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Objective To evaluate immersive virtual reality’s (IVR) effectiveness as a distraction in reducing perceived pain and anxiety among adults undergoing intravenous (IV) blood draw. Methods In this randomized controlled trial, we recruited adult patients 18-50 years of age scheduled for routine blood draws at the phlebotomy lab and randomized them into experimental and control groups. The experimental group underwent IV blood draw with IVR, and the control group underwent IV blood draw with standard practice. Before the procedure, subjects rated their anxiety level and the pain they “expected” to experience during blood draw. Immediately afterward, the subjects rated their actual “perceived” pain level. We measured the “expected” and the “perceived” pain and anxiety scores using a 100 mm visual analog scale. The primary outcome was the difference in “perceived” pain scores (0-100) between the two cohorts. Secondary outcomes were differences between the anxiety scores and the “expected” and “perceived” pain between the two cohorts, as well as degree of satisfaction with IVR during the blood draw and willingness to use IVR in future procedures. Results Fifty-nine subjects completed the study, 31 in the experimental group and 28 in the control group. For the primary outcome, the control group reported a perceived median pain score of 6.5 vs. the experimental group of 5; P = .55. For the secondary outcomes, the median anxiety scores were 22 (6.25-45.75) and 24 (2.00-35.00) for the control and the experimental groups, respectively, P = .44. The control group reported an expected median pain score of 20 vs. a perceived score of 6.5; P = .25, and the experimental group reported an expected median pain score of 22 vs. a perceived score of 5; P < .01. Median Likert scores were 5 (1-5) for satisfaction and preference for future use during painful procedures. Conclusions The results of our study demonstrated that there was no significantly lower perceived pain or anxiety when using IVR compared to standard practice in adults undergoing IV blood draw.

Introduction In recent U.S. Military conflicts, hemorrhage remains the leading cause of preventable death with 30%-40% mortality rates. Management consists of effective bleeding control and rapid resuscitation with blood products. Rapid and accurate circulatory access is crucial in battlefield trauma management. This study evaluates the insertion success rate and time to successfully insert the NIO automatic intraosseous (IO) device and the Tactical Advanced Lifesaving IO Needle (TALON) manual IO device. The primary outcome is successful first attempt insertion. Secondary outcomes are the time taken for the successful insertion, user-reported “ease of use” for both devices, and user-reported device preference. Materials and Methods This is a prospective randomized crossover study comparing the NIO and TALON devices. As they are often the frontline health care providers, combat medics (68W) were recruited to participate in this study. They were randomized into two cohorts based on the IO device and location they would start first. Each medic performed a total of four IO cannulations on the proximal tibia and the humeral head of cadaveric human models. Results Sixty medics participated in the study, performing a total of 240 IO insertions, 120 with NIO (60 at the proximal tibia and 60 at the humeral head) and 120 with TALON (60 at the proximal tibia and 60 at the humeral head). The first attempt success rate was 89.2% for the NIO and 83.3% for the TALON, P = .19. The time to successful first attempt insertion for the NIO [M = 24.71 seconds, SD = 4.72] and the TALON, [M = 24.70 seconds, SD = 4.74] were similar, P = .98. The differences between the success of device insertion and time to successful insertion did not achieve statistical significance. The “ease of use” score (5-point Likert Scale) for the NIO [M = 4.73] and the TALON, [M = 4.11], demonstrated a significant difference, P < .001. Ninety percent [n = 54] of the combat medics preferred the NIO versus only 10% [n = 6] preferred TALON. Conclusions Our findings indicate that the overall insertion success rate and time to successful insertion were similar between NIO automatic IO device and the TALON manual IO device. In our study, Army combat medics learned how to use both devices rapidly but felt the NIO automatic IO device easier to use and overwhelmingly preferred this device.

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Latrodectism from black widow spider (BWS) bites is rare in the United States. Latrodectism is a severe systemic manifestation of the envenomation that includes severe abdominal pain mimicking acute surgical abdomen and, in rare cases, could lead to acute myocarditis and rhabdomyolysis. The BWS typically inhabits dark, low-lying areas such as woodpiles, tree stumps, outdoor storage, outdoor furniture, outdoor toilets, and rock piles and is most active during warm weather months. Military service members often participate in field training exercises during warm weather in wooded areas littered with woodpiles and tree stumps; therefore, they are at an increased risk for bites by arachnids. We report the case of a 26-year-old active duty male soldier evacuated from field training with latrodectism and possible envenomation-induced myocarditis after a suspected BWS bite.

Introduction Pulmonary embolism (PE) can be difficult to rule out without computed tomography pulmonary angiograms (CTPAs), as presentations vary. Multiple clinical decision rules (CDRs) exist to risk-stratify patients to avoid unnecessary CTPAs. However, the currently used CDRs are complex, and research has shown low compliance with their usage. The YEARS algorithm is less complex and excludes patients from CTPA if PE is not the most likely diagnosis, they do not have a history of hemoptysis, and no clinical signs of deep vein thrombosis, is less complex. However, no studies have evaluated YEARS in the U.S. Military health care beneficiary population. Therefore, this study sought to determine if implementing the YEARS algorithm could decrease the number of CTPAs ordered to rule out PE in low-risk patients. Methods This retrospective, single-center cohort study applied the YEARS algorithm to low-risk military beneficiaries presenting to the emergency department in the calendar year 2020 at a single U.S. Army MTF. The primary outcome was the number of CTPAs indicated by the YEARS algorithm versus the number ordered via standard practice. We used chi-square testing to compare the number of subjects in whom YEARS indicated CTPA (meets criteria/does not meet criteria) versus the actual number of subjects who underwent CTPA (meets criteria/does not meet criteria). The secondary outcomes included applying YEARS similarly to the number of subjects >50 years of age (as opposed to age-adjusted d-dimer), determining the number of pregnant patients who could have avoided CTPA via application of YEARS, and assessing possible cost savings via reduction of CTPA. Results We included 353 subjects during the study period, 271 of whom underwent CTPA. YEARS would have only indicated 25 of them, P = .018. In patients >50 years of age, 164 underwent CTPA versus nine who met YEARS criteria, P = .014. Among pregnant patients, six underwent CTPA versus one who YEARS would have indicated, P = .130. Application of the YEARS algorithm would have led to a 90.8% reduction in CTPAs ordered with an overall known missed PE rate of 1.1%. Applying the YEARS algorithm in 2020 could have led to 246 fewer CTPAs at a minimum cost savings of $38,762.22 for the MTF based on the coded billing cost of $157.57 per CTPA when local staff radiologists performed image interpretation. This estimate does not consider the additional undisclosed cost of contracted radiologists interpreting after regular duty hours. Conclusions For our military beneficiaries, our study indicates that the YEARS algorithm would have reduced CTPA utilization in all age ranges and potentially among pregnant patients with a known missed PE rate of 1.1%.

We report the case of a 37-year-old man presenting with pain out of proportion to the exam with hydrofluoric acid burns to his upper extremities after he spilled a wheel-stripping compound on his forearms while working at his powder coating business. His burns initially appeared mild and superficial, but over the course of several days, these evolved from simple erythema to significant partial thickness tissue destruction and ulceration. He required substantial topical, intradermal, and intravenous therapies to control the unseen burning process during his index visit to the emergency department. We transferred the patient to a burn center given the location of his burns and the causative agent. The burn center clinicians observed him over the course of two nights and then discharged him with instructions to come for multiple follow-up visits during the subsequent month. Following nonoperative management, he had an uneventful recovery with full function retained in the affected extremities. Hydrofluoric acid burns require prompt treatment with calcium to neutralize the burning process, despite a potentially benign initial appearance. The emergency clinician should use an aggressive diagnostic and therapeutic approach to patients presenting with pain out of proportion to their exam, as this finding is associated with various serious underlying pathology.

Diarrhea is a common condition seen among soldiers in both garrison and deployed environments. Although the vast majority of soldiers with diarrhea will recover uneventfully with supportive care, clinicians should also maintain suspicion for less common causes and perform a thorough physical exam. We report the case of a young, healthy soldier with chronic diarrhea and progressively worsening abdominal distention that began during his deployment to Honduras who was subsequently found to have a large intra-abdominal desmoid tumor. Desmoid tumor is a rare and benign neoplasm that typically appears on the extremity, abdominal wall, intra-abdominal space, and occasionally in the chest wall. This tumor may be associated with abdominal distension and gastrointestinal complaints. A large tumor can compress organs, causing local tissue damage and, in rare cases, death.