Original/Research Article

Correlation of Ordered Cervical Spine X-rays in Emergency Department with NEXUS and Canadian C-Spine Rules; a Clinical Audit

Hamid Kariman, Mostafa Alavi Moghadam, Zhale Rajavi, Batsabe Masjoodi

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 150-154

Introduction: Evaluation of cervical spine injuries makes up a major part of trauma patient assessments. Based on the existing sources, more than 98% of the cervical spine X-rays show no positive findings. Therefore, the present clinical audit aimed to evaluate the correlation of ordered cervical spine X-rays in multiple trauma patients with NEXUS and Canadian c-spine clinical decision rules. Methods: The present clinical audit, evaluated the correlation of cervical spine imaging orders in multiple trauma patients presented to the emergency department, with NEXUS and Canadian c-spine rules. Initially, in a pilot study, the mentioned correlation was evaluated, and afterwards the results of this phase was analyzed. Since the correlation was low, an educational training was planned for all the physicians in charge. Finally, the calculated correlations for before and after training were compared using SPSS version 21. Results: Before and after training, cervical spine X-ray was ordered for 98 (62.82%) and 85 (54.48%) patients, respectively. Accuracy of cervical spine X-ray orders, based on the standard clinical decision rules, increased from 100 (64.1%) cases before training, to 143 (91.7%) cases after training (p < 0.001). Area under the receiver operating characteristic (ROC) curve regarding the correlation also raised from 52 (95% confidence interval (CI): 43 – 61) to 92 (95% CI: 87 – 97). Conclusion: Teaching NEXUS and Canadian c-spine clinical decision rules plays a significant role in improving the correlation of cervical spine X-ray orders in multiple trauma patients with the existing standards. 

Emergency Medical Service Personnel Satisfaction Regarding Ambulance Service Facilities and Welfare

Ali Asghar Jesmi, Hadiseh Monadi Ziyarat, Mahmoud Marhamati, Taghi Mollaei, Hadi Ahmadi Chenari

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 155-160

Introduction: Personnel job satisfaction, facilities and welfare are among the most important factors affecting quality of service. To date, no study has been done in the field of Emergency medical service (EMS) personnel satisfaction regarding facilities and welfare in Iran. Therefore, the present study was designed to evaluate the level of satisfaction among EMS personnel regarding facilities and welfare. Methods: In the present cross-sectional study, 68 of the EMS personnel of Northern Khorasan, Iran, were selected by simple randomization and their level of satisfaction was evaluated using a 23-question questionnaire. Afterwards, their satisfaction level was divided into 2 groups of desirable and non-desirable and the findings were reported as frequency and percentage. Results: The lowest satisfaction level regarding facilities were reported to be linked to the physicians being out of reach (14.7%), presence of help (27.0%), comfortableness of nurse’s chair (29.8%), and ability of patients’ bed to be positioned (32.3%). Minimum satisfaction regarding welfare was also seen concerning the time of receiving their wage (4.4%) and place for rest (5.9%). Based on the classifications done, only 22 (32.4%) of the personnel were satisfied with the facilities and 5 (7.4%) were satisfied with the welfare conditions. Conclusion: The findings of the present study showed that satisfaction rate of the EMS personnel regarding facilities and welfare is low. All the factors leading to this decrease in satisfaction level of the personnel could be prevented and relieved, therefore intervention in these regards can improve satisfaction rate among the personnel. 

Agreement between the Continuous Medical Education Programs and Necessary Training Topics in the Field of Emergency Medicine

Afshin Amini, Mehrnoosh Haraghi, Hojjat Derakhshanfar, Majid Shojaee, Hossein Alimohammadi, Alireza Majidi, Kamran Heidari

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 161-168

Introduction: Currently, there is a lack of data on the agreement between the continuous medical education (CME) programs and the necessary training topics in the field of emergency medicine in Iran. The present study aimed to evaluate the mentioned agreement in CME programs held during 2010-2014, all over the country. Methods: In the present cross-sectional study, the data recorded regarding emergency medicine-related CME programs were extracted from continuous training database of the Ministry of Health. Then, 30 items from the most important topics taught in emergency medicine training were selected by 3 emergency medicine specialists. Subsequently, the agreement of the selected training topics and CME programs was evaluated regarding duration of training, annual changes, and efficiency. Results: During 2010-2014, a total of 10147 hours of CME programs were held in relation to emergency medicine topics in Iran, which were most frequently (1015 hours) related to surgical emergencies. The next most frequent emergency-related CME programs were in the fields of toxicology with 810 hours (8.0%), neurology with 700 hours (6.9%), pediatric emergencies with 695 hours (6.8%), internal medicine with 675 hours (6.7%), and cardiopulmonary resuscitation with 555 hours (5.5%). In addition, it was determined that none of the CME programs were in complete agreement with the expected standards. Cohen’s kappa test showed that the agreement between the current conditions of CME programs with the standard was only 46.7% (95% confidence interval: 40.9 – 52.55) which shows a weak agreement (p = 0.19). Conclusion: The findings of the present study show the weak agreement of the CME programs held in the field of emergency medicine with the expected standards. 

The Effect of Using a Checklist on Quality Improvement of History Taking from Trauma Patients

Gholamreza Faridaalaee, Behzad Boushehri, Bahram Ebrahimi

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 169-173

Introduction: To date, no study with a proper sample size has been done to evaluate the efficiency of using pre-designed checklists in history taking of trauma patients in Iran. Therefore, the present study was designed to evaluate the pre-designed checklist’s effects on the quality of history taking in trauma patients referred to the emergency department (ED). Methods: In the present prospective cross-sectional study, data of the trauma patients presented to the ED were recorded either with or without using a checklist, randomly. The designed checklist consisted of personal data, trauma mechanism, wound characteristics and trauma severity, severity and location of injuries, and the patient’s diagnostic and therapeutic plans. The quality of data gathering in each evaluated item was divided into 3 groups of complete recording, incomplete recording, and not recorded. Data recording quality was compared between the 2 groups using chi square or exact Fisher’s test. In all analyses, p < 0.05 was defined as significance level. Results: In the preset study, patient data were gathered without using a checklist in 795 and using a checklist in 384 cases. Complete and accurate data recording in all items was more frequent in the group that had used the checklist (p < 0.001). Recording injury location without using a checklist was complete in only 20.8% of the cases. This rate increased to 95.6% when the checklist was used. In addition, complete and accurate recording of the diagnostic plan increased from 9% to 72.8%, and complete and accurate recording of the therapeutic plan raised from 14% to 68.7%. The improvements in data recording quality was significant in all cases. Conclusion: It seems that using pre-designed checklists for history taking in trauma patients, leads to a significant increase in quality of data recording and history taking.


Accuracy of Inferior Vena Cava, Aorta, and Jugular Vein Ultrasonographic Diameters in Identifying Pediatric Dehydration

Hamid Kariman, Amir Heidarian, Alireza Majidi, Hamidreza Hatamabadi, Ali Arhami Dolatabadi, Baharak Najafi Fakhraee Azar

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 174-181

Introduction: Evaluating intravascular volume is an important but complicated matter in management of critically ill patients, especially in children. Although invasive techniques have the ability to accurately estimate the intravascular volume, but they have dangerous side effects. Therefore, the present study was designed with the aim of comparing the diagnostic accuracy of sonographic diameters of inferior vena cava (IVC), aorta, internal jugular vein (IJV), and IVC/aorta ratio in identifying pediatric dehydration in children presented to the emergency department (ED). Methods: The present prospective cross-sectional study was carried out with the aim of determining the diagnostic accuracy of sonographic diameters of IVC, IJV, and aorta, in estimation of dehydration rate for children presented to the ED with mild to moderate dehydration. Their screening performance characteristics, such as area under the ROC curve, sensitivity and specificity, were calculated and used for this purpose. The data were analyzed using STATA 11.0 and 0.05 was considered as significance level. Results: In the end, 54 patients were enrolled in the study (57.4% male, mean age of 4.9 ± 2.7 years). Area under the ROC curve for IVC in diagnosis of moderate dehydration in sagittal and transverse planes were 0.775 (95% CI: 0.65 – 0.91) and 0.8086 (95%CI: 0.96 – 0.93), respectively. In addition, the diameter of aorta in this regard were 0.658 (95%CI: 0.51 – 0.81) for the sagittal and 0.7126 (95% CI: 0.57 – 0.86) for the transverse plane. IJV diameter had an area under the curve of 0.7332 (95% CI: 0.59 – 0.88). Comparing the area under the ROC curves for the studied parameters showed that IVC diameter in the sagittal (p = 0.004) and transverse (p < 0.001) planes is a better index for diagnosis of moderate dehydration. Conclusion: Based on the findings of the present study, it seems that IJV, IVC, and aorta diameters are not very accurate for determining the condition of pediatric dehydration, since even sonographic IVC diameter, which was more accurate than the other parameters, had a sensitivity of 81.48% and specificity of 48.15% in differentiating mild and moderate dehydration. 

Case Report

A Case of Lip Foreign Body; Introducing an Innovative Removal Method

saeed safari, Alireza Baratloo

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 182-184

Foreign bodies commonly enter the human body due to traumatic injuries and rarely do so iatrogenically. Reporting various cases of foreign bodies and the treatments used, can help other physicians act more experienced in probable similar situations. This article introduces the case of an uncommon foreign body in inferior lip and its innovative removal procedure. 


Evidence Based Medicine; Positive and Negative Likelihood Ratios of Diagnostic Tests

Alireza Baratloo, Saeed Safari

Iranian Journal of Emergency Medicine, Vol. 2 No. 4 (2015), 21 October 2015, Page 185-186

In the previous two parts of educational manuscript series in Emergency, we explained some screening characteristics of diagnostic tests including accuracy, sensitivity, specificity, and positive and negative predictive values. In the 3rd  part we aimed to explain positive and negative likelihood ratio (LR) as one of the most reliable performance measures of a diagnostic test. To better understand this characteristic of a test, it is first necessary to fully understand the concept of sensitivity and specificity. So we strongly advise you to review the 1st part of this series again. In short, the likelihood ratios are about the percentage of people with and without a disease but having the same test result. The prevalence of a disease can directly influence screening characteristics of a diagnostic test, especially its sensitivity and specificity. Trying to eliminate this effect, LR was developed. Pre-test probability of a disease multiplied by positive or negative LR can estimate post-test probability. Therefore, LR is the most important characteristic of a test to rule out or rule in a diagnosis. A positive likelihood ratio > 1 means higher probability of the disease to be present in a patient with a positive test. The further from 1, either higher or lower, the stronger the evidence to rule in or rule out the disease, respectively. It is obvious that tests with LR close to one are less practical. On the other hand, LR further from one will have more value for application in medicine. Usually tests with 0.1 < LR > 10 are considered suitable for implication in routine practice.