Frontiers in Emergency Medicine
Volume:7 Issue: 3, Summer 2023

A startling high number emergency medicine (EM) residency positions in Iran remained unfilled in this year’s National Residency Examination. In fact, the unprecedented numbers of unoccupied EM residency training positions over the past few years had already shocked the specialty, but this year’s statistics are alarming. Working as an emergency physician has never been an easy task, yet, since its establishment as a specialty in Iran in the year 2000 (1,2), EM continued to attract applicants over years. The trend of disfavoring EM, which started a few years ago, has important implications for nationwide residency programs, applicants, and most importantly our patients. It has also contributed to a state of general anxiety within the EM community, who feel that EM is a “profession in peril”, perpetuating the situation and starting a vicious cycle. EM departments are struggling to find a solution to ensure that delivery of quality care amid staffing shortages, and the authorities in the Ministry of Health and Medical Education (MOHME) are trying to solve the problem by “supplemental offer”, in the hope of recruiting applicants for unclaimed spots. However, besides these temporizing measures, it is imperative to deep dive into the factors contributing to this unprecedented national trend in order to shed light on the factors behind it and the solutions ahead of us. The problem is multifaceted and influenced by a myriad of interconnected factors. It is partly driven by the current landscape of the healthcare system and the changes to specialty preferences by students (3) in general. Moreover, the trend seems to be present in other parts of the world as well (3). Yet, there are aspects that are unique or more significant for EM in Iran: As a specialty driven by the needs of the society, its existence requires constant support and recognition by the society (mainly represented in the health sector by MOHME). It seems that the current authorities have forgotten what the emergency rooms were like in the era before EM, and have taken the current situation of emergency healthcare for granted. This is represented not only in their speeches and statements, but also in their decisions regarding regulations for compensation. Establishment of EM as a specialty was a fundamental action toward improving emergency care (4,5), but it was too optimistic to think that it can solve the entire problem. More actions were needed including training other related providers and ancillary staff, restructuring the design of the departments, and changing the employment structure of ED healthcare providers. Eluded by the drastic changes created just by the introduction of competent and energetic EM physicians, the authorities neglected many of these crucial actions. In an effort to solve quickly a problem that existed for a long time, MOHME created a surge in EM positions, jeopardizing the quality of EM training programs and ignoring the supply-demand dynamics of the discipline. They even failed to consider the advice of the National Board of Emergency Medicine, who repeatedly warned them against the dangers of expanding the number of residency programs and training sites without enough quality assurance system in place. This mass production of emergency physicians with inconsistent qualities, considered by many as the main trigger of the shift in the situation of EM, require a detailed exploration in its own right. Surprisingly, the number of EM residency positions has increased in recent years, while the number of applicants continued to decline. High levels of burnout (resulting from poor compensation and financial reward mechanisms, high prevalence of violence (6,7), overcrowding of the EDs with extended boarding of the patients, and exacerbated by the COVID pandemic) has disappointed many EM practitioners who selected this specialty with great enthusiasm. Some of these people role model burnout explicitly during their shifts and fail to interact positively with medical students, who are potential applicants of EM residency. This atmosphere of despair reassure the hesitant applicants not to opt this field as the future of their carriers. As emergency physicians, we are accustomed to dealing with unanticipated, unfavorable events and we have been trained to handle these conditions calmly and efficiently. In this case, too, we must take this situation as an opportunity to shape the future of our specialty. Convincing those who are responsible for healthcare workforce planning to work in tandem with the authorities in charge of graduate medical training in order to find logical and feasible solutions including an organized approach to a balanced workforce is a first step. This requires diplomacy and tactfulness of the EM community, and perhaps more importantly, an open mind and a listening ear on the administration side.

Serum biomarkers are important for accurately predicting clinical outcomes in coronavirus disease 2019 (COVID-19) patients. Although previous studies showed that lymphopenia in patients is related to disease severity, it is unclear how other serum biomarkers improve the prognostic accuracy of lymphopenia. Changes in urea, and lactate dehydrogenase (LDH) were noted to have considerable predictive value in determining the severity of disease in COVID-19 patients. Therefore, the purpose of this study is to determine whether increases in urea, and LDH are linked to worse outcomes in COVID-19 patients and whether the urea/lymphocyte and LDH/lymphocyte ratios improve the prognostic accuracy of lymphopenia. 

The data of confirmed COVID-19 patients in our emergency department (ED) between March 2020, and January 2021, were analyzed retrospectively. The area under the curve (AUC) and logistic regression analysis were used to evaluate the discriminative power of the urea/lymphocyte and LDH/lymphocyte ratios in estimating 30-day mortality. 

The study included 795 confirmed COVID-19 patients admitted to the ED. Twenty-three patients (2.9%) died, and 772 (97.1%) survived in 30 days. The median age of the patients was 51. The number of males (n: 447, 56.2%) was higher than females (n: 348, 43.8%). The ratios of urea/lymphocyte and LDH/lymphocyte were significantly higher in non-survivors (median: 71.21 and 754.1, respectively) compared to survivors (median: 19.51 and 297.42, respectively) (P<0.001). The AUC for 30-day mortality for the urea/lymphocyte and LDH/lymphocyte ratios was 0.864 and 0.840, respectively. Multivariate logistic regression adjustment found the urea/lymphocyte ratio to be an independent and significant predictor of mortality (P=0.007). The optimum cut-off point for the urea/lymphocyte ratio was 28.07, which had a 91.3% sensitivity and a 68.6% specificity. 

The urea/lymphocyte and LDH/lymphocyte ratios are useful markers that can be evaluated independently to identify high-risk patients and predict the prognosis of COVID-19.

 The resolution of ST-segment elevation (>50%) indicates successful reperfusion with thrombolytic therapy. The aim of this study is to evaluate the relation of ST-segment resolution post-primary percutaneous cardiac intervention (PCI) with in-hospital mortality and coronary thrombolysis in myocardial infarction (TIMI) blood flow. 

 This study is a single-centred retrospective study. The study enrolled 100 patients who were referred to the Nasiriya Heart Centre for primary PCI. We measured the ST segment amplitude in the lead with the highest elevation prior to primary PCI and assessed the ST-segment elevation post-primary PCI. The ratio of ST-segment resolution was calculated and considered complete if reaches ≥70% from the initial ST-segment elevation. We assessed the association of ST-segment resolution with in-hospital mortality. 

 Analysis of the electrocardiogram (ECG) showed that 21 patients (21%) had complete ST-segment (≥ 70%) resolution. No significant association was shown between ST-segment resolution and in-hospital mortality. Two out of 21 patients with complete ST-segment resolution died in the hospital and 6 out of 79 patients with incomplete ST-segment resolution died (P=0.77). There is no significant association between ST-segment resolution and coronary TIMI flow grades. In patients with complete ST-segment resolution, 19 patients had TIMI III flow and 2 patients had TIMI II flow. In patients with incomplete ST-segment resolution, 72 patients had TIMI III flow, 6 patients had TIMI II flow; and 1 patient had no-reflow (P=0.84). 

 Complete ST-segment resolution in post-primary PCI settings has no significant association with in-hospital mortality. Absent or incomplete ST-segment resolution is not necessarily an indicator of coronary artery re-occlusion after primary PCI.

It is important to know people’s perceptions of the risks related to coronavirus disease 2019 (COVID-19) for controlling the pandemic. This study aims to assess the risk perception of COVID-19 among non-infected people referred to emergency departments (ED) of hospitals in Khorramabad, Iran during the pandemic and its related demographic factors. 

This is descriptive/analytical study with a cross-sectional design. Participants were 380 adults referred to the ED of four hospitals (Shohadaye Ashayer, Shahid Rahimi, Asali, and Shahid Madani) in Khorramabad city in 2021 who were not infected by COVID-19. For data collection, the risk perception of COVID-19 questionnaire was used. Data were described using mean, standard deviation, frequency, and percentage. Chi-squared test was used in SPSS v.22 software to find the related demographic factors. 

It was found that 5 people (1.3%) had a moderate perception, 206 (54.2%) had good perception, and 169 (44.5%) had high perception. No one had poor risk perception. According to them, “own knowledge and experience” was the most effective factor in preventing COVID-19 followed by “the advice of experts in the media” and “the advice of friends and family”. Chi-squared test results showed a significant difference in risk perception among people in terms of age (P=0.002) and marital status (P=0.001); the age group <25 years and single people had lower risk perceptions. 

The risk perception of COVID-19 in people referred to the EDs in western Iran is at good level but is not high. It is necessary to improve their risk perception by education and increasing awareness on social media.

Aim of this study was to examine immature granulocyte/total granulocyte (IG/TG) ratio for prediction of return of spontaneous circulation (ROSC) and early mortality in post cardiac arrest survivors.

The study was carried out prospectively between January 2021 and January 2022. Non-traumatic out-of-hospital cardiac arrest (OHCA), over the age of 18 and non-pregnant were included. Patients’ whose IG levels were not studied, with hematological disease and who receiving immunosuppressive therapy were excluded. A palpable pulsation of the main arteries for at least 15 minutes was considered ROSC. Data were compared between the<4 hour and ≥4 hour survival groups and patients with and without ROSC.

Total of 254 OHCA patients were included in the study. ROSC was achieved in 84 (33.1%) of these patients and 170 (66.9%) patients were died. There were 28 patients (33.3%) with survival of <4 hours and 56 patients (66.7%) with survival of ≥4 hours in patients    with ROSC. The IG count and IG/TG ratio did not differ significantly between the ROSC groups and  between the groups separated by survival time (P>0.05).

We found                  no significant differences between subgroups defined according to survival duration. Similarly, no differences found between OHCA patients with and without sustained ROSC.

During emergency laparotomy surgeries, a wide incision is usually created in the abdomen causing the exposure of visceral organs to cold temperatures in the operation room. Other factors such as excessive stress, intra-operation blood transfusion, and prolonged anesthesia increase the risk of hypothermia in these patients. In this study, we studied the effects of forced air warming systems on the hemodynamic status, pain intensity, tremors, nausea and vomiting in emergency laparotomy patients. 

In the present double-blinded clinical trial, 80 candidates for emergency laparotomy were randomized into two groups: intervention (patients receiving forced air warming during anesthesia) and control (patients without an active warming system). Patients’ hemodynamic status (during anesthesia and at post anesthesia care unit (PACU), pain intensity, opioids received, tremors, nausea, vomiting, and antiemetics administration were compared between the two groups. 

The amounts of opioids (P=0.041) and relaxants (P=0.039) received by the patients were significantly lower in the intervention group than in the control group. The hemodynamic status was more stable in the patients of the intervention group than those in the control group at all times measured. Pain intensity (per minute) at the PACU was significantly higher in the control group than in the intervention group (P=0.041). Among the patients admitted to the PACU, participants with no tremors (P=0.005) or nausea (P=0.005) were significantly higher in the intervention group than in the control group. Also, in the recovery unit, patients in the intervention group received significantly lower amounts of opioids (i.e., mg of pethidine, P=0.036) and antiemetics (P=0.011) compared to the control group. 

The use of a forced air warming system in the operation room stabilizes the hemodynamic status and reduces the pain intensity, tremors, nausea and vomiting in emergency laparotomy patients. As a non-pharmacological strategy, this method was observed to have satisfactory safety.

X-rays are routinely utilized for different diagnostic purposes but there is always the risk of an inaccurate diagnosis. This systematic review was designed to investigate whether inverse grayscale mode increased diagnostic accuracy. From inception to February 2022, MEDLINE, Embase, Scopus, Web of Science, and CENTRAL were searched for studies comparing grayscale inversion diagnostic accuracy to the conventional method. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies version 2 (QUADAS-2) tool. Eighteen studies were included with an overall patient population of 1704. The number of studies investigating each lesion are as follows, lung masses: 13, pneumothoraces: 4, bony lesions: 3, interstitial lung diseases: 3, orthopedic studies: 2, bullous lung disease: 1, pleural effusion: 1, urinary calculus: 1, and large vascular occlusion: 1. Two studies had an overall moderate risk of bias and the remainders had low risk. The combined mode, featuring the conventional mode with the addition of the inverse grayscale, demonstrated better performance or insignificant difference in comparison with the conventional mode in all studies except one, which showed lower sensitivity in detecting pulmonary nodules. Also, meta-analysis of 250 patients in four pulmonary nodule studies showed better area under the ROC curve (AUC) of inverse mode (0.83, 95% CI: 0.75,0.90) in comparison with conventional mode (0.80, 95% CI: 0.72,0.88). Application of inverse mode when using radiography for detection of pulmonary nodules might improve diagnostic accuracy. Also, the inverse/combined mode showed better performance for lesions other than pulmonary nodule in some studies. However, there was insufficient evidence to draw a consistent conclusion.

Flash pulmonary edema is a potentially fatal condition that can suddenly deteriorate a patient's status in a variety of settings, including the catheterization laboratory. We describe a 51-year-old woman with a history of hypertension who was admitted for a second valve operation for degenerated aortic bioprosthesis. Before undergoing coronary angiography, she looked a little worried, she experienced respiratory distress and a significant increase in blood pressure in favor of acute flash pulmonary edema, which was immediately and successfully managed by respiratory support and administration of high-dose intravenous nitroglycerine and loop diuretic therapy. The present scenario highlights the significance of being aware of the warning signs of acute flash pulmonary edema to make a prompt diagnosis and initiate the appropriate treatment to prevent catastrophic consequences.

A 26-year-old pregnant lady was referred from a private hospital to the emergency department with a cough, shortness of breath, decreased oxygen saturation, and repeated vomiting. She went to the private hospital for obstetrics and gynecology follow-up for her pregnancy. The patient is 21 weeks pregnant with no known comorbidities. She is gravida three and para two. The patient claimed that since 3 days, the shortness of breath (SOB) and cough have been worsening, and she has been inducing herself to vomit more frequently, however, there is no associated dysphagia. She denied fever, headache, dizziness, abdominal pain, or a change in bowel habits.