Thyrotoxic periodic paralysis is a rare cause of acute paralysis in the emergency department (ED). The disorder is generally thought to be due to acute hypokalemia leading to paralysis. Treatment is generally targeted at correcting the thyrotoxic state with careful potassium repletion. We present a rare case of normokalemic, thyrotoxic periodic paralysis with acute resolution while in the ED.

Introduction The Military Health System (MHS) offers an example of a socialized healthcare model, operating within a larger “purchased care” civilian healthcare market. This arrangement has facilitated a trend wherein MHS clinicians often transfer moderate-to-complex patients to surrounding civilian hospitals, despite having the capability to care for such patients in-house. In an effort to stem this behavior, two initiatives were introduced at Carl R Darnall Army Medical Center (CRDAMC): A Transfer Policy Statement and Transfer Rounds. The Transfer Policy Statement emphasized that patients ought to be transferred only for capability gaps within the hospital. Transfer Rounds were then used to review the care received by each transferred patient and assess if that care could have been delivered internally. The purpose of this study is to assess the effect of these initiatives on reducing transfers from our hospital. Materials and Methods We performed a retrospective chart review from July 2019 through June 2020 to identify the number of total emergency department (ED) transfers, subcategorized as either transfers we had the capability to care for or transfers we did not have the capability to care for. The Transfer Policy Statement was published in August 2019, and Transfer Rounds were instituted in November 2019. We hypothesized that the two interventions would decrease the number of monthly inappropriate transfers. This was assessed by analyzing the proportion of inappropriate to appropriate patient transfers via Cochran and Armitage using SAS 9.4 (SAS Institute, Cary, NC). The projected received an Exemption Determination from the CRDAMC’s Human Research Protections Office. The Defense Health Agency approved the data-sharing agreement. Results Over the study period, a total of 706 transfers met the criteria for analysis. The monthly median for total ED transfers was 64.5 (Interquartile Range (IQR) 45-74); appropriate transfers averaged 29.5 (median, IQR 24.5-36) and inappropriate 25.5 (median, IQR 9-41.5). A statistically significant downward trend in the fraction of inappropriate transfers was demonstrated by Cochran and Armitage (P < .0001). Conclusion Our analysis supports the hypothesis that implementing a Transfer Policy and Transfer Rounds can significantly reduce the amount of MHS Leakage—that is the number of transferred patients that the MHS could have equally cared for. The effects of reduced patient transfers have many implications for the MHS: patients experience improved continuity of care by remaining in the same hospital system; clinicians maintain and extend their scope of practice by treating more complex patients; and patient flow and ED wait times are reduced by eliminating the transfer process. The financial implications of reduced MHS Leakage were not directly evaluated by our study, however may be assessed in future study.

Pyogenic flexor tenosynovitis is a rare, though well known infectious process of the flexor tendon sheath of the hand. This condition is generally diagnosed in adults by the observance of the four Kanavel signs. Application of the Kanavel signs to diagnosis in the pediatric population, however, is of unknown utility. We present the case of a 13-month-old male with pyogenic flexor tenosynovitis who presented with all four of the Kanavel signs.

The Multinational Force and Observers in Sinai is a 13-nation international peacekeeping organization with the mission to implement the security provisions of the 1979 Egyptian–Israeli Treaty of Peace and continues today after approximately four decades. Despite not having significant changes to its core mission of force health protection, the medical team has recently evolved to face several challenges, with a coronavirus pandemic and a fatal helicopter crash. This article describes the medical challenges and experiences of the medical team from August 2019 to December 2020, highlighting changes from previous years. This article also updates three previous articles on the subject published in Military Medicine in 1983, 1991, and 2003.

A patient with myasthenia gravis who survived 2 COVID-19 infections required plasmapheresis to recover from an acute crisis.