Medical Student Research Fellowship for Summer 2003
Mentor: Lynn Roppolo, MD
Department: Surgery, Division of Emergency Medicine
Room number: CS2.102A
Mail Code: 8579
Phone number: 214-648-9584 (o) 214-992-7851 (p)
E-mail: lynn.roppolo@utsouthwestern.edu
Two Projects
Project I title: THE UTILITY OF BEDSIDE ULTRASOUND IN THE DIAGNOSIS AND TREATMENT OF EXTREMITY ABSCESSES
Human subjects IRB approved project number (where applicable): IRB 0103-088
Animal subjects IRB approved project number (where applicable): n/a
Project Type (patient-based research, animal-based research, or basic research; this characterization is only to permit a general classification for grouping similar types of projects) Patient-based research
Brief Description of Project:
This is a prospective, observational study where providers will perform bedside
ultrasound on all suspected extremity abscesses. Providers will document physical
findings which will include redness, swelling, warmth, presence of a fluctuant
mass, and the size of the fluctuance. Each case will be seen by two different
providers: 1) one provider will perform bedside ultrasound on the suspected
extremity abscess 2) the second provider will perform needle aspiration. The
second provider will be blinded to the results of the ultrasound findings by
the first provider. The providers will be a PGY2 or PGY3 EM resident or an EM
faculty at Parkland Health & Hospital System (PHHS) Emergency Department.
All providers will be given the same 15 minute instruction on the technique
of ultrasound to determine the presence of a fluid collection in the extremities.
Project II
PURPOSE:
The goal of the study is to compare various aspects of African American, white,
and Hispanic patients who present to an urban emergency department with chest
pain. The other major goal is to assess the impact of not speaking English as
the primary language. Factors that will be assessed include: demographics, living
conditions and transportation availability, insurance and/or "regular"
doctor availability, emergency department resource utilization and length of
stay, final diagnoses and 4 week outcomes, perception of severity of the complaint
by the patients and by the physicians.
BACKGROUND:
Chest pain is a common complaint among patients presenting to emergency departments
(ED). Severe ramifications may occur if the evaluation and management are inappropriate.
It is assumed that the most common concern among patients with chest pain is
whether it represents an acute cardiac problem.
Numerous trials have focused on how patients' race and sex affect their presentation with an acute coronary syndrome (ACS). The focus of previous trials has generally not focused on patients who present with a chief complaint of chest pain. Most have focused on patients who have a final diagnosis of an ACS i.e. ST-elevation myocardial infarction (MI), non-ST-elevation MI, or unstable angina. Surprisingly little data exist about the demographics, presentations, and outcomes of patients who present to EDS with chest pain.
Demographic information is particularly lacking about the Hispanic population. The effects of many factors are unclear: language barriers and the use of translators, presentation symptoms, patients' perception of severity of the pain, health care providers' perceptions of the significance of the pain, housing situations, transportation issues, presence of comorbidities, ED lengths of stay and test ordering, insurance status, use of "regular" providers of care, and medication usage.
Trials assessing the effects of race often exclude those who don't use English as their primary language.{Klingler2002} There is little information on the Hispanic population. Waxman and Levine{Waxman2000} compared ED test ordering and length of stay between patients who spoke English versus those who did not. Test ordering was comparable for chest pain assessment. However, non-English speaking patients with abdominal pain had significantly more CBCs, electrolytes, ECGs, and CT scans ordered.{Waxman2000} Virtually no information exist on how translators are used. One West-coast urban hospital found that 80% of the translations were done by lay people.{Waxman2000}
There is some information relative to the pain characteristics associated with admission to a hospital. Significantly more admissions are associated with a pressure sensation, intense pain, pain with effort, or the presence of radiation.{Gupta2003} Hospitalization frequency directly correlates with symptoms other than chest pain including dyspnea, sweating, and weakness.{Gupta2003} African American and white patients who were admitted with chest pain{Klingler2002} or with unstable angina{Canto2002}were equally likely to have presented with atypical symptoms. Atypical presentations with unstable angina occur more often in patients with older age, female gender, dementia, no history of MI or hypercholesterolemia, and no family history of heart disease. Patients with prior MI were more likely to have a typical presentation.{Canto2002} Comparable information for Hispanic population is not available.
The impact of patients' living conditions and employment status upon ED evaluations and management is poorly understood. African American patients admitted with chest pain are more likely to live alone or with family than white patients.{Klingler2002} African American patients admitted with chest pain are also more likely to be unemployed and to have a lower median income.{Klingler2002}
While health care providers consider chest pain to be serious complaint, we only assume that patients have the same concern. African American patients admitted with chest pain are more likely to have perceived their presenting symptoms as life threatening than white patients.{Klingler2002} African American patients admitted with chest pain assessed their pain to be significantly higher than that of white patients when using the classic "0 to 10" pain scale.{Klingler2002} There are no comparable data on Hispanic patients. The top reason (58% of patients) for choosing the ER over other health care sources in one urban teaching hospital survey was that the patients thought their problem was serious or needed immediate attention.{Lucas1998}
The effects of ethnic background upon the actual decision to seek health care
is poorly understood. The time required to decide to seek care and the time
it takes to actually arrive for care has been the same for African American
and white patients.{Klingler2002} The mode of transportation has been similar
when comparing African American and white patients who are admitted with chest
pain.{Klingler2002}
There has been much concern about the "abuse" of ambulance services
for transport to health care. However, in one series, only 22% of patients admitted
as an inpatient used an ambulance to seek care.{Klingler2002} Hispanics are
more likely than African Americans or whites to have difficulty obtaining transportation
for health care.{Baker1996}
The regular sources of care for African American, white, and Hispanic patients presenting to an urban, teaching hospital ED has been compared in only one trial. The ED was the "regular" source of care in 8% of white patients, 17% of black patients, and 19% of Hispanic patients in an urban teaching hospital ED.{Baker1996}
Controversy exists as to the impact of having insurance on the use of ED services. Having insurance was actually associated with increased ED use in one study at an urban teaching hospital.{Baker1996} However, in another survey at a different urban ED, having Medicare or Medicaid was associated with increased ED use while having no insurance or other forms of insurance was not associated with the frequency of ED use.{Lucas1998}
The final diagnosis of patients admitted as inpatients is more likely to be "chest pain" or "noncardiac" among African American patients than among white patients who were more likely to be diagnosed with an myocardial infarction.{Klingler2002}
The frequency of ED use based upon various demographic parameters and ethnic background has been minimally investigated. Emergency Department use during the preceding three months was greater for African Americans than for white or Hispanic patients in one survey of ED patients in an urban teaching hospital.{Baker1996} However, after adjusting for other factors that affect ED use, they found no significant difference in ED use among African American, white, and Hispanic patients.{Baker1996} In multivariate analysis, older age, having health insurance, having a regular source of care, and difficulty obtaining transportation to a physician's office all were associated with more frequent ED use.{Baker1996}
SUMMARY:
This is a survey and ED record review of patients with chest pain who present
to the ED of a large, urban, public, teaching facility. Medical students will
perform the surveys and complete the case report forms while the patients are
in the ED. Demographic information will be obtained directly from the patient
and from the review of the ED registration information. The ED records will
be reviewed to capture the ED evaluation and treatments rendered. Physicians
providing the initial evaluations of the patients will note their level of concern
for an acute coronary syndrome on a 10-centimeter visual analog scale. Patients
will also record on a similar scale their level of concern relative to their
chest pain. The medical students will call the patients ~ 4 weeks after the
ED visit to ascertain their outcomes. The surveyors will use a translator unless
he/she is fluent is Spanish.
The surveyors will be trained in the use of the survey instrument and case
report form. The surveys/case report forms will be field tested before the actual
beginning of the trial with final modifications performed in accordance with
the testing results. The ED physicians will be kept blinded as to the purpose
of the study.
INCLUSION CRITERIA:
Consecutive patients who present to the Parkland Memorial Hospital Emergency
Department who are > 35 years-old with chest pain as the chief complaint
or who are < 35 years-old who have chest pain and either diabetes or recent
use of cocaine.
EXCLUSION CRITERIA:
Patients to be excluded from the study include those who:
· Arrive to the ED in cardiac or pulmonary arrest
· Do not have a telephone for completing the follow-up telephone call
· Have an altered mental status
· Can not communicate
SOURCES OF RESEARCH MATERIAL:
A prospectively developed data collection tool will be used. All data for the
research project will be recorded on this tool. Data will be obtained by interviewing
the patient and reviewing the ED record. The ED record will include the EmSTAT
patient care computer database system. Patients will also be called in follow-up
2-6 weeks after the ED visit to assess their status.
RECRUITMENT OF SUBJECTS:
Patients will be interviewed by medical students. Patients will be approached
during their ED evaluation. The students will obtain consent. Patients will
be told that the study is only observational and that we are obtaining information
about them, their worries and needs, the results of any evaluation done, and
the results of follow-up done 1-2 months after the ED visit. Patients will be
informed that their care will not be changed if they don't participate. Signed
consent forms will be maintained in a secure research file.
POTENTIAL RISKS:
There are no physical, psychological, social, or economic risks associated with
this study. Patients will not experience discomfort by participating in the
study.
SPECIAL PRECAUTIONS:
There are no potential risks. There will be no adverse events because this is
an observational survey. Data will not be released to outside resources and
will be maintained confidentially.
PROCEDURES TO MAINTAIN CONFIDENTIALITY:
Information will only be given to co-investigators and to statisticians involved
in this study. The information that will be furnished will include the database
of patient demographics, clinical characteristics of the chest pain, physician
perspectives of the patients' complaints, and patients' perceptions of their
complaint. Information disclosure will be done to enable analysis of the data
and critique and analysis of the data. Confidentiality will be maintained by
keeping the case report forms secured in the primary investigator's office.
The electronic database, on Microsoft Access, will be maintained by the primary
investigator who will share it with the statisticians as needed. The electronic
database will identify patients according to a case report form number and will
not include the patients' names or medical record numbers. Executed consent
forms will be maintained in a locked file in the primary investigator's office.
POTENTIAL BENEFITS:
The human subjects involved in the study will not derive benefit. Future patients
with a similar complaint will benefit from the improved knowledge the effects
of race, sex, and socioeconomic factors on the presentation characteristics
and needs.
BIOSTATISTICS:
Standard statistics will be applied by a statistician.
RISK/BENEFIT ASSESSMENT:
There are no physical, psychological, social, and/or economic risks to the subjects.
Thus, the benefit to future patients will easily outweigh the non-existent risks.
Previous Research Activities or Publications with Medical Students: I am new
faculty but am working with Dr. Adam Miller who has done several studies with
students.
Return to UT Southwestern Homepage
Return to Student Research Projects Index