriate antidiuretic hormone secretion secondary to MDMA use. Hyperthermic patients were managed with active cooling.

Laboratory evaluation revealed elevated troponin levels in six patients, though none of the patients required emergent cardiac intervention. The elevated troponin levels were possibly secondary to demand ischemia from sympathomimetic toxidromes.

Although many patients admitted to using recreational drugs, few specified the type or amount of drug taken, either because they were too altered to communicate, were unfamiliar with what they ingested, or feared legal repercussions. Ethanol, marijuana, and MDMA were the most commonly reported drugs.

Lessons Learned

Over the 2-day 2016 EDM festival, 235 patients were treated at the field hospital, and 68 were transported to ORMC—almost 100 fewer hospital transports than during the 2015 EDM festival, which lacked a field hospital. Although two attendees at the 2016 event required intensive care at ORMC, there were no deaths. Overall, the field hospital and cooperative approach provided a safer method for treating patients and without overwhelming hospital or EMS resources. 
Successful utilization of a field hospital at the 2016 EDM festival required the coordinated efforts of multiple organizations, including the EMS system, ORMC, festival organizers, and disaster response groups. The deployment of this strategy required a great deal of planning, coordination, and efforts months before the actual event, and included a sufficient number of trained emergency and medical personnel, support staff for equipment set-up, operation, and takedown, and insurance coverage.

In reviewing the medical care model provided for the 2016 EDM festival, we concluded that a more effective and efficient staffing model would have deployed more nurses and fewer physicians. Utilizing the event as training for residents and medical students resulted in a large number of providers on-site, but inadequate support staff.

When planning for this event, we did not anticipate the extent of the primary care and urgent care concerns encountered during the event, though we did anticipate that the most critical medical concerns were sympathomimetic and hallucinogenic toxidromes requiring restraint, benzodiazepines, and antipsychotics.

Over the past 5 to 10 years, electronic dance music (EDM) festivals have grown in popularity in the United States, developing into massive, multiday events drawing crowds of tens of thousands of attendees.¹ The nature of these events—ie, long outdoor performances attended by a primarily youthful audience in sometimes austere environments¹—presents several unique challenges to local EDs, including the ability to effectively manage mass cases of polysubstance abuse, exposure to extremes of weather, and dehydration.

Since 2011, Orlando, Florida has been host to a popular annual EDM festival—one that has nearly doubled in size since its inception. In 2015, both the volume of 911 calls related to this event and number of attendees seeking care at the city’s first aid stations located at the festival overwhelmed our local emergency medical services (EMS) system and the nearest ED. The acuity of these patient interactions ranged from cases that could have been treated and released on-site to several critical care cases, including two fatalities.

In advance of the November 2016 festival, event staff, EMS, and hospital planners worked together to improve attendee safety and to avoid unnecessary admissions to the area receiving hospital, Orlando Regional Medical Center (ORMC). This cooperative endeavor resulted in the creation of a unique, fully staffed field hospital that was seamlessly integrated with EMS personnel and in constant communication with ORMC. The implementation of a field hospital on-site at the event decreased mortality and provided a reasonable and manageable way to safely treat and release patients who would have otherwise required transportation to the receiving center.

The 2016 Festival: Background

Location and Setup

In November 2016, the EDM festival was held at its usual location in the fields and areas surrounding a large stadium near downtown Orlando. Although the fall season in Florida can be unpredictable, the weather during the day is typically hot and humid, with temperatures averaging 80°F to 90°F. The festival took place over a 2-day period between noon and midnight each day. Unlike similar multiday festivals that run over a consecutive period of 24 to 48 hours, there were no overnight activities at this event.

Whereas other similar festivals often take place in more remote, austere environments such as deserts or forests, the Orlando EDM festival was held within the city but did not have on-site overnight accommodations. While this location eased some of our concerns, overnight closure of the field hospital altered our approach to patient management. When the facility closed, many patients who may have been observed overnight and subsequently released, required transport to the hospital for further observation and monitoring.

Attendees and Layout

The festival drew approximately 30,000 to 40,000 attendees each day, with multiple stages and fairground-type attractions spread over approximately 45 acres. The area was transformed by massive stages and production equipment, including complex lighting, pyrotechnics, expansive sound systems, and carnival rides. There were also dozens of on-site kiosks and pop-up structures selling food, merchandise, and alcoholic and nonalcoholic beverages.

Substance Abuse and Elemental Exposures

Although festival planners expressly prohibit illicit drug use at EDM events, substance use has been and continues to be prevalent at these types of festivals—particularly the use of alcohol, amphetamines such as 3,4-methylenedioxymethamphetamine (MDMA, also known as “ecstasy” and “Molly”), lysergic acid diethylamide (LSD), cocaine, and marijuana (Table).²

Lessons From the 2015 Festival

The 2015 EDM festival in Orlando had taken place without significant coordination between local EMS medical directors and ORMC, and was treated in a similar manner to other mass gatherings held in the area—ie, with extra EMS personnel on-site as well as several first aid stations. However, over the course of the 2015 event, the medics on-site were overwhelmed by the number of attendees seeking care, and felt obligated to transport a large number of these patients to ORMC (many of whom did not require hospital care), or to treat and release patients in a manner that was not in accordance with existing protocol.

As a result, the online medical control doctors at ORMC were overwhelmed by the sudden influx of calls for treat-and-release orders or intravenous (IV) hydration—not a common occurrence at this institution. This resulted in dozens of patient transports to the ED. Many of these patients did not require emergent care but simply needed shelter from the elements, rest because of sleep deprivation, or a place to recover from the effects of alcohol or drugs. Some patients, however, presented to ORMC in critical condition, two of whom died from suspected drug-related causes and/or severe hyperthermia.

After-Action Review

An after-action review of the 2015 EDM festival conducted by the Orlando Fire Department (OFD) concluded that significantly more medical support was needed for this and similar large-scale events in the future. Together with OFD, we examined how other regions in the United States handled similar festivals, and it became clear that a multidisciplinary approach, including a field hospital, EMS, ORMC, and festival planners, would be necessary for the 2016 festival.

Collaborative Planning for the 2016 Festival

Festival planners and promoters worked closely with the City of Orlando and EMS medical directors for months leading up to the 2016 EDM festival. The complexities of stage set-up alone required significant coordination, including the closure of several roads. To set up the field hospital, we first tried to acquire “real estate” on festival grounds. When this proved not to be feasible, we worked with city officials to create a field hospital on a street just outside the festival’s side gate.

Resources

Throughout the process, we worked closely with the festival’s planners, as well as a medical team designated by its parent company, to coordinate shared resources. The medical team provided a significant amount of medical supplies to our field hospital. In addition, the festival obtained and paid for an insurance rider extending coverage to our medical staff while working at the event.

Ground Control Staff

The planners and promoters of the EDM festival host several other festivals each year, including some that are larger and longer than the annual event held in Orlando. A small team from Orlando visited their set-up at a larger festival in Nevada several months prior to the 2016 EDM festival, gathering information on how we could best execute our plans. In addition to equipment and support, the festival also designated ground controllers (GCs) stationed throughout the festival area. These were individuals without medical training who could be easily identified and could guide those in need of medical attention to the nearest first aid station or to the field hospital, or contact us when someone was in need of immediate or emergent care.

Access and Communications

Several areas identified for improvement from 2015 included better ambulance access, radio communication (especially with physicians), and appropriate staffing. To provide additional medical staff for the 2016 EDM festival, the Office of the Medical Director (OMD) and the Central Florida Disaster Coalition (CFDC), a regional nonprofit organization that assists with disaster-health response in the area, utilized this event as a drill for a large-scale disaster that would require a self-sufficient field hospital. Part of this initiative included radio transmission equipment that would allow the routing of all 911 and other emergency calls from the festival grounds directly to on-site medical personnel.

In addition to the CFDC resources, we had dedicated medical control on the radio to answer questions from the paramedics staffing the outer first aid stations. This was separate from our normal medical control base-station process, and allowed our traditional EMS operating structure to continue outside the event without any confusion or added burden from within.

Field Hospital and First Aid Stations

Created just beyond the fencing that surrounded the event, the field hospital was a 3,200-square-foot, enclosed, air-conditioned structure powered by generators. In addition to the field hospital, three first aid stations were strategically placed around the festival grounds, and groups of medical personnel were assigned to walk the grounds.

The field hospital was staffed by physicians, nurses, paramedics, respiratory therapists, administrative staff, and pharmacists, and was divided into three separate color-coded sections based on patient acuity—a “green” section with 16 beds for low-acuity patients; a “yellow” section with 10 beds for medium-acuity patients; and a “red” section with four beds for critical care patients. The critical care area, which was set up as a free-standing ED, had ventilators, ultrasound equipment, an ice bath, and advanced life support equipment. Board-certified emergency physicians were present in each area at all times throughout the event, in addition to several emergency medicine residents and medical students. The field hospital also housed a fully stocked pharmacy.

To direct and manage patients, a registration section was set up in front of the field hospital; intake/triage took place in a separate 15-chair, low-acuity area located beyond the front door. Charting was performed on CFDC charts and maintained for records; however, no patients were billed for care.

Separate command vehicles were set up for operations, radio communication, and storage of the staff’s personal belongings. The festival organizers provided meals to all medical personnel.

Access, Communications, and Transportation

A designated road was closed off to all nonemergency traffic leading from the field hospital to an open access point. Our closed communication system meant that 911 calls inside the event would be dispatched to our personnel stationed on-site.

The field hospital served as a single casualty collection point for the entire event, so any patient transported out would first go to the field hospital for evaluation, then move to a waiting transport vehicle, if necessary. This arrangement not only allowed the on-scene staff to evaluate and, when necessary, stabilize patients before transport, but also permitted us to identify and care for those who could be treated on-scene instead of sending them to the hospital. Routing all patients through one location also allowed the EMS staff to appropriately monitor the exact number of patients being treated. The first aid stations were staffed by paramedics and emergency medical technicians, and stocked with advanced life support and first aid equipment.

Motorized golf carts, “gators,” and hand-held carts were used to convey patients from first aid stations and other parts of the festival grounds to the field hospital. On several occasions, physicians accompanied paramedics responding to calls on the festival grounds.

The 2016 Festival: First-Person Report

An hour before the event began, we arrived at the scene, familiarized ourselves with the layout, and met with incident command, EMS, medical directors, and festival staff to discuss plans and divide the teams up. Prior to the event, a medical toxicologist reviewed with participating medical staff several priority resuscitation measures for patients presenting with drug intoxication. These priorities included control of hyperthermia, management of drug-related arrhythmias, seizures, and agitation, all of which permitted smooth transition of care and mutual understanding about which patients ultimately required transfer to the hospital.

Unexpected Needs

The medical needs were not great during the daytime hours. However, by sunset, a constant stream of attendees visited our field hospital, bringing their own prescription medications, including some requiring refrigeration, and requested that we store these on their behalf. We quickly created a process for safe storage and accountability of these medications.

In addition to requesting an unanticipated storage facility, attendees presented with more expected and typical “urgent care needs,” including headaches, rashes, and blisters. By the late afternoon, we began seeing patients who had been vomiting after riding fair attractions and those with heat-related syncope.

As evening descended, our triage area became busy with a wave of agitated, intoxicated patients presenting via EMS, friends, and GCs. When indicated, benzodiazepines (lorazepam and midazolam) were administered to mild-to-moderately agitated patients after verbal de-escalation attempts were unsuccessful. Severely agitated patients required sedative treatment with an antipsychotic (haloperidol or ziprasidone).

In the low-acuity (green) section, arousable patients whose vital signs were stable rested on cots, as did those requiring oral ondansetron for vomiting and who were able to tolerate oral hydration. The moderate-­acuity (yellow) section housed a large number of dehydrated and/or intoxicated patients who required IV fluid therapy. Patients in the critical care (red) area suffered primarily from behavioral issues and altered mental status requiring chemical or physical restraint; many of these patients were transported to the hospital once they could be safely moved. Other critical care patients with medical emergencies were also housed in this area, including an overdose victim for whom endotracheal intubation was needed for airway protection.

As the evening progressed, we saw more severe overdoses and intoxications, including several cases of alcohol- and drug-induced seizures. Any seizure that occurred on the festival grounds was considered a potential cardiac arrest, requiring physician response. Some of our most difficult patient encounters included seizing or postictal patients presenting in an agitated fashion among crowds of intoxicated people who were attempting to help. We also treated a middle-aged festival employee with cardiac disease who presented with chest pain and acute electrocardiogram changes.

One festival attendee with a history of shoulder dislocation presented with a recurrent dislocation. Without needing to sedate the patient, we successfully reduced the dislocated shoulder at the field hospital. Afterward, the patient refused transport to the hospital and insisted on returning to the festival in a sling. Several patients were seen for complaints of eye pain or irritation attributed to vigorous wind and pyrotechnic displays around the large stages—two underwent ophthalmologic evaluation with a small eye kit (topical anesthetic, fluorescein stain, and a Woods lamp) and were diagnosed with corneal abrasions.

Multiple patients with histories of asthma presented with respiratory complaints ranging from mild to severe. Most of these patients were successfully treated with albuterol, though some required supplemental oxygen and corticosteroid therapy. One patient required transport to ORMC for additional care and treatment.

Nonmedical Presentations

The location of the field hospital beyond the perimeter fence of the event created a slight “disconnect” from the crowds and lights—but not from the sound. Several attendees presented to the field hospital, asking for a place to “chill out.” To accommodate these presentations, several chairs were set up under the cover of a pop-up tent for a place to rest and drink a bottle of water. Some individuals remained in this tent for nearly the entire event—refusing care, but feeling more comfortable being in proximity of the field hospital. Although many of these individuals appeared to be intoxicated, the area remained calm throughout the event. This makeshift rest area also served as cover during a brief rain storm in the late afternoon on day 1, as well as for those seeking shelter from the hot afternoon.

Emergency Medical Services

The OFD contributed substantial resources to the 2016 festival, and their support continued throughout the event. Operations were based on the National Incident Management System’s framework, which was developed in coordination with the OMD, OFD, and other stakeholders within ORMC. Logistics and medical groups were created, and the event was divided geographically into “northern,” “southern,” and “eastern” divisions. The unified command structure included a fire department deputy chief and a liaison officer (the OFD off-duty coordinator) who maintained face-to-face communications with festival operators throughout the event. The medical group was coordinated by the OFD EMS chief in collaboration with the OMD. A communications plan was created and used effectively throughout the event to coordinate patient movement, transfers, and transports to the field hospital and ORMC. Briefings were conducted for each operational period and included all personnel involved in the event.

At least one EMS medical director was on-site at all times, in constant communication with the EMS chief on scene, who functioned primarily at the field hospital to guide throughput of patients. The OFD staffed three first aid stations with advanced and basic life support providers, and had personnel roving the festival grounds. In addition to having advanced life support capabilities, the first aid stations dispensed acetaminophen, adhesive bandages, ear plugs, and bottled water, and responded to nearby calls for help and transported patients to the field hospital as needed.

The OFD was also the primary transport agency. Ambulances were dedicated to the event and stationed at the field hospital to transport patients to ORMC. In total, 32 EMS personnel were on scene, including ambulance personnel, staffing at first aid stations, and personnel circulating among the crowd.

The Orlando Police Department (OPD) was also a constant presence at the event, providing security for both festivalgoers and staff at the field hospital. We did not have our own security personnel at the field hospital, and OPD provided a comfort level for the medical staff as the number of agitated, intoxicated patients increased.

Orlando Regional Medical Center

During the 2015 EDM festival, ORMC had been inundated with festivalgoers. Many required only minor care, but some were in need of critical care, including two cardiac arrest patients. Based on this festival experience, hospital administration at ORMC ensured adequate staffing for the 2016 festival, including nursing, medical technicians, radiology technicians, and respiratory therapists. Communication between familiar colleagues, operating under mutually understood protocols, and the ability to communicate with the field hospital, allowed for very smooth transitions of care throughout the 2016 event.

There was a direct correlation between the time of day and number and severity of patients transported to the hospital. Early in the day, patients presented with heat illness and altered mental status, syncope, and confusion; all were easily managed. By late evening, patients with possible arrhythmias, seizures, hyperthermia, chest pain, and altered mental status began to arrive. While the number of patients with the clinical presentation of intoxication and agitation was not surprising, the outcomes were occasionally unexpected—including several elevated troponin levels and occasional arrhythmias.

The hospital received 68 patients directly from the field hospital at the festival. More than 100 presented to the field hospital with altered mental status, of which dozens resolved with observation and close monitoring. Thirty patients had transient arrhythmias ranging from tachycardia and a slightly widened QRS complex. Six had seizures which responded to benzodiazepine treatment. One patient suffered respiratory failure; he was managed by mechanical ventilation, which was performed at the field hospital, and afterward transported to ORMC with a resident physician. Five patients had hyponatremia, which may have been dilutional from excess free-water intake or mediated by syndrome of inappropriate antidiuretic hormone secretion secondary to MDMA use. Hyperthermic patients were managed with active cooling.

Laboratory evaluation revealed elevated troponin levels in six patients, though none of the patients required emergent cardiac intervention. The elevated troponin levels were possibly secondary to demand ischemia from sympathomimetic toxidromes.

Although many patients admitted to using recreational drugs, few specified the type or amount of drug taken, either because they were too altered to communicate, were unfamiliar with what they ingested, or feared legal repercussions. Ethanol, marijuana, and MDMA were the most commonly reported drugs.

Lessons Learned

Over the 2-day 2016 EDM festival, 235 patients were treated at the field hospital, and 68 were transported to ORMC—almost 100 fewer hospital transports than during the 2015 EDM festival, which lacked a field hospital. Although two attendees at the 2016 event required intensive care at ORMC, there were no deaths. Overall, the field hospital and cooperative approach provided a safer method for treating patients and without overwhelming hospital or EMS resources. 
Successful utilization of a field hospital at the 2016 EDM festival required the coordinated efforts of multiple organizations, including the EMS system, ORMC, festival organizers, and disaster response groups. The deployment of this strategy required a great deal of planning, coordination, and efforts months before the actual event, and included a sufficient number of trained emergency and medical personnel, support staff for equipment set-up, operation, and takedown, and insurance coverage.

In reviewing the medical care model provided for the 2016 EDM festival, we concluded that a more effective and efficient staffing model would have deployed more nurses and fewer physicians. Utilizing the event as training for residents and medical students resulted in a large number of providers on-site, but inadequate support staff.

When planning for this event, we did not anticipate the extent of the primary care and urgent care concerns encountered during the event, though we did anticipate that the most critical medical concerns were sympathomimetic and hallucinogenic toxidromes requiring restraint, benzodiazepines, and antipsychotics.

Coronary heart disease remains the leading cause of death of US adults aged 35 years and older due to the downstream consequences of arterial occlusion and ensuing myocardial ischemia.^1,2 Among patients with coronary heart disease, 30% to 33% will present with ST-segment elevation myocardial infarction (STEMI).^3-5

For STEMI patients, access to a facility with percutaneous coronary intervention (PCI) capabilities is critical. Door-to-balloon (D2B) time is used as a performance measure to assess the quality of care that STEMI patients are receiving. Data show that decreasing D2B times can improve outcomes of STEMI patients, with lower D2B time associated with lower mortality rates.⁵ To obtain and maintain the lowest D2B times possible, health care systems must adopt best practice models to continually improve patient outcomes.

The current best practice for patients with an acute STEMI involves bypassing non-PCI centers and transporting patients directly to PCI-enabled centers—as long as the patient’s total emergency medical services (EMS) contact-to-balloon time remains low. In a study by Le May et al,⁶ patients directly transported to a PCI-enabled center had a mortality rate of 5% within 180 days compared to 11.5% for those who were first seen at a center without PCI capabilities.

Longer EMS transport time to PCI centers, however, requires earlier cardiac catheterization laboratory (CCL) activation to prevent delays in care. Emergency physicians (EPs) must work with local EMS, PCI and non-PCI centers, and interventional cardiologists to establish protocols to expedite STEMI patient care. Previous studies, however, have shown that paramedics are able to diagnose STEMI patients during transport and can activate the catheterization team from the field, with beneficial patient outcomes.^7-11 Prior to July 2011, all patients with a suspected MI who were transported to our institution via EMS were not diagnosed with STEMI until evaluation by an EP. Because the CCL had no in-house staff after hours, the interventional cardiology team required 30 minutes to respond and prepare. In 2011, our EMS, in conjunction with county hospitals, EPs, and cardiologists, implemented an initiative that empowered paramedics to activate STEMI alerts from the field. This provided advanced notification to the interventional cardiology laboratory team to initiate preparation for patients in need of immediate PCI.

Since the best practice for STEMI patients involves early diagnosis and immediate activation of the cardiac catheterization team, we sought to improve the outcomes for STEMI patients by utilizing prehospital care initiatives to lower D2B times. Other health care systems have utilized EPs to receive the transmitted electrocardiogram (ECG) and to initiate CCL team activation. We found that having both the EP and cardiologist review the ECG delayed the activation process when compared to direct activation by EMS. Our initiatives to improve time to CCL activation included the following:

(1) Training and enabling paramedics to diagnose a STEMI on the ECG;

(2) Bypassing non-PCI centers for PCI centers during STEMI patient transport;

(3) Allowing paramedics to activate the CCL at our institution prior to transmitting an ECG and prior to patient arrival at the hospital; and

(4) Bypassing the ED to go directly to the CCL when the CCL was ready to receive the patient. (When the CCL was not ready, patients were transported to the ED. After reviewing the transmitted ECG, the EPs could cancel the STEMI alert if indicated.)

By empowering EMS to diagnose and activate the CCL, we also measured the rate of unnecessary activations, which was defined as patients who did not present with chest pain and an ECG showing ≥1 mm ST segment elevation in two contiguous limb leads, or ≥2 mm ST segment elevation in two contiguous precordial leads.

Causes of unnecessary activation by EMS included left ventricular hypertrophy, left bundle branch block, early repolarization, non-specific ST segment changes, pericarditis, and ventricular paced rhythms. We recorded and analyzed D2B times and the unnecessary activation rates, and continuously used these data for quality improvement. Our goal was to decrease D2B times and unnecessary activation rates, while maintaining these improvements over time.

Our ED has 93,000 patient visits annually, and our hospital serves as the only PCI center within a county encompassing 1,255 square miles. Our hospital EMS used 12 Lifepak monitors to help interpret patients’ ECG. To study the impact of our initiative, data were collected each year from 2011 to 2015. The 2011 data were recorded before EMS began to activate the CCL and served as the baseline for the D2B times. These data were then compared to postintervention D2B data from 2012 to 2015.

In addition to collecting unnecessary activation rates by EMS paramedics from 2012 to 2015, we continuously used the unnecessary activation data to identify why these activations were occurring and to devise a strategy to improve rates. Emergency physicians have a leadership role regarding EMS training and oversight, ongoing paramedic education, and the quality improvement process.

A Reduction in D2B Time

Our baseline D2B time prior to the intervention was 52.5 minutes. After our intervention, average D2B times for 2012, 2013, 2014, and 2015 were 38.2, 33.5, 39, and 37.25 minutes, respectively. The institution’s baseline rate of unnecessary activation prior to intervention in 2011 was 19.1%. After intervention, the EMS unnecessary activation rates for 2012, 2013, 2014, and 2015 were 30%, 18%, 15%, and 19% respectively, averaging 20.5% over 4 years, or 17.3% for 2013 through 2015.

Emergency medical services averaged approximately 164 STEMI activations each year. We decreased D2B times for patients by over 15 minutes from 2011 compared to 2012 through 2015. These results were sustained, with attention to metrics, over four years. Furthermore, the proportion of STEMI patients receiving immediate PCI within the recommended 90 minutes was 100% of patients in 2014 and 2015, reflecting consistent improvement over 2012 and 2013.

We also demonstrated an overall reduction in the unnecessary CCL activation rate by EMS over the time of our intervention. Our analysis of unnecessary activation causes and EMS education led to improvement in the unnecessary activation rate from 2012-2015, and these rates have been sustained over time. The rate of unnecessary activation by EMS in 2012 to 2015 was 20.5%.

Conclusion

Lower D2B time for STEMI patients is associated with lower mortality following PCI for patients with acute MI, fewer complications, and shorter length of stay in the hospital. We successfully lowered D2B time after empowering EMS to activate our interventional cardiology laboratory prior to arrival at the hospital for patients with acute STEMI, coupled with the ability to bypass the ED for patients with acute STEMI presentations. With rigorous attention to metrics and ongoing aggressive medic education, we were able to achieve consistent, sustained D2B times under 40 minutes over the course of four consecutive years. We present our experience as a potential model of a multifaceted intervention for other systems to consider replicating.

Coronary heart disease remains the leading cause of death of US adults aged 35 years and older due to the downstream consequences of arterial occlusion and ensuing myocardial ischemia.^1,2 Among patients with coronary heart disease, 30% to 33% will present with ST-segment elevation myocardial infarction (STEMI).^3-5

For STEMI patients, access to a facility with percutaneous coronary intervention (PCI) capabilities is critical. Door-to-balloon (D2B) time is used as a performance measure to assess the quality of care that STEMI patients are receiving. Data show that decreasing D2B times can improve outcomes of STEMI patients, with lower D2B time associated with lower mortality rates.⁵ To obtain and maintain the lowest D2B times possible, health care systems must adopt best practice models to continually improve patient outcomes.

The current best practice for patients with an acute STEMI involves bypassing non-PCI centers and transporting patients directly to PCI-enabled centers—as long as the patient’s total emergency medical services (EMS) contact-to-balloon time remains low. In a study by Le May et al,⁶ patients directly transported to a PCI-enabled center had a mortality rate of 5% within 180 days compared to 11.5% for those who were first seen at a center without PCI capabilities.

Longer EMS transport time to PCI centers, however, requires earlier cardiac catheterization laboratory (CCL) activation to prevent delays in care. Emergency physicians (EPs) must work with local EMS, PCI and non-PCI centers, and interventional cardiologists to establish protocols to expedite STEMI patient care. Previous studies, however, have shown that paramedics are able to diagnose STEMI patients during transport and can activate the catheterization team from the field, with beneficial patient outcomes.^7-11 Prior to July 2011, all patients with a suspected MI who were transported to our institution via EMS were not diagnosed with STEMI until evaluation by an EP. Because the CCL had no in-house staff after hours, the interventional cardiology team required 30 minutes to respond and prepare. In 2011, our EMS, in conjunction with county hospitals, EPs, and cardiologists, implemented an initiative that empowered paramedics to activate STEMI alerts from the field. This provided advanced notification to the interventional cardiology laboratory team to initiate preparation for patients in need of immediate PCI.

Since the best practice for STEMI patients involves early diagnosis and immediate activation of the cardiac catheterization team, we sought to improve the outcomes for STEMI patients by utilizing prehospital care initiatives to lower D2B times. Other health care systems have utilized EPs to receive the transmitted electrocardiogram (ECG) and to initiate CCL team activation. We found that having both the EP and cardiologist review the ECG delayed the activation process when compared to direct activation by EMS. Our initiatives to improve time to CCL activation included the following:

(1) Training and enabling paramedics to diagnose a STEMI on the ECG;

(2) Bypassing non-PCI centers for PCI centers during STEMI patient transport;

(3) Allowing paramedics to activate the CCL at our institution prior to transmitting an ECG and prior to patient arrival at the hospital; and

(4) Bypassing the ED to go directly to the CCL when the CCL was ready to receive the patient. (When the CCL was not ready, patients were transported to the ED. After reviewing the transmitted ECG, the EPs could cancel the STEMI alert if indicated.)

By empowering EMS to diagnose and activate the CCL, we also measured the rate of unnecessary activations, which was defined as patients who did not present with chest pain and an ECG showing ≥1 mm ST segment elevation in two contiguous limb leads, or ≥2 mm ST segment elevation in two contiguous precordial leads.

Causes of unnecessary activation by EMS included left ventricular hypertrophy, left bundle branch block, early repolarization, non-specific ST segment changes, pericarditis, and ventricular paced rhythms. We recorded and analyzed D2B times and the unnecessary activation rates, and continuously used these data for quality improvement. Our goal was to decrease D2B times and unnecessary activation rates, while maintaining these improvements over time.

Our ED has 93,000 patient visits annually, and our hospital serves as the only PCI center within a county encompassing 1,255 square miles. Our hospital EMS used 12 Lifepak monitors to help interpret patients’ ECG. To study the impact of our initiative, data were collected each year from 2011 to 2015. The 2011 data were recorded before EMS began to activate the CCL and served as the baseline for the D2B times. These data were then compared to postintervention D2B data from 2012 to 2015.

In addition to collecting unnecessary activation rates by EMS paramedics from 2012 to 2015, we continuously used the unnecessary activation data to identify why these activations were occurring and to devise a strategy to improve rates. Emergency physicians have a leadership role regarding EMS training and oversight, ongoing paramedic education, and the quality improvement process.

A Reduction in D2B Time

Our baseline D2B time prior to the intervention was 52.5 minutes. After our intervention, average D2B times for 2012, 2013, 2014, and 2015 were 38.2, 33.5, 39, and 37.25 minutes, respectively. The institution’s baseline rate of unnecessary activation prior to intervention in 2011 was 19.1%. After intervention, the EMS unnecessary activation rates for 2012, 2013, 2014, and 2015 were 30%, 18%, 15%, and 19% respectively, averaging 20.5% over 4 years, or 17.3% for 2013 through 2015.

Emergency medical services averaged approximately 164 STEMI activations each year. We decreased D2B times for patients by over 15 minutes from 2011 compared to 2012 through 2015. These results were sustained, with attention to metrics, over four years. Furthermore, the proportion of STEMI patients receiving immediate PCI within the recommended 90 minutes was 100% of patients in 2014 and 2015, reflecting consistent improvement over 2012 and 2013.

We also demonstrated an overall reduction in the unnecessary CCL activation rate by EMS over the time of our intervention. Our analysis of unnecessary activation causes and EMS education led to improvement in the unnecessary activation rate from 2012-2015, and these rates have been sustained over time. The rate of unnecessary activation by EMS in 2012 to 2015 was 20.5%.

Conclusion

Lower D2B time for STEMI patients is associated with lower mortality following PCI for patients with acute MI, fewer complications, and shorter length of stay in the hospital. We successfully lowered D2B time after empowering EMS to activate our interventional cardiology laboratory prior to arrival at the hospital for patients with acute STEMI, coupled with the ability to bypass the ED for patients with acute STEMI presentations. With rigorous attention to metrics and ongoing aggressive medic education, we were able to achieve consistent, sustained D2B times under 40 minutes over the course of four consecutive years. We present our experience as a potential model of a multifaceted intervention for other systems to consider replicating.

Coronary heart disease remains the leading cause of death of US adults aged 35 years and older due to the downstream consequences of arterial occlusion and ensuing myocardial ischemia.^1,2 Among patients with coronary heart disease, 30% to 33% will present with ST-segment elevation myocardial infarction (STEMI).^3-5

For STEMI patients, access to a facility with percutaneous coronary intervention (PCI) capabilities is critical. Door-to-balloon (D2B) time is used as a performance measure to assess the quality of care that STEMI patients are receiving. Data show that decreasing D2B times can improve outcomes of STEMI patients, with lower D2B time associated with lower mortality rates.⁵ To obtain and maintain the lowest D2B times possible, health care systems must adopt best practice models to continually improve patient outcomes.

The current best practice for patients with an acute STEMI involves bypassing non-PCI centers and transporting patients directly to PCI-enabled centers—as long as the patient’s total emergency medical services (EMS) contact-to-balloon time remains low. In a study by Le May et al,⁶ patients directly transported to a PCI-enabled center had a mortality rate of 5% within 180 days compared to 11.5% for those who were first seen at a center without PCI capabilities.

Longer EMS transport time to PCI centers, however, requires earlier cardiac catheterization laboratory (CCL) activation to prevent delays in care. Emergency physicians (EPs) must work with local EMS, PCI and non-PCI centers, and interventional cardiologists to establish protocols to expedite STEMI patient care. Previous studies, however, have shown that paramedics are able to diagnose STEMI patients during transport and can activate the catheterization team from the field, with beneficial patient outcomes.^7-11 Prior to July 2011, all patients with a suspected MI who were transported to our institution via EMS were not diagnosed with STEMI until evaluation by an EP. Because the CCL had no in-house staff after hours, the interventional cardiology team required 30 minutes to respond and prepare. In 2011, our EMS, in conjunction with county hospitals, EPs, and cardiologists, implemented an initiative that empowered paramedics to activate STEMI alerts from the field. This provided advanced notification to the interventional cardiology laboratory team to initiate preparation for patients in need of immediate PCI.

Since the best practice for STEMI patients involves early diagnosis and immediate activation of the cardiac catheterization team, we sought to improve the outcomes for STEMI patients by utilizing prehospital care initiatives to lower D2B times. Other health care systems have utilized EPs to receive the transmitted electrocardiogram (ECG) and to initiate CCL team activation. We found that having both the EP and cardiologist review the ECG delayed the activation process when compared to direct activation by EMS. Our initiatives to improve time to CCL activation included the following:

(1) Training and enabling paramedics to diagnose a STEMI on the ECG;

(2) Bypassing non-PCI centers for PCI centers during STEMI patient transport;

(3) Allowing paramedics to activate the CCL at our institution prior to transmitting an ECG and prior to patient arrival at the hospital; and

(4) Bypassing the ED to go directly to the CCL when the CCL was ready to receive the patient. (When the CCL was not ready, patients were transported to the ED. After reviewing the transmitted ECG, the EPs could cancel the STEMI alert if indicated.)

By empowering EMS to diagnose and activate the CCL, we also measured the rate of unnecessary activations, which was defined as patients who did not present with chest pain and an ECG showing ≥1 mm ST segment elevation in two contiguous limb leads, or ≥2 mm ST segment elevation in two contiguous precordial leads.

Causes of unnecessary activation by EMS included left ventricular hypertrophy, left bundle branch block, early repolarization, non-specific ST segment changes, pericarditis, and ventricular paced rhythms. We recorded and analyzed D2B times and the unnecessary activation rates, and continuously used these data for quality improvement. Our goal was to decrease D2B times and unnecessary activation rates, while maintaining these improvements over time.

Our ED has 93,000 patient visits annually, and our hospital serves as the only PCI center within a county encompassing 1,255 square miles. Our hospital EMS used 12 Lifepak monitors to help interpret patients’ ECG. To study the impact of our initiative, data were collected each year from 2011 to 2015. The 2011 data were recorded before EMS began to activate the CCL and served as the baseline for the D2B times. These data were then compared to postintervention D2B data from 2012 to 2015.

In addition to collecting unnecessary activation rates by EMS paramedics from 2012 to 2015, we continuously used the unnecessary activation data to identify why these activations were occurring and to devise a strategy to improve rates. Emergency physicians have a leadership role regarding EMS training and oversight, ongoing paramedic education, and the quality improvement process.

A Reduction in D2B Time

Our baseline D2B time prior to the intervention was 52.5 minutes. After our intervention, average D2B times for 2012, 2013, 2014, and 2015 were 38.2, 33.5, 39, and 37.25 minutes, respectively. The institution’s baseline rate of unnecessary activation prior to intervention in 2011 was 19.1%. After intervention, the EMS unnecessary activation rates for 2012, 2013, 2014, and 2015 were 30%, 18%, 15%, and 19% respectively, averaging 20.5% over 4 years, or 17.3% for 2013 through 2015.

Emergency medical services averaged approximately 164 STEMI activations each year. We decreased D2B times for patients by over 15 minutes from 2011 compared to 2012 through 2015. These results were sustained, with attention to metrics, over four years. Furthermore, the proportion of STEMI patients receiving immediate PCI within the recommended 90 minutes was 100% of patients in 2014 and 2015, reflecting consistent improvement over 2012 and 2013.

We also demonstrated an overall reduction in the unnecessary CCL activation rate by EMS over the time of our intervention. Our analysis of unnecessary activation causes and EMS education led to improvement in the unnecessary activation rate from 2012-2015, and these rates have been sustained over time. The rate of unnecessary activation by EMS in 2012 to 2015 was 20.5%.

Conclusion

Lower D2B time for STEMI patients is associated with lower mortality following PCI for patients with acute MI, fewer complications, and shorter length of stay in the hospital. We successfully lowered D2B time after empowering EMS to activate our interventional cardiology laboratory prior to arrival at the hospital for patients with acute STEMI, coupled with the ability to bypass the ED for patients with acute STEMI presentations. With rigorous attention to metrics and ongoing aggressive medic education, we were able to achieve consistent, sustained D2B times under 40 minutes over the course of four consecutive years. We present our experience as a potential model of a multifaceted intervention for other systems to consider replicating.

Case

A 29-year-old man presented to the ED with a 3-day history of constant left-sided low back pain that radiated to his left buttock and groin. The patient stated the pain worsened with movement, making it difficult for him to walk. He reported lifting heavy boxes at work, but denied any trauma. The patient also denied recent fevers, chills, chest pain, dyspnea, abdominal pain, urinary or fecal incontinence, weakness, numbness, or saddle anesthesia. Regarding his medical history, he had an appendectomy as a child, but reported no other surgeries or medical issues. His social history was significant for narcotic and inhalant use and daily tobacco use. The patient also reported taking heroin intravenously (IV) 6 months prior.

Vital signs at presentation were: heart rate (HR), 92 beats/min; respiratory rate, 15 breaths/min; blood pressure, 118/80 mm Hg; and temperature, 98.2°F. Oxygen saturation was 98% on room air.

The patient was a well-developed young man in no apparent distress. Dermatological examination showed bilateral track marks in the antecubital fossa. The musculoskeletal (MSK) examination demonstrated left gluteal tenderness to palpation and decreased active and passive range of motion of the left hip, especially with internal rotation and flexion. He had no midline tenderness, and the lower extremities had normal pulses and no motor or sensory deficits.

The patient’s pain improved with IV fluids, diazepam, and ketorolac, and he was able to ambulate with assistance. He was clinically diagnosed with sciatica, and discharged home with prescriptions for diazepam and ibuprofen. He was also instructed to follow-up with an orthopedist within 7 days from discharge.

The patient returned to the ED the following day with similar complaints of unabating left-sided pain and difficulty ambulating. His vital signs were notable for an elevated HR of 106 beats/min. Physical examination findings were unchanged from his presentation the previous day, and an X-ray of the lumbar spine showed no abnormalities.

After receiving IV analgesics, the patient’s pain improved and his tachycardia resolved. He was discharged home with instructions to continue taking diazepam, and was also given prescriptions for prednisone and oxycodone/acetaminophen. He was instructed to follow-up with an orthopedist within 24 hours.

Over the next 9 days, the patient was seen twice by an orthopedist, who ordered imaging of the lumbar spine, including a repeat X-ray and contrast-enhanced magnetic resonance imaging (MRI), both of which were unremarkable. The patient completed the prescribed course of diclofenac, oxycodone/acetaminophen, and prednisone, but experienced only minimal pain relief. The orthopedist prescribed the diclofenac to supplement the medication regimen that he was already on.

At the second follow-up visit, the orthopedist ordered an MRI of the patient’s left hip, which demonstrated inflammation of the left sacroiliac joint (SIJ) with effusion, and a 1-cm by 1-cm collection adjacent to the left psoas muscle; these findings were concerning for septic arthritis (Figure). Based on the MRI study, a computed tomography (CT)-guided arthrocentesis of the left SIJ was performed by an interventional radiologist.

Discussion

Infectious sacroiliitis (ISI) is a rare form of infectious arthritis affecting the SIJ, with an incidence of 1 to 2 reported cases per year.¹ The literature on ISI currently consists only of case reports and case series. This infection is often diagnosed after the disease has progressed, with a mean time to diagnosis of 43.3 days.²

Infectious arthritis of any joint has a prevalence of 2 to 10 per 100,000 people. In 50% of cases, the knee is the joint most commonly affected, followed by the hip, shoulder, and elbow.³ Regardless of location, infectious arthritis is associated with significant morbidity and mortality due to sepsis and irreversible loss of joint function.⁴

Risk factors for ISI include IV drug use, pregnancy, trauma, endocarditis, and immunosuppression.¹ The decision to initiate the workup for ISI can be difficult to make because the condition may present without signs of an infectious etiology, such as toxic appearance, inflammatory changes surrounding the joint, or even fever—only 41% of affected patients in one case series were febrile.² The workup is often time-consuming, invasive, and expensive.

Although delayed diagnosis and treatment of septic arthritis is associated with significant adverse effects, there is unfortunately no consensus to guide the workup for ISI. As opposed to Kocher’s criteria for the differentiation of septic hip arthritis from transient synovitis in pediatric patients or well-known red-flags for further evaluation of low back pain, physicians are left without much guidance when considering laboratory workup or imaging decisions to evaluate for ISI.

Sacroiliac Joint

As previously noted, the SIJ is not commonly affected by infection. It is a diarthrodial, L-shaped joint comprised of the posterior ilium and sacrum, and is a near-rigid structure with very limited movement that provides stability to the axial skeleton.⁵ The SIJ is often overlooked as a secondary cause of low back pain in younger patients with rheumatologic conditions (eg, ankylosing spondylitis, Reiter syndrome), pregnancy-associated ligamentous laxity, and osteoarthritis in elderly patients. In one study, 88.2% of sacroiliitis cases were inflammatory, 8.8% infectious, and 2.9% degenerative.⁶

Signs and Symptoms

As our case illustrates, ISI often presents with nonspecific symptoms and physical findings.⁷ Patients typically present with fever, painful manipulation of the SIJ, and unilateral lumbo-gluteal pain.² The components of the history and physical examination suspicious for an infectious etiology include the subacute presentation; unresolved pain despite treatment; tenderness to palpation; decreased range of motion; and recent IV drug use, which increases the risk of infectious disease due to unsterile practices and direct inoculation of pathogens into the bloodstream⁸ and a further predilection into the axial skeleton. ⁹ It is important to obtain an accurate social history; however, patients may not be forthright about disclosing sensitive information such as sexual history and illicit drug use.

Physical Assessment

The SIJ is best appreciated in the seated patient by palpating one fingerbreadth medial to the posterior superior iliac spine as he or she slowly bends forward.¹⁰ Tenderness elicited while in this position is suggestive of SIJ inflammation. The area of tenderness may be lower than anticipated and lateral to the gluteal cleft, as synovial fluid is typically relegated to the lower half of the joint.

Several adjunctive physical examination maneuvers, such as the Gaenslen test and Flexion Abduction External Rotation test (FABER test or Patrick’s test) can isolate SIJ pathology or dysfunction. The Gaenslen test is performed by asking the patient to lie supine and flex the affected hip and knee, with the lumbar spine flat against the examination table. Hyperextending the contralateral thigh downward will reproduce pain in the affected SIJ.

The FABER test is a simple but less specific examination technique to assess joint pain in the hip, lumbar, and sacroiliac joints.¹¹ In this assessment, the clinician flexes the patient’s affected knee to 90°, externally rotates the hip, and applies downward pressure on the knee. Pain reproduced in the affected SI region is sensitive for joint inflammation.

Laboratory and Imaging Studies

Laboratory studies typically show inconsistent and nonspecific findings, such as the elevated ESR and CRP levels seen in our patient.^2,12 Imaging studies to assess the SIJ for signs of infection are therefore essential for confirming infection.

Magnetic resonance imaging is the preferred imaging modality to assess for ISI, since it has the highest sensitivity in visualizing joint effusion and bone marrow edema compared to other modalities. Computed tomography, however, can be helpful in visualizing associated abscesses and guiding arthrocentesis.¹² Plain X-ray may not demonstrate early changes in bone.¹³ The confirmatory study for ISI is synovial fluid analysis and culture.⁷

Treatment

Infectious sacroiliitis secondary to P aeruginosa, a gram-negative bacillus, is difficult to treat because of the glycocalyx and slime production that protects the pathogen from antibiotics, the development of multiple-antimicrobial resistance, and poor drug penetration into bones and abscesses.¹⁴ Antibiotic treatment should cover Staphylococcus aureus and may be broadened to cover gram-negative bacilli. The recommended duration of treatment is at least a 2-week course of IV antibiotics, followed by a 6-week course of oral antibiotics.² Therapy also includes pain control and surgical intervention for abscesses, osteomyelitis, and refractory cases.⁷

Complications

Complications and long-term sequelae are common in ISI, often due to late diagnosis of the condition. Our case illustrates the delayed diagnosis of Pseudomonas ISI with candidemia in a young man with a history of IV drug use presenting with atraumatic low back pain. His clinical course was complicated by a thromboembolic event, likely secondary to immobility and a hypercoagulable state from infection and inflammation.¹⁵ Infectious sacroiliitis secondary to P aeruginosa is most commonly seen in patients with immunosuppression, hospitalization, and IV drug use.²

Summary

Infectious sacroiliitis remains a diagnostic challenge for physicians due to its rare incidence and nonspecific clinical manifestations. Our case illustrates the importance of maintaining a high level of clinical suspicion for infectious arthritis in young patients presenting with common MSK complaints in the presence of infectious risk factors. Emergency physicians should consider red flags, abnormal vital signs, and patient recidivism when deciding on the most appropriate workup.

Case

A 29-year-old man presented to the ED with a 3-day history of constant left-sided low back pain that radiated to his left buttock and groin. The patient stated the pain worsened with movement, making it difficult for him to walk. He reported lifting heavy boxes at work, but denied any trauma. The patient also denied recent fevers, chills, chest pain, dyspnea, abdominal pain, urinary or fecal incontinence, weakness, numbness, or saddle anesthesia. Regarding his medical history, he had an appendectomy as a child, but reported no other surgeries or medical issues. His social history was significant for narcotic and inhalant use and daily tobacco use. The patient also reported taking heroin intravenously (IV) 6 months prior.

Vital signs at presentation were: heart rate (HR), 92 beats/min; respiratory rate, 15 breaths/min; blood pressure, 118/80 mm Hg; and temperature, 98.2°F. Oxygen saturation was 98% on room air.

The patient was a well-developed young man in no apparent distress. Dermatological examination showed bilateral track marks in the antecubital fossa. The musculoskeletal (MSK) examination demonstrated left gluteal tenderness to palpation and decreased active and passive range of motion of the left hip, especially with internal rotation and flexion. He had no midline tenderness, and the lower extremities had normal pulses and no motor or sensory deficits.

The patient’s pain improved with IV fluids, diazepam, and ketorolac, and he was able to ambulate with assistance. He was clinically diagnosed with sciatica, and discharged home with prescriptions for diazepam and ibuprofen. He was also instructed to follow-up with an orthopedist within 7 days from discharge.

The patient returned to the ED the following day with similar complaints of unabating left-sided pain and difficulty ambulating. His vital signs were notable for an elevated HR of 106 beats/min. Physical examination findings were unchanged from his presentation the previous day, and an X-ray of the lumbar spine showed no abnormalities.

After receiving IV analgesics, the patient’s pain improved and his tachycardia resolved. He was discharged home with instructions to continue taking diazepam, and was also given prescriptions for prednisone and oxycodone/acetaminophen. He was instructed to follow-up with an orthopedist within 24 hours.

Over the next 9 days, the patient was seen twice by an orthopedist, who ordered imaging of the lumbar spine, including a repeat X-ray and contrast-enhanced magnetic resonance imaging (MRI), both of which were unremarkable. The patient completed the prescribed course of diclofenac, oxycodone/acetaminophen, and prednisone, but experienced only minimal pain relief. The orthopedist prescribed the diclofenac to supplement the medication regimen that he was already on.

At the second follow-up visit, the orthopedist ordered an MRI of the patient’s left hip, which demonstrated inflammation of the left sacroiliac joint (SIJ) with effusion, and a 1-cm by 1-cm collection adjacent to the left psoas muscle; these findings were concerning for septic arthritis (Figure). Based on the MRI study, a computed tomography (CT)-guided arthrocentesis of the left SIJ was performed by an interventional radiologist.

Discussion

Infectious sacroiliitis (ISI) is a rare form of infectious arthritis affecting the SIJ, with an incidence of 1 to 2 reported cases per year.¹ The literature on ISI currently consists only of case reports and case series. This infection is often diagnosed after the disease has progressed, with a mean time to diagnosis of 43.3 days.²

Infectious arthritis of any joint has a prevalence of 2 to 10 per 100,000 people. In 50% of cases, the knee is the joint most commonly affected, followed by the hip, shoulder, and elbow.³ Regardless of location, infectious arthritis is associated with significant morbidity and mortality due to sepsis and irreversible loss of joint function.⁴

Risk factors for ISI include IV drug use, pregnancy, trauma, endocarditis, and immunosuppression.¹ The decision to initiate the workup for ISI can be difficult to make because the condition may present without signs of an infectious etiology, such as toxic appearance, inflammatory changes surrounding the joint, or even fever—only 41% of affected patients in one case series were febrile.² The workup is often time-consuming, invasive, and expensive.

Although delayed diagnosis and treatment of septic arthritis is associated with significant adverse effects, there is unfortunately no consensus to guide the workup for ISI. As opposed to Kocher’s criteria for the differentiation of septic hip arthritis from transient synovitis in pediatric patients or well-known red-flags for further evaluation of low back pain, physicians are left without much guidance when considering laboratory workup or imaging decisions to evaluate for ISI.

Sacroiliac Joint

As previously noted, the SIJ is not commonly affected by infection. It is a diarthrodial, L-shaped joint comprised of the posterior ilium and sacrum, and is a near-rigid structure with very limited movement that provides stability to the axial skeleton.⁵ The SIJ is often overlooked as a secondary cause of low back pain in younger patients with rheumatologic conditions (eg, ankylosing spondylitis, Reiter syndrome), pregnancy-associated ligamentous laxity, and osteoarthritis in elderly patients. In one study, 88.2% of sacroiliitis cases were inflammatory, 8.8% infectious, and 2.9% degenerative.⁶

Signs and Symptoms

As our case illustrates, ISI often presents with nonspecific symptoms and physical findings.⁷ Patients typically present with fever, painful manipulation of the SIJ, and unilateral lumbo-gluteal pain.² The components of the history and physical examination suspicious for an infectious etiology include the subacute presentation; unresolved pain despite treatment; tenderness to palpation; decreased range of motion; and recent IV drug use, which increases the risk of infectious disease due to unsterile practices and direct inoculation of pathogens into the bloodstream⁸ and a further predilection into the axial skeleton. ⁹ It is important to obtain an accurate social history; however, patients may not be forthright about disclosing sensitive information such as sexual history and illicit drug use.

Physical Assessment

The SIJ is best appreciated in the seated patient by palpating one fingerbreadth medial to the posterior superior iliac spine as he or she slowly bends forward.¹⁰ Tenderness elicited while in this position is suggestive of SIJ inflammation. The area of tenderness may be lower than anticipated and lateral to the gluteal cleft, as synovial fluid is typically relegated to the lower half of the joint.

Several adjunctive physical examination maneuvers, such as the Gaenslen test and Flexion Abduction External Rotation test (FABER test or Patrick’s test) can isolate SIJ pathology or dysfunction. The Gaenslen test is performed by asking the patient to lie supine and flex the affected hip and knee, with the lumbar spine flat against the examination table. Hyperextending the contralateral thigh downward will reproduce pain in the affected SIJ.

The FABER test is a simple but less specific examination technique to assess joint pain in the hip, lumbar, and sacroiliac joints.¹¹ In this assessment, the clinician flexes the patient’s affected knee to 90°, externally rotates the hip, and applies downward pressure on the knee. Pain reproduced in the affected SI region is sensitive for joint inflammation.

Laboratory and Imaging Studies

Laboratory studies typically show inconsistent and nonspecific findings, such as the elevated ESR and CRP levels seen in our patient.^2,12 Imaging studies to assess the SIJ for signs of infection are therefore essential for confirming infection.

Magnetic resonance imaging is the preferred imaging modality to assess for ISI, since it has the highest sensitivity in visualizing joint effusion and bone marrow edema compared to other modalities. Computed tomography, however, can be helpful in visualizing associated abscesses and guiding arthrocentesis.¹² Plain X-ray may not demonstrate early changes in bone.¹³ The confirmatory study for ISI is synovial fluid analysis and culture.⁷

Treatment

Infectious sacroiliitis secondary to P aeruginosa, a gram-negative bacillus, is difficult to treat because of the glycocalyx and slime production that protects the pathogen from antibiotics, the development of multiple-antimicrobial resistance, and poor drug penetration into bones and abscesses.¹⁴ Antibiotic treatment should cover Staphylococcus aureus and may be broadened to cover gram-negative bacilli. The recommended duration of treatment is at least a 2-week course of IV antibiotics, followed by a 6-week course of oral antibiotics.² Therapy also includes pain control and surgical intervention for abscesses, osteomyelitis, and refractory cases.⁷

Complications

Complications and long-term sequelae are common in ISI, often due to late diagnosis of the condition. Our case illustrates the delayed diagnosis of Pseudomonas ISI with candidemia in a young man with a history of IV drug use presenting with atraumatic low back pain. His clinical course was complicated by a thromboembolic event, likely secondary to immobility and a hypercoagulable state from infection and inflammation.¹⁵ Infectious sacroiliitis secondary to P aeruginosa is most commonly seen in patients with immunosuppression, hospitalization, and IV drug use.²

Summary

Infectious sacroiliitis remains a diagnostic challenge for physicians due to its rare incidence and nonspecific clinical manifestations. Our case illustrates the importance of maintaining a high level of clinical suspicion for infectious arthritis in young patients presenting with common MSK complaints in the presence of infectious risk factors. Emergency physicians should consider red flags, abnormal vital signs, and patient recidivism when deciding on the most appropriate workup.

Case

A 29-year-old man presented to the ED with a 3-day history of constant left-sided low back pain that radiated to his left buttock and groin. The patient stated the pain worsened with movement, making it difficult for him to walk. He reported lifting heavy boxes at work, but denied any trauma. The patient also denied recent fevers, chills, chest pain, dyspnea, abdominal pain, urinary or fecal incontinence, weakness, numbness, or saddle anesthesia. Regarding his medical history, he had an appendectomy as a child, but reported no other surgeries or medical issues. His social history was significant for narcotic and inhalant use and daily tobacco use. The patient also reported taking heroin intravenously (IV) 6 months prior.

Vital signs at presentation were: heart rate (HR), 92 beats/min; respiratory rate, 15 breaths/min; blood pressure, 118/80 mm Hg; and temperature, 98.2°F. Oxygen saturation was 98% on room air.

The patient was a well-developed young man in no apparent distress. Dermatological examination showed bilateral track marks in the antecubital fossa. The musculoskeletal (MSK) examination demonstrated left gluteal tenderness to palpation and decreased active and passive range of motion of the left hip, especially with internal rotation and flexion. He had no midline tenderness, and the lower extremities had normal pulses and no motor or sensory deficits.

The patient’s pain improved with IV fluids, diazepam, and ketorolac, and he was able to ambulate with assistance. He was clinically diagnosed with sciatica, and discharged home with prescriptions for diazepam and ibuprofen. He was also instructed to follow-up with an orthopedist within 7 days from discharge.

The patient returned to the ED the following day with similar complaints of unabating left-sided pain and difficulty ambulating. His vital signs were notable for an elevated HR of 106 beats/min. Physical examination findings were unchanged from his presentation the previous day, and an X-ray of the lumbar spine showed no abnormalities.

After receiving IV analgesics, the patient’s pain improved and his tachycardia resolved. He was discharged home with instructions to continue taking diazepam, and was also given prescriptions for prednisone and oxycodone/acetaminophen. He was instructed to follow-up with an orthopedist within 24 hours.

Over the next 9 days, the patient was seen twice by an orthopedist, who ordered imaging of the lumbar spine, including a repeat X-ray and contrast-enhanced magnetic resonance imaging (MRI), both of which were unremarkable. The patient completed the prescribed course of diclofenac, oxycodone/acetaminophen, and prednisone, but experienced only minimal pain relief. The orthopedist prescribed the diclofenac to supplement the medication regimen that he was already on.

At the second follow-up visit, the orthopedist ordered an MRI of the patient’s left hip, which demonstrated inflammation of the left sacroiliac joint (SIJ) with effusion, and a 1-cm by 1-cm collection adjacent to the left psoas muscle; these findings were concerning for septic arthritis (Figure). Based on the MRI study, a computed tomography (CT)-guided arthrocentesis of the left SIJ was performed by an interventional radiologist.

Discussion

Infectious sacroiliitis (ISI) is a rare form of infectious arthritis affecting the SIJ, with an incidence of 1 to 2 reported cases per year.¹ The literature on ISI currently consists only of case reports and case series. This infection is often diagnosed after the disease has progressed, with a mean time to diagnosis of 43.3 days.²

Infectious arthritis of any joint has a prevalence of 2 to 10 per 100,000 people. In 50% of cases, the knee is the joint most commonly affected, followed by the hip, shoulder, and elbow.³ Regardless of location, infectious arthritis is associated with significant morbidity and mortality due to sepsis and irreversible loss of joint function.⁴

Risk factors for ISI include IV drug use, pregnancy, trauma, endocarditis, and immunosuppression.¹ The decision to initiate the workup for ISI can be difficult to make because the condition may present without signs of an infectious etiology, such as toxic appearance, inflammatory changes surrounding the joint, or even fever—only 41% of affected patients in one case series were febrile.² The workup is often time-consuming, invasive, and expensive.

Although delayed diagnosis and treatment of septic arthritis is associated with significant adverse effects, there is unfortunately no consensus to guide the workup for ISI. As opposed to Kocher’s criteria for the differentiation of septic hip arthritis from transient synovitis in pediatric patients or well-known red-flags for further evaluation of low back pain, physicians are left without much guidance when considering laboratory workup or imaging decisions to evaluate for ISI.

Sacroiliac Joint

As previously noted, the SIJ is not commonly affected by infection. It is a diarthrodial, L-shaped joint comprised of the posterior ilium and sacrum, and is a near-rigid structure with very limited movement that provides stability to the axial skeleton.⁵ The SIJ is often overlooked as a secondary cause of low back pain in younger patients with rheumatologic conditions (eg, ankylosing spondylitis, Reiter syndrome), pregnancy-associated ligamentous laxity, and osteoarthritis in elderly patients. In one study, 88.2% of sacroiliitis cases were inflammatory, 8.8% infectious, and 2.9% degenerative.⁶

Signs and Symptoms

As our case illustrates, ISI often presents with nonspecific symptoms and physical findings.⁷ Patients typically present with fever, painful manipulation of the SIJ, and unilateral lumbo-gluteal pain.² The components of the history and physical examination suspicious for an infectious etiology include the subacute presentation; unresolved pain despite treatment; tenderness to palpation; decreased range of motion; and recent IV drug use, which increases the risk of infectious disease due to unsterile practices and direct inoculation of pathogens into the bloodstream⁸ and a further predilection into the axial skeleton. ⁹ It is important to obtain an accurate social history; however, patients may not be forthright about disclosing sensitive information such as sexual history and illicit drug use.

Physical Assessment

The SIJ is best appreciated in the seated patient by palpating one fingerbreadth medial to the posterior superior iliac spine as he or she slowly bends forward.¹⁰ Tenderness elicited while in this position is suggestive of SIJ inflammation. The area of tenderness may be lower than anticipated and lateral to the gluteal cleft, as synovial fluid is typically relegated to the lower half of the joint.

Several adjunctive physical examination maneuvers, such as the Gaenslen test and Flexion Abduction External Rotation test (FABER test or Patrick’s test) can isolate SIJ pathology or dysfunction. The Gaenslen test is performed by asking the patient to lie supine and flex the affected hip and knee, with the lumbar spine flat against the examination table. Hyperextending the contralateral thigh downward will reproduce pain in the affected SIJ.

The FABER test is a simple but less specific examination technique to assess joint pain in the hip, lumbar, and sacroiliac joints.¹¹ In this assessment, the clinician flexes the patient’s affected knee to 90°, externally rotates the hip, and applies downward pressure on the knee. Pain reproduced in the affected SI region is sensitive for joint inflammation.

Laboratory and Imaging Studies

Laboratory studies typically show inconsistent and nonspecific findings, such as the elevated ESR and CRP levels seen in our patient.^2,12 Imaging studies to assess the SIJ for signs of infection are therefore essential for confirming infection.

Magnetic resonance imaging is the preferred imaging modality to assess for ISI, since it has the highest sensitivity in visualizing joint effusion and bone marrow edema compared to other modalities. Computed tomography, however, can be helpful in visualizing associated abscesses and guiding arthrocentesis.¹² Plain X-ray may not demonstrate early changes in bone.¹³ The confirmatory study for ISI is synovial fluid analysis and culture.⁷

Treatment

Infectious sacroiliitis secondary to P aeruginosa, a gram-negative bacillus, is difficult to treat because of the glycocalyx and slime production that protects the pathogen from antibiotics, the development of multiple-antimicrobial resistance, and poor drug penetration into bones and abscesses.¹⁴ Antibiotic treatment should cover Staphylococcus aureus and may be broadened to cover gram-negative bacilli. The recommended duration of treatment is at least a 2-week course of IV antibiotics, followed by a 6-week course of oral antibiotics.² Therapy also includes pain control and surgical intervention for abscesses, osteomyelitis, and refractory cases.⁷

Complications

Complications and long-term sequelae are common in ISI, often due to late diagnosis of the condition. Our case illustrates the delayed diagnosis of Pseudomonas ISI with candidemia in a young man with a history of IV drug use presenting with atraumatic low back pain. His clinical course was complicated by a thromboembolic event, likely secondary to immobility and a hypercoagulable state from infection and inflammation.¹⁵ Infectious sacroiliitis secondary to P aeruginosa is most commonly seen in patients with immunosuppression, hospitalization, and IV drug use.²

Summary

Infectious sacroiliitis remains a diagnostic challenge for physicians due to its rare incidence and nonspecific clinical manifestations. Our case illustrates the importance of maintaining a high level of clinical suspicion for infectious arthritis in young patients presenting with common MSK complaints in the presence of infectious risk factors. Emergency physicians should consider red flags, abnormal vital signs, and patient recidivism when deciding on the most appropriate workup.

Case

A 61-year-old woman presented to the ED for evaluation of left-side facial pain following a fall. The patient stated that she lost her balance as she was getting out of her car and fell to the ground, striking her left face and head. She denied any loss of consciousness, and complained of primarily left periorbital pain and swelling. She also denied neck or extremity pain, and was ambulatory after the fall. Her medical history was significant for hypertension and gastroesophageal reflux disease, for which she took medications. She admitted to a modest use of alcohol but denied tobacco use.

On physical examination, the patient’s vital signs were: blood pressure, 148/92 mm Hg; heart rate, 104 beats/min; respiratory rate, 18 breaths/min; and temperature, 98.8^oF. Oxygen saturation was 98% on room air. Examination of the head and face revealed marked left periorbital bruising and swelling, and abrasions to the left forehead and anterior temporal area. The left eye was swollen shut. The right pupil was round and reactive to light, with intact extraocular muscle movement. The patient was tender to palpation around the left periorbital area, but not on any other areas of her face or cranium. The neck was nontender in the midline posteriorly, and the patient’s neurological examination was normal. Examination of the lungs, heart, and abdomen were likewise normal. No measurement of visual acuity was obtained.

The emergency physician (EP) ordered a computed tomography (CT) scan of the head and face without contrast. Because the patient could not remember the date of her last tetanus shot, a tetanus immunization was administered. The EP made several attempts to open the patient’s left eye to examine the pupil and anterior chamber, but was unable to do so because of the marked swelling and the patient’s discomfort.

Radiology services reported that the CT scan of the head was normal, while the CT scan of the face revealed a left orbital floor fracture. The patient was discharged home with instructions to place ice on the areas of swelling and to avoid blowing her nose. She was also given a prescription for hydrocodone/acetaminophen and instructed to follow-up with an ophthalmologist in 1 week.

Unfortunately, the patient suffered permanent and complete loss of sight in the left eye. She sued the hospital and the EP for failure to perform a complete physical examination and consult with an ophthalmologist to determine the extent of her injuries. In addition, an overread of the CT scan of the face revealed entrapment of the left inferior rectus muscle, which the original radiologist did not include in his report. The jury returned a defense verdict.

Discussion

This case is unfortunate because the critical injury, entrapment of the inferior rectus muscle, was missed by two physicians—the EP and the radiologist. While this injury can sometimes be detected on CT, most clinicians agree that orbital muscle entrapment is a clinical diagnosis. The most significant omission in this case is that the EP neither examined the affected eye nor tested the extraocular muscles. If the EP had done so, then in all likelihood this injury would have been identified and ophthalmology services would have been consulted.

Visual acuity should be considered a sixth vital sign in patients who present with an eye injury. This test can be performed using a wall, pocket, or mobile-app Snellen chart.¹ If the patient is unable to perform an eye examination, the EP should assess for light and color perception.¹ A complete loss of vision implies injury to the optic nerve or globe.¹

When possible, it is best to attempt to examine the eyes prior to the onset of significant eyelid swelling. In the presence of significant swelling, lid retractors (eg, paper clip retractors) can be used to allow proper examination of the eye. The pupil, sclera, anterior chamber, and eye movement should all be assessed. Limited vertical movement of the globe, vertical diplopia, and pain in the inferior orbit on attempted vertical movement are consistent with entrapment of the inferior rectus muscle.² The presence of enophthalmos (posterior displacement of the globe within the orbit) and globe ptosis (downward displacement of the globe within the orbit) should be noted because these often indicate a significant fracture.²

The majority of orbital floor fractures do not require surgical repair. Most are followed for 5 to 10 days to allow swelling and orbital hemorrhage to subside.² Prednisone (1 mg/kg/d for 7 days) can decrease edema and may limit the risk of diplopia from inferior rectus muscle contractions and fibrosis. However, the presence of tight entrapment of the inferior rectus muscle, or CT scan demonstration of the inferior rectus muscle within the maxillary sinus, is an indication for immediate surgical intervention.²

As physicians, it is imperative that we thoroughly examine the area of primary complaint which, as this case demonstrates, is not always easy.

Case

A 61-year-old woman presented to the ED for evaluation of left-side facial pain following a fall. The patient stated that she lost her balance as she was getting out of her car and fell to the ground, striking her left face and head. She denied any loss of consciousness, and complained of primarily left periorbital pain and swelling. She also denied neck or extremity pain, and was ambulatory after the fall. Her medical history was significant for hypertension and gastroesophageal reflux disease, for which she took medications. She admitted to a modest use of alcohol but denied tobacco use.

On physical examination, the patient’s vital signs were: blood pressure, 148/92 mm Hg; heart rate, 104 beats/min; respiratory rate, 18 breaths/min; and temperature, 98.8^oF. Oxygen saturation was 98% on room air. Examination of the head and face revealed marked left periorbital bruising and swelling, and abrasions to the left forehead and anterior temporal area. The left eye was swollen shut. The right pupil was round and reactive to light, with intact extraocular muscle movement. The patient was tender to palpation around the left periorbital area, but not on any other areas of her face or cranium. The neck was nontender in the midline posteriorly, and the patient’s neurological examination was normal. Examination of the lungs, heart, and abdomen were likewise normal. No measurement of visual acuity was obtained.

The emergency physician (EP) ordered a computed tomography (CT) scan of the head and face without contrast. Because the patient could not remember the date of her last tetanus shot, a tetanus immunization was administered. The EP made several attempts to open the patient’s left eye to examine the pupil and anterior chamber, but was unable to do so because of the marked swelling and the patient’s discomfort.

Radiology services reported that the CT scan of the head was normal, while the CT scan of the face revealed a left orbital floor fracture. The patient was discharged home with instructions to place ice on the areas of swelling and to avoid blowing her nose. She was also given a prescription for hydrocodone/acetaminophen and instructed to follow-up with an ophthalmologist in 1 week.

Unfortunately, the patient suffered permanent and complete loss of sight in the left eye. She sued the hospital and the EP for failure to perform a complete physical examination and consult with an ophthalmologist to determine the extent of her injuries. In addition, an overread of the CT scan of the face revealed entrapment of the left inferior rectus muscle, which the original radiologist did not include in his report. The jury returned a defense verdict.

Discussion

This case is unfortunate because the critical injury, entrapment of the inferior rectus muscle, was missed by two physicians—the EP and the radiologist. While this injury can sometimes be detected on CT, most clinicians agree that orbital muscle entrapment is a clinical diagnosis. The most significant omission in this case is that the EP neither examined the affected eye nor tested the extraocular muscles. If the EP had done so, then in all likelihood this injury would have been identified and ophthalmology services would have been consulted.

Visual acuity should be considered a sixth vital sign in patients who present with an eye injury. This test can be performed using a wall, pocket, or mobile-app Snellen chart.¹ If the patient is unable to perform an eye examination, the EP should assess for light and color perception.¹ A complete loss of vision implies injury to the optic nerve or globe.¹

When possible, it is best to attempt to examine the eyes prior to the onset of significant eyelid swelling. In the presence of significant swelling, lid retractors (eg, paper clip retractors) can be used to allow proper examination of the eye. The pupil, sclera, anterior chamber, and eye movement should all be assessed. Limited vertical movement of the globe, vertical diplopia, and pain in the inferior orbit on attempted vertical movement are consistent with entrapment of the inferior rectus muscle.² The presence of enophthalmos (posterior displacement of the globe within the orbit) and globe ptosis (downward displacement of the globe within the orbit) should be noted because these often indicate a significant fracture.²

The majority of orbital floor fractures do not require surgical repair. Most are followed for 5 to 10 days to allow swelling and orbital hemorrhage to subside.² Prednisone (1 mg/kg/d for 7 days) can decrease edema and may limit the risk of diplopia from inferior rectus muscle contractions and fibrosis. However, the presence of tight entrapment of the inferior rectus muscle, or CT scan demonstration of the inferior rectus muscle within the maxillary sinus, is an indication for immediate surgical intervention.²

As physicians, it is imperative that we thoroughly examine the area of primary complaint which, as this case demonstrates, is not always easy.

Case

A 61-year-old woman presented to the ED for evaluation of left-side facial pain following a fall. The patient stated that she lost her balance as she was getting out of her car and fell to the ground, striking her left face and head. She denied any loss of consciousness, and complained of primarily left periorbital pain and swelling. She also denied neck or extremity pain, and was ambulatory after the fall. Her medical history was significant for hypertension and gastroesophageal reflux disease, for which she took medications. She admitted to a modest use of alcohol but denied tobacco use.

On physical examination, the patient’s vital signs were: blood pressure, 148/92 mm Hg; heart rate, 104 beats/min; respiratory rate, 18 breaths/min; and temperature, 98.8^oF. Oxygen saturation was 98% on room air. Examination of the head and face revealed marked left periorbital bruising and swelling, and abrasions to the left forehead and anterior temporal area. The left eye was swollen shut. The right pupil was round and reactive to light, with intact extraocular muscle movement. The patient was tender to palpation around the left periorbital area, but not on any other areas of her face or cranium. The neck was nontender in the midline posteriorly, and the patient’s neurological examination was normal. Examination of the lungs, heart, and abdomen were likewise normal. No measurement of visual acuity was obtained.

The emergency physician (EP) ordered a computed tomography (CT) scan of the head and face without contrast. Because the patient could not remember the date of her last tetanus shot, a tetanus immunization was administered. The EP made several attempts to open the patient’s left eye to examine the pupil and anterior chamber, but was unable to do so because of the marked swelling and the patient’s discomfort.

Radiology services reported that the CT scan of the head was normal, while the CT scan of the face revealed a left orbital floor fracture. The patient was discharged home with instructions to place ice on the areas of swelling and to avoid blowing her nose. She was also given a prescription for hydrocodone/acetaminophen and instructed to follow-up with an ophthalmologist in 1 week.

Unfortunately, the patient suffered permanent and complete loss of sight in the left eye. She sued the hospital and the EP for failure to perform a complete physical examination and consult with an ophthalmologist to determine the extent of her injuries. In addition, an overread of the CT scan of the face revealed entrapment of the left inferior rectus muscle, which the original radiologist did not include in his report. The jury returned a defense verdict.

Discussion

This case is unfortunate because the critical injury, entrapment of the inferior rectus muscle, was missed by two physicians—the EP and the radiologist. While this injury can sometimes be detected on CT, most clinicians agree that orbital muscle entrapment is a clinical diagnosis. The most significant omission in this case is that the EP neither examined the affected eye nor tested the extraocular muscles. If the EP had done so, then in all likelihood this injury would have been identified and ophthalmology services would have been consulted.

Visual acuity should be considered a sixth vital sign in patients who present with an eye injury. This test can be performed using a wall, pocket, or mobile-app Snellen chart.¹ If the patient is unable to perform an eye examination, the EP should assess for light and color perception.¹ A complete loss of vision implies injury to the optic nerve or globe.¹

When possible, it is best to attempt to examine the eyes prior to the onset of significant eyelid swelling. In the presence of significant swelling, lid retractors (eg, paper clip retractors) can be used to allow proper examination of the eye. The pupil, sclera, anterior chamber, and eye movement should all be assessed. Limited vertical movement of the globe, vertical diplopia, and pain in the inferior orbit on attempted vertical movement are consistent with entrapment of the inferior rectus muscle.² The presence of enophthalmos (posterior displacement of the globe within the orbit) and globe ptosis (downward displacement of the globe within the orbit) should be noted because these often indicate a significant fracture.²

The majority of orbital floor fractures do not require surgical repair. Most are followed for 5 to 10 days to allow swelling and orbital hemorrhage to subside.² Prednisone (1 mg/kg/d for 7 days) can decrease edema and may limit the risk of diplopia from inferior rectus muscle contractions and fibrosis. However, the presence of tight entrapment of the inferior rectus muscle, or CT scan demonstration of the inferior rectus muscle within the maxillary sinus, is an indication for immediate surgical intervention.²

As physicians, it is imperative that we thoroughly examine the area of primary complaint which, as this case demonstrates, is not always easy.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

A 20-year-old woman with no significant medical history presented to the ED with a several-month history of worsening abdominal pain. She reported that although she previously had been evaluated at multiple EDs, no cause of her abdominal pain had been identified. The patient further noted that the pain had significantly increased the day of this presentation.

Physical examination revealed guarding and rebound tenderness in the midabdomen. Computed tomography (CT) studies of the abdomen and pelvis were performed; representative scout and axial images of the upper abdomen are shown above (Figures 1 and 2).

What is the suspected diagnosis?

Answer

The scout image of the abdomen revealed a distended stomach (white arrows, Figure 3), which displaced multiple loops of small bowel into the lower abdomen. The axial image through the upper abdomen showed air and solid material within the distended stomach (white arrows, Figure 4). Multiple foci of extraluminal (free) air were seen anteriorly (white asterisks, Figure 4). A coronal reformat of the CT better demonstrated the distended stomach filled with debris (white arrows, Figure 5), extraluminal air (white asterisk, Figure 5), and pneumatosis (air within the walls of multiple small bowel loops; red arrows, Figure 5).

These findings indicated a bowel obstruction and perforation due to the presence of a gastric bezoar. Upon further questioning, the patient admitted to a stress-related habit of eating her own hair (trichophagia) over the past 3 to 4 months.

Bezoars

Gastric bezoars are aggregates of nondigestible material that collect within the gastrointestinal system, usually fruit/vegetable matter (phytobezoars) or hair (trichobezoars). Phytobezoars are most common in patients with a history of reduced gastric motility and/or prior gastric surgery. Trichobezoars, similar to the one seen in this case, typically occur in young women and/or patients with psychiatric illness.¹

Gastric bezoars are typically located in the gastric body but may extend into the small bowel and cause bowel obstruction. Trichobezoars that extend into the small bowel are referred to as “Rapunzel syndrome” (based on the fairy tale of the princess with long hair).

Clinical Presentation

Patients with gastric bezoars often present to the ED with nonspecific complaints of abdominal pain, including early satiety, weight loss, signs of anemia, abdominal pain, bloating, and symptoms of small bowel obstruction (SBO).² Obtaining a thorough history is important to identify trichophagia, as only a small percentage of patients have evidence of alopecia on examination.

Workup

The workup for patients with gastric bezoars typically involves multiple imaging modalities. While abdominal radiography may demonstrate distention of the stomach, these findings are often nonspecific, and the characteristic feature of a mass with a diffusely mottled appearance is visualized in less than 20% of cases.

Computed tomography is the test of choice for detecting a bezoar, with a reported sensitivity of 97%.³ This modality is also useful for assessing the size of a bezoar and evaluating for complications such as SBO, perforation (free-air), or pneumatosis—all of which were revealed on this patient’s CT studies.

Treatment

The treatment for patients with large or obstructing gastric bezoars is surgical resection; both open and laparoscopic techniques have been described in the literature.^2,4 The patient in this case was admitted to the hospital, where she underwent surgical removal of the bezoar. She was discharged home on hospital day 6 with outpatient psychiatric follow-up.

BY JEFF BAUER

Use of a blood collection system that diverts and sequesters the initial 1.5 to 2 mL of blood was associated with a significant decrease in blood culture contamination compared to standard practice, according to an open-label trial conducted at a single ED. The results were published online in the journal Clinical Infectious Diseases.

An estimated 0.6% to 6% of blood cultures are contaminated. Some blood cultures may become contaminated by skin fragments colonized with bacteria that are dislodged during venipuncture. Such false-positive results lead to increased costs and harm associated with unnecessary additional testing and treatment.

Researchers at the University of Nebraska Medical Center evaluated a novel sterile blood collection system, the SteriPath initial specimen diversion device (ISDD), to determine if it could reduce contamination rates by diverting and excluding the initial portion of collected blood. Investigators evaluated 1,808 blood cultures from 904 adult ED patients at an urban 689-bed university hospital. The patients’ mean age was 59 years, and 55% were male. For each patient, the first 20-mL blood sample was obtained using a standard procedure in which blood was drawn into a syringe and then injected into blood culture vials. A second 20-mL sample was obtained using the ISDD; the initial 1.5 to 2 mL of blood was diverted into a holding chamber, and the rest of the sample was directed into the blood culture vials. A culture was determined to be contaminated if one or more of several skin-residing organisms, including coagulase-negative staphylococci, Propionibacterium species, Micrococcus species, viridans group streptococci, Corynebacterium species, or Bacillus species, was recovered from only one of the paired cultures.

Compared to standard practice, use of the ISDD was associated with a significant reduction in blood culture contamination. Overall, two of the 904 samples (0.22%) collected with the ISDD were contaminated, compared to 16 of the 904 samples (1.78%) collected via standard practice (P = .001). Sensitivity was not affected by use of the ISDD; true septicemia was observed in 65 of 904 samples (7.2%) collected via ISDD and 69 of 904 samples (7.6%) collected via standard procedure (P = .41).

Rupp ME, Cavalieri RJ, Marolf C, Lyden E. Reduction in blood culture contamination through use of initial specimen diversion device. Clin Infect Dis. 2017 Apr 3. [Epub ahead of print]. doi:10.1093/cid/cix304.

FDA: Fluoroquinolone Use Not Linked to Retinal Detachment, Aortic Problems

LUCAS FRANKI

FRONTLINE MEDICAL NEWS

The Food and Drug Administration (FDA) has found no evidence of a link between fluoroquinolone antibiotic use and retinal detachment or aortic aneurysm and dissection, according to a new Drug Safety Communication update on potential serious, disabling adverse effects of oral and injectable fluoroquinolones.

Fluoroquinolones are used to treat acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections.

In a Safety Communication published May 12, 2016, the FDA noted that serious adverse effects were possible from fluoroquinolone usage and that fluoroquinolones should be prescribed only when no other treatment options are possible. Serious adverse effects associated with fluoroquinolone use include hallucination, depression, suicidal thoughts, tendinitis and tendon rupture, a pins-and-needles feeling in the arms and legs, joint pain and swelling, skin rash, and severe diarrhea.

After reviewing patient cases and study findings, the FDA said the evidence did not support an association between fluoroquinolone use and potential retinal or aortic dangers, according to its May 10, 2017, Drug Safety Communication update.

“We will continue to assess safety issues with fluoroquinolones, and will update the public if additional actions are needed,” the FDA said in a statement.

US Food and Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. May 10, 2017. https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm. Accessed May 25, 2017.

Intravenous tPA Increases Risk of Mortality in Children With Acute Ischemic Stroke

SHARON WORCESTER

FRONTLINE MEDICAL NEWS

Intravenous thrombolysis with tissue plasminogen activator (tPA) is associated with adverse outcomes, including an increased risk of death, in children with acute ischemic stroke, based on a review of cases from the 2006-2010 Nationwide Inpatient Survey.

Of 20,587 patients ages 0 to 17 years who were included in the survey, 198 received an intervention, including tPA in 169 patients, intra-arterial thrombectomy (IAT) in five patients, and both tPA and IAT in 24 patients. The overall mortality rate was 7.8%, but in those who received tPA, it was 13.8%, compared with 7.7% in those who did not, Kathryn Ess, MD, of Rush University Medical Center, Chicago, reported at the annual meeting of the American Academy of Neurology. No deaths occurred in those who underwent only IAT, said Dr Ess.

Other outcomes were also worse for those who received tPA. For example, untreated patients were more likely to be discharged home than were tPA-treated patients (67.8% vs 47.5%), and intracerebral hemorrhage was more common in treated vs untreated patients (10.1% vs 3.8%). Costs for treated patients averaged $200,346 vs $123,015 for untreated patients.

Children included in the review had a mean age of 6 years, 43.9% were girls, and 47.7% were white. Treated patients were older (10 years vs 5.9 years), and comorbidities included Moyamoya disease in 12.4% of patients, cardiac valvular disease in 6.6%, and sickle cell disease in 6.5%. Those who received tPA had a higher prevalence of procoagulable conditions (15.2% vs 2%). Of note, the higher prevalence of intracerebral hemorrhage in treated patients was not explained by Moyamoya or sickle cell disease, as patients with those comorbidities were less likely than those without those conditions to receive treatment, Dr Ess said.

Though limited by the retrospective study design, small numbers of treated patients, a lack of data on stroke severity or functional outcomes, and the inclusion of data from years before newer thrombectomy devices became available, the findings highlight concerns about the safety and efficacy of tPA in children with ischemic stroke, she said, noting that few studies have looked at the utility of tPA with or without IAT in the pediatric population.

“Studies of the efficacy of ischemic stroke treatment in adults can’t necessarily be extrapolated to children,” she said, adding that this is especially true given the difference in etiologies of pediatric acute ischemic stroke.

Indeed, the findings underscore “the age-old adage that children are not just little adults,” said Andrew Southerland, MD, of the University of Virginia, Charlottesville, who was the discussant for the session. “We need prospective clinical trials in children,” he said.

HCV Seroconversion Rate 0.1% After Occupational Exposure

BIANCA NOGRADY

FRONTLINE MEDICAL NEWS

An analysis of 13 years of accidental occupational exposures to hepatitis C virus (HCV)-contaminated fluids or instruments has revealed a seroconversion rate of just 0.1%, significantly lower than that previously reported in the literature. This finding is from a longitudinal analysis of data from a prospectively maintained database of 1,361 occupational injuries involving HCV-positive source that occurred between 2002 and 2015 conducted by Francesco M. Egro, MD, and his colleagues from the University of Pittsburgh Medical Center. Results were published online in the American Journal of Infection Control.

The two incidents of seroconversion occurred in patients who were exposed to blood from an HCV-positive patient via percutaneous injuries to the thumb from a hollow-bore needle, representing an overall seroconversion rate of 0.1%. In both cases, the source patients whose blood was involved were not coinfected with hepatitis B virus or human immunodeficiency virus.

Researchers also conducted a review of literature on needlestick injuries and occupational exposure to HCV-infected blood and fluids; from this review, they calculated an overall seroconversion rate average of 0.7%, with an average rate of 0.8% for percutaneous exposures. The review did not include mucomembranous exposure, as there were not enough data.

In this study, 65% of exposures were caused by percutaneous injuries and 34% were caused by mucocutaneous injuries; the cause of the remaining 1% was uncertain.

The hand was the most common site of injury (63%), followed by the face and neck (28%), and the arm, foot, leg, or trunk (4%). There was no record of the anatomical location of the injury in 5% of cases.

In nearly three-quarters of cases, blood was the source of exposure, while blood-containing saliva accounted for 3% of cases. The remaining 24% of cases were linked to other fluids, such as peritoneal fluid, tracheal secretions, amniotic fluid, bloody irrigation fluid, and blood-containing feces.

“The risk of transmission after exposure to HCV-positive patients’ fluids or tissues other than blood is expected to be low, but has not been formally quantified,” the authors wrote. “Although there have been reports of HCV seroconversion after human bites and after punching a HCV-positive individual in the teeth, percutaneous exposures to the blood of a HCV-positive source remain the most common cause of occupational HCV transmission.”

While the rate of seroconversion was low, the authors encouraged prompt reporting, testing, and follow-up of exposed individuals.

Egro FM, Nwaiwu CA, Smith S, Harper JD, Spiess AM. Seroconversion rates among health care workers exposed to hepatitis C virus-contaminated body fluids: The University of Pittsburgh 13-year experience. Am J Infect Control. 2017 Apr 24. [Epub ahead of print]. doi:10.1016/j.ajic.2017.03.011.

BY JEFF BAUER

Use of a blood collection system that diverts and sequesters the initial 1.5 to 2 mL of blood was associated with a significant decrease in blood culture contamination compared to standard practice, according to an open-label trial conducted at a single ED. The results were published online in the journal Clinical Infectious Diseases.

An estimated 0.6% to 6% of blood cultures are contaminated. Some blood cultures may become contaminated by skin fragments colonized with bacteria that are dislodged during venipuncture. Such false-positive results lead to increased costs and harm associated with unnecessary additional testing and treatment.

Researchers at the University of Nebraska Medical Center evaluated a novel sterile blood collection system, the SteriPath initial specimen diversion device (ISDD), to determine if it could reduce contamination rates by diverting and excluding the initial portion of collected blood. Investigators evaluated 1,808 blood cultures from 904 adult ED patients at an urban 689-bed university hospital. The patients’ mean age was 59 years, and 55% were male. For each patient, the first 20-mL blood sample was obtained using a standard procedure in which blood was drawn into a syringe and then injected into blood culture vials. A second 20-mL sample was obtained using the ISDD; the initial 1.5 to 2 mL of blood was diverted into a holding chamber, and the rest of the sample was directed into the blood culture vials. A culture was determined to be contaminated if one or more of several skin-residing organisms, including coagulase-negative staphylococci, Propionibacterium species, Micrococcus species, viridans group streptococci, Corynebacterium species, or Bacillus species, was recovered from only one of the paired cultures.

Compared to standard practice, use of the ISDD was associated with a significant reduction in blood culture contamination. Overall, two of the 904 samples (0.22%) collected with the ISDD were contaminated, compared to 16 of the 904 samples (1.78%) collected via standard practice (P = .001). Sensitivity was not affected by use of the ISDD; true septicemia was observed in 65 of 904 samples (7.2%) collected via ISDD and 69 of 904 samples (7.6%) collected via standard procedure (P = .41).

Rupp ME, Cavalieri RJ, Marolf C, Lyden E. Reduction in blood culture contamination through use of initial specimen diversion device. Clin Infect Dis. 2017 Apr 3. [Epub ahead of print]. doi:10.1093/cid/cix304.

FDA: Fluoroquinolone Use Not Linked to Retinal Detachment, Aortic Problems

LUCAS FRANKI

FRONTLINE MEDICAL NEWS

The Food and Drug Administration (FDA) has found no evidence of a link between fluoroquinolone antibiotic use and retinal detachment or aortic aneurysm and dissection, according to a new Drug Safety Communication update on potential serious, disabling adverse effects of oral and injectable fluoroquinolones.

Fluoroquinolones are used to treat acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections.

In a Safety Communication published May 12, 2016, the FDA noted that serious adverse effects were possible from fluoroquinolone usage and that fluoroquinolones should be prescribed only when no other treatment options are possible. Serious adverse effects associated with fluoroquinolone use include hallucination, depression, suicidal thoughts, tendinitis and tendon rupture, a pins-and-needles feeling in the arms and legs, joint pain and swelling, skin rash, and severe diarrhea.

After reviewing patient cases and study findings, the FDA said the evidence did not support an association between fluoroquinolone use and potential retinal or aortic dangers, according to its May 10, 2017, Drug Safety Communication update.

“We will continue to assess safety issues with fluoroquinolones, and will update the public if additional actions are needed,” the FDA said in a statement.

US Food and Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. May 10, 2017. https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm. Accessed May 25, 2017.

Intravenous tPA Increases Risk of Mortality in Children With Acute Ischemic Stroke

SHARON WORCESTER

FRONTLINE MEDICAL NEWS

Intravenous thrombolysis with tissue plasminogen activator (tPA) is associated with adverse outcomes, including an increased risk of death, in children with acute ischemic stroke, based on a review of cases from the 2006-2010 Nationwide Inpatient Survey.

Of 20,587 patients ages 0 to 17 years who were included in the survey, 198 received an intervention, including tPA in 169 patients, intra-arterial thrombectomy (IAT) in five patients, and both tPA and IAT in 24 patients. The overall mortality rate was 7.8%, but in those who received tPA, it was 13.8%, compared with 7.7% in those who did not, Kathryn Ess, MD, of Rush University Medical Center, Chicago, reported at the annual meeting of the American Academy of Neurology. No deaths occurred in those who underwent only IAT, said Dr Ess.

Other outcomes were also worse for those who received tPA. For example, untreated patients were more likely to be discharged home than were tPA-treated patients (67.8% vs 47.5%), and intracerebral hemorrhage was more common in treated vs untreated patients (10.1% vs 3.8%). Costs for treated patients averaged $200,346 vs $123,015 for untreated patients.

Children included in the review had a mean age of 6 years, 43.9% were girls, and 47.7% were white. Treated patients were older (10 years vs 5.9 years), and comorbidities included Moyamoya disease in 12.4% of patients, cardiac valvular disease in 6.6%, and sickle cell disease in 6.5%. Those who received tPA had a higher prevalence of procoagulable conditions (15.2% vs 2%). Of note, the higher prevalence of intracerebral hemorrhage in treated patients was not explained by Moyamoya or sickle cell disease, as patients with those comorbidities were less likely than those without those conditions to receive treatment, Dr Ess said.

Though limited by the retrospective study design, small numbers of treated patients, a lack of data on stroke severity or functional outcomes, and the inclusion of data from years before newer thrombectomy devices became available, the findings highlight concerns about the safety and efficacy of tPA in children with ischemic stroke, she said, noting that few studies have looked at the utility of tPA with or without IAT in the pediatric population.

“Studies of the efficacy of ischemic stroke treatment in adults can’t necessarily be extrapolated to children,” she said, adding that this is especially true given the difference in etiologies of pediatric acute ischemic stroke.

Indeed, the findings underscore “the age-old adage that children are not just little adults,” said Andrew Southerland, MD, of the University of Virginia, Charlottesville, who was the discussant for the session. “We need prospective clinical trials in children,” he said.

HCV Seroconversion Rate 0.1% After Occupational Exposure

BIANCA NOGRADY

FRONTLINE MEDICAL NEWS

An analysis of 13 years of accidental occupational exposures to hepatitis C virus (HCV)-contaminated fluids or instruments has revealed a seroconversion rate of just 0.1%, significantly lower than that previously reported in the literature. This finding is from a longitudinal analysis of data from a prospectively maintained database of 1,361 occupational injuries involving HCV-positive source that occurred between 2002 and 2015 conducted by Francesco M. Egro, MD, and his colleagues from the University of Pittsburgh Medical Center. Results were published online in the American Journal of Infection Control.

The two incidents of seroconversion occurred in patients who were exposed to blood from an HCV-positive patient via percutaneous injuries to the thumb from a hollow-bore needle, representing an overall seroconversion rate of 0.1%. In both cases, the source patients whose blood was involved were not coinfected with hepatitis B virus or human immunodeficiency virus.

Researchers also conducted a review of literature on needlestick injuries and occupational exposure to HCV-infected blood and fluids; from this review, they calculated an overall seroconversion rate average of 0.7%, with an average rate of 0.8% for percutaneous exposures. The review did not include mucomembranous exposure, as there were not enough data.

In this study, 65% of exposures were caused by percutaneous injuries and 34% were caused by mucocutaneous injuries; the cause of the remaining 1% was uncertain.

The hand was the most common site of injury (63%), followed by the face and neck (28%), and the arm, foot, leg, or trunk (4%). There was no record of the anatomical location of the injury in 5% of cases.

In nearly three-quarters of cases, blood was the source of exposure, while blood-containing saliva accounted for 3% of cases. The remaining 24% of cases were linked to other fluids, such as peritoneal fluid, tracheal secretions, amniotic fluid, bloody irrigation fluid, and blood-containing feces.

“The risk of transmission after exposure to HCV-positive patients’ fluids or tissues other than blood is expected to be low, but has not been formally quantified,” the authors wrote. “Although there have been reports of HCV seroconversion after human bites and after punching a HCV-positive individual in the teeth, percutaneous exposures to the blood of a HCV-positive source remain the most common cause of occupational HCV transmission.”

While the rate of seroconversion was low, the authors encouraged prompt reporting, testing, and follow-up of exposed individuals.

Egro FM, Nwaiwu CA, Smith S, Harper JD, Spiess AM. Seroconversion rates among health care workers exposed to hepatitis C virus-contaminated body fluids: The University of Pittsburgh 13-year experience. Am J Infect Control. 2017 Apr 24. [Epub ahead of print]. doi:10.1016/j.ajic.2017.03.011.

BY JEFF BAUER

Use of a blood collection system that diverts and sequesters the initial 1.5 to 2 mL of blood was associated with a significant decrease in blood culture contamination compared to standard practice, according to an open-label trial conducted at a single ED. The results were published online in the journal Clinical Infectious Diseases.

An estimated 0.6% to 6% of blood cultures are contaminated. Some blood cultures may become contaminated by skin fragments colonized with bacteria that are dislodged during venipuncture. Such false-positive results lead to increased costs and harm associated with unnecessary additional testing and treatment.

Researchers at the University of Nebraska Medical Center evaluated a novel sterile blood collection system, the SteriPath initial specimen diversion device (ISDD), to determine if it could reduce contamination rates by diverting and excluding the initial portion of collected blood. Investigators evaluated 1,808 blood cultures from 904 adult ED patients at an urban 689-bed university hospital. The patients’ mean age was 59 years, and 55% were male. For each patient, the first 20-mL blood sample was obtained using a standard procedure in which blood was drawn into a syringe and then injected into blood culture vials. A second 20-mL sample was obtained using the ISDD; the initial 1.5 to 2 mL of blood was diverted into a holding chamber, and the rest of the sample was directed into the blood culture vials. A culture was determined to be contaminated if one or more of several skin-residing organisms, including coagulase-negative staphylococci, Propionibacterium species, Micrococcus species, viridans group streptococci, Corynebacterium species, or Bacillus species, was recovered from only one of the paired cultures.

Compared to standard practice, use of the ISDD was associated with a significant reduction in blood culture contamination. Overall, two of the 904 samples (0.22%) collected with the ISDD were contaminated, compared to 16 of the 904 samples (1.78%) collected via standard practice (P = .001). Sensitivity was not affected by use of the ISDD; true septicemia was observed in 65 of 904 samples (7.2%) collected via ISDD and 69 of 904 samples (7.6%) collected via standard procedure (P = .41).

Rupp ME, Cavalieri RJ, Marolf C, Lyden E. Reduction in blood culture contamination through use of initial specimen diversion device. Clin Infect Dis. 2017 Apr 3. [Epub ahead of print]. doi:10.1093/cid/cix304.

FDA: Fluoroquinolone Use Not Linked to Retinal Detachment, Aortic Problems

LUCAS FRANKI

FRONTLINE MEDICAL NEWS

The Food and Drug Administration (FDA) has found no evidence of a link between fluoroquinolone antibiotic use and retinal detachment or aortic aneurysm and dissection, according to a new Drug Safety Communication update on potential serious, disabling adverse effects of oral and injectable fluoroquinolones.

Fluoroquinolones are used to treat acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, and uncomplicated urinary tract infections.

In a Safety Communication published May 12, 2016, the FDA noted that serious adverse effects were possible from fluoroquinolone usage and that fluoroquinolones should be prescribed only when no other treatment options are possible. Serious adverse effects associated with fluoroquinolone use include hallucination, depression, suicidal thoughts, tendinitis and tendon rupture, a pins-and-needles feeling in the arms and legs, joint pain and swelling, skin rash, and severe diarrhea.

After reviewing patient cases and study findings, the FDA said the evidence did not support an association between fluoroquinolone use and potential retinal or aortic dangers, according to its May 10, 2017, Drug Safety Communication update.

“We will continue to assess safety issues with fluoroquinolones, and will update the public if additional actions are needed,” the FDA said in a statement.

US Food and Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and injectable fluoroquinolone antibiotics due to disabling side effects. May 10, 2017. https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm. Accessed May 25, 2017.

Intravenous tPA Increases Risk of Mortality in Children With Acute Ischemic Stroke

SHARON WORCESTER

FRONTLINE MEDICAL NEWS

Intravenous thrombolysis with tissue plasminogen activator (tPA) is associated with adverse outcomes, including an increased risk of death, in children with acute ischemic stroke, based on a review of cases from the 2006-2010 Nationwide Inpatient Survey.

Of 20,587 patients ages 0 to 17 years who were included in the survey, 198 received an intervention, including tPA in 169 patients, intra-arterial thrombectomy (IAT) in five patients, and both tPA and IAT in 24 patients. The overall mortality rate was 7.8%, but in those who received tPA, it was 13.8%, compared with 7.7% in those who did not, Kathryn Ess, MD, of Rush University Medical Center, Chicago, reported at the annual meeting of the American Academy of Neurology. No deaths occurred in those who underwent only IAT, said Dr Ess.

Other outcomes were also worse for those who received tPA. For example, untreated patients were more likely to be discharged home than were tPA-treated patients (67.8% vs 47.5%), and intracerebral hemorrhage was more common in treated vs untreated patients (10.1% vs 3.8%). Costs for treated patients averaged $200,346 vs $123,015 for untreated patients.

Children included in the review had a mean age of 6 years, 43.9% were girls, and 47.7% were white. Treated patients were older (10 years vs 5.9 years), and comorbidities included Moyamoya disease in 12.4% of patients, cardiac valvular disease in 6.6%, and sickle cell disease in 6.5%. Those who received tPA had a higher prevalence of procoagulable conditions (15.2% vs 2%). Of note, the higher prevalence of intracerebral hemorrhage in treated patients was not explained by Moyamoya or sickle cell disease, as patients with those comorbidities were less likely than those without those conditions to receive treatment, Dr Ess said.

Though limited by the retrospective study design, small numbers of treated patients, a lack of data on stroke severity or functional outcomes, and the inclusion of data from years before newer thrombectomy devices became available, the findings highlight concerns about the safety and efficacy of tPA in children with ischemic stroke, she said, noting that few studies have looked at the utility of tPA with or without IAT in the pediatric population.

“Studies of the efficacy of ischemic stroke treatment in adults can’t necessarily be extrapolated to children,” she said, adding that this is especially true given the difference in etiologies of pediatric acute ischemic stroke.

Indeed, the findings underscore “the age-old adage that children are not just little adults,” said Andrew Southerland, MD, of the University of Virginia, Charlottesville, who was the discussant for the session. “We need prospective clinical trials in children,” he said.

HCV Seroconversion Rate 0.1% After Occupational Exposure

BIANCA NOGRADY

FRONTLINE MEDICAL NEWS

An analysis of 13 years of accidental occupational exposures to hepatitis C virus (HCV)-contaminated fluids or instruments has revealed a seroconversion rate of just 0.1%, significantly lower than that previously reported in the literature. This finding is from a longitudinal analysis of data from a prospectively maintained database of 1,361 occupational injuries involving HCV-positive source that occurred between 2002 and 2015 conducted by Francesco M. Egro, MD, and his colleagues from the University of Pittsburgh Medical Center. Results were published online in the American Journal of Infection Control.

The two incidents of seroconversion occurred in patients who were exposed to blood from an HCV-positive patient via percutaneous injuries to the thumb from a hollow-bore needle, representing an overall seroconversion rate of 0.1%. In both cases, the source patients whose blood was involved were not coinfected with hepatitis B virus or human immunodeficiency virus.

Researchers also conducted a review of literature on needlestick injuries and occupational exposure to HCV-infected blood and fluids; from this review, they calculated an overall seroconversion rate average of 0.7%, with an average rate of 0.8% for percutaneous exposures. The review did not include mucomembranous exposure, as there were not enough data.

In this study, 65% of exposures were caused by percutaneous injuries and 34% were caused by mucocutaneous injuries; the cause of the remaining 1% was uncertain.

The hand was the most common site of injury (63%), followed by the face and neck (28%), and the arm, foot, leg, or trunk (4%). There was no record of the anatomical location of the injury in 5% of cases.

In nearly three-quarters of cases, blood was the source of exposure, while blood-containing saliva accounted for 3% of cases. The remaining 24% of cases were linked to other fluids, such as peritoneal fluid, tracheal secretions, amniotic fluid, bloody irrigation fluid, and blood-containing feces.

“The risk of transmission after exposure to HCV-positive patients’ fluids or tissues other than blood is expected to be low, but has not been formally quantified,” the authors wrote. “Although there have been reports of HCV seroconversion after human bites and after punching a HCV-positive individual in the teeth, percutaneous exposures to the blood of a HCV-positive source remain the most common cause of occupational HCV transmission.”

While the rate of seroconversion was low, the authors encouraged prompt reporting, testing, and follow-up of exposed individuals.

Egro FM, Nwaiwu CA, Smith S, Harper JD, Spiess AM. Seroconversion rates among health care workers exposed to hepatitis C virus-contaminated body fluids: The University of Pittsburgh 13-year experience. Am J Infect Control. 2017 Apr 24. [Epub ahead of print]. doi:10.1016/j.ajic.2017.03.011.

Visit the Society of Gynecologic Surgeons online: sgsonline.org

More videos from SGS:

• Approaches to isolating the uterine artery at its origin from the internal iliac artery
• Advanced techniques in cystectomy for mature cystic teratomas
• Novel classification of labial anatomy and evaluation in the treatment of labial agglutination
• Strategies for prophylactic oophoropexy
• Tips and tricks for open laparoscopy
• Complete colpectomy & colpocleisis: Model for simulation
• Natural orifice sacral colpopexy
• Alternative options for visualizing ureteral patency during intraoperative cystoscopy
• Use of suprapubic Carter-Thomason needle to assist in cystoscopic excision of an intravesical foreign object
• Uterine artery ligation: Advanced techniques and considerations for the difficult laparoscopic hysterectomy
• Cervical injection of methylene blue for identification of sentinel lymph nodes in cervical cancer
• Misplaced hysteroscopic sterilization micro-insert in the peritoneal cavity: A corpus alienum
• Laparoscopic cystectomy for large, bilateral ovarian dermoids
• Small bowel surgery for the benign gynecologist

Visit the Society of Gynecologic Surgeons online: sgsonline.org

More videos from SGS:

• Approaches to isolating the uterine artery at its origin from the internal iliac artery
• Advanced techniques in cystectomy for mature cystic teratomas
• Novel classification of labial anatomy and evaluation in the treatment of labial agglutination
• Strategies for prophylactic oophoropexy
• Tips and tricks for open laparoscopy
• Complete colpectomy & colpocleisis: Model for simulation
• Natural orifice sacral colpopexy
• Alternative options for visualizing ureteral patency during intraoperative cystoscopy
• Use of suprapubic Carter-Thomason needle to assist in cystoscopic excision of an intravesical foreign object
• Uterine artery ligation: Advanced techniques and considerations for the difficult laparoscopic hysterectomy
• Cervical injection of methylene blue for identification of sentinel lymph nodes in cervical cancer
• Misplaced hysteroscopic sterilization micro-insert in the peritoneal cavity: A corpus alienum
• Laparoscopic cystectomy for large, bilateral ovarian dermoids
• Small bowel surgery for the benign gynecologist

Visit the Society of Gynecologic Surgeons online: sgsonline.org

More videos from SGS:

• Approaches to isolating the uterine artery at its origin from the internal iliac artery
• Advanced techniques in cystectomy for mature cystic teratomas
• Novel classification of labial anatomy and evaluation in the treatment of labial agglutination
• Strategies for prophylactic oophoropexy
• Tips and tricks for open laparoscopy
• Complete colpectomy & colpocleisis: Model for simulation
• Natural orifice sacral colpopexy
• Alternative options for visualizing ureteral patency during intraoperative cystoscopy
• Use of suprapubic Carter-Thomason needle to assist in cystoscopic excision of an intravesical foreign object
• Uterine artery ligation: Advanced techniques and considerations for the difficult laparoscopic hysterectomy
• Cervical injection of methylene blue for identification of sentinel lymph nodes in cervical cancer
• Misplaced hysteroscopic sterilization micro-insert in the peritoneal cavity: A corpus alienum
• Laparoscopic cystectomy for large, bilateral ovarian dermoids
• Small bowel surgery for the benign gynecologist

SAN DIEGO – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.

Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.

Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.

The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.

Cynthia L. Arfken, PhD, of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD, also of the university, led the research.

The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.

The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.

The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.

Adults were screened for PTSD using the PTSD checklist for adults, and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.

The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).

Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”

The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.

Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.

Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.

The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.

This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.

“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.

Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.

“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.

Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.
 

[email protected]

SAN DIEGO – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.

Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.

Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.

The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.

Cynthia L. Arfken, PhD, of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD, also of the university, led the research.

The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.

The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.

The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.

Adults were screened for PTSD using the PTSD checklist for adults, and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.

The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).

Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”

The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.

Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.

Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.

The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.

This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.

“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.

Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.

“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.

Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.
 

[email protected]

SAN DIEGO – Psychiatrists may encounter refugee patients from war-torn countries in virtually every part of the United States with complex mental health needs, including high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms, according to two presenters at the annual meeting of the American Psychiatric Association.

Over the past decade, refugees from Middle Eastern counties – particularly Iraq, Syria, and Afghanistan – have increased fourfold as a percentage of all refugees in the United States, while those from Sub-Saharan Africa continue to make up a large share. Despite heated political wrangling, the U.S. Department of State recently increased limits on the number of refugees that can be accepted. California, Texas, New York, Michigan, Ohio, and Washington are the states resettling the most new arrivals.

Refugees with trauma exposure have high rates of posttraumatic stress disorder, chronic pain, and somatic symptoms. In addition, recent research suggests, these refugees may have poorly understood stressors related to migration and adjustment that also may be significant contributors to mental illness risk. Despite this, refugees generally have less access to mental health care than does the general population.

The presenters shared their perspectives on refugee mental health with findings that could inform the timing and nature of interventions in these potentially vulnerable populations.

Cynthia L. Arfken, PhD, of Wayne State University in Detroit, presented results from an ongoing cohort study of Syrian families presenting to a primary care clinic as part of their State Department–mandated health check upon resettlement. Arash Javanbakht, MD, also of the university, led the research.

The investigators recruited families at a primary care clinic in southeastern Michigan, where refugees receive health assessments within the first month of arrival in the United States.

The researchers consecutively enrolled and evaluated 297 individuals, including 59 children aged 6 and older (mean age, 11.3) from Syria. These families represented 95% of refugees seen at the clinic during the study period, from June to December 2016.

The researchers also collected hair and saliva samples from consenting families for a separate study looking at biomarkers and mental health outcomes.

Adults were screened for PTSD using the PTSD checklist for adults, and children for anxiety using the Screen for Child Anxiety Related Emotional Disorders, or SCARED, measure. Psychiatric nurses and bilingual health care workers helped the team obtain consent and conduct assessments.

The researchers found that 61% of the children had a probable anxiety diagnosis, and nearly 85% had probable separation anxiety. Higher child anxiety scores were associated with higher PTSD scores in mothers (P = .05).

Dr. Arfken said in an interview that she and her team were “shocked” at the high prevalence of probable anxiety disorders in the cohort, in part because they’d conducted an earlier study enrolling adult Iraqi refugees and “found hardly any psychiatric symptoms at all.”

The high levels of anxiety seen among the Syrian refugees may be related to the severity of the ongoing conflict, Dr. Arfken said. The children’s results were sufficiently jarring to the team that “we changed our whole plan,” she said, “to concentrate on following up both the children who showed distress and those who did not.” They also attempted some nonmedical interventions, such as dance and mindfulness groups.

Also at the conference, Christopher Morrow, MD, of the University of Maryland in Baltimore, presented findings from a case study that illuminates some of the potential mental health risks for resettled refugees.

Dr. Morrow described a 31-year-old man from Afghanistan who had worked for the U.S. Special Forces in Afghanistan as a translator and subsequently entered the United States as a refugee. About a year later he was admitted to an inpatient psychiatric unit after a violent suicide attempt and was treated for depression.

The researchers noted that the patient had no previous history of depression or other mental illness prior to arriving in the United States. “His symptoms developed over the course of the first year of resettlement,” Dr. Morrow said in an interview.

This patient, Dr. Morrow said, was single and was not religious, leaving him not inclined to join a mosque or other Islamic community group. He was placed in an unskilled work assignment, despite his well-developed skills as a translator. Over the course of a year, he became increasingly isolated and “decompensated to the point where there was a really violent suicide attempt.

“We think that some kind of programmed follow-up – be it a community resource or through primary care – could have helped stabilize him before he got to a point of real hopelessness,” Dr. Morrow said.

Dr. Morrow and his colleagues proposed two interventions as adjustments to current health policy for refugees: adding universal mental health screening to each refugee’s health check in the first month after arrival, and scheduling follow-up later in the resettlement process.

“If there is active follow-up, a way that you could check in with these individuals as they’re acclimating, that’s probably the point where you could intervene best,” he said.

Dr. Morrow and Dr. Arfken disclosed no conflicts of interest related to their research.
 

[email protected]

Children often present for evaluation of a melanocytic lesion that is new, evolving, or worrisome to parents and caregivers.

“In the pediatric health care system, malignant melanoma is considered an especially heinous crime. In San Diego, dedicated pediatric providers who identify this disease are members of an elite squad known as the mole patrol unit.” Dr. Sheila Fallon Friedlander opened her presentation on pediatric moles with this tongue-in-cheek statement, adapted from the popular TV show “Law and Order SVU,” at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego.

The National Cancer Institute

Children often present for evaluation of a melanocytic lesion that is new, evolving, or worrisome to parents and caregivers.

“In the pediatric health care system, malignant melanoma is considered an especially heinous crime. In San Diego, dedicated pediatric providers who identify this disease are members of an elite squad known as the mole patrol unit.” Dr. Sheila Fallon Friedlander opened her presentation on pediatric moles with this tongue-in-cheek statement, adapted from the popular TV show “Law and Order SVU,” at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego.

The National Cancer Institute

Children often present for evaluation of a melanocytic lesion that is new, evolving, or worrisome to parents and caregivers.

“In the pediatric health care system, malignant melanoma is considered an especially heinous crime. In San Diego, dedicated pediatric providers who identify this disease are members of an elite squad known as the mole patrol unit.” Dr. Sheila Fallon Friedlander opened her presentation on pediatric moles with this tongue-in-cheek statement, adapted from the popular TV show “Law and Order SVU,” at a pediatric dermatology meeting sponsored by Rady Children’s Hospital–San Diego and University of California, San Diego.

The National Cancer Institute