The total number of minimally invasive cosmetic procedures topped 15 million for the first time in 2016, with onabotulinumtoxinA injections leading the way, according to the American Society of Plastic Surgeons.

An estimated 15.4 million minimally invasive cosmetic procedures were performed last year, with onabotulinumtoxinA making up over 45% – approximately 7.1 million anatomic sites injected – of that total, ASPS data show.

Next in popularity was injection of soft tissue fillers, with just over 2.6 million procedures – almost 17% of the procedures performed in 2016 – followed by chemical peels with almost 1.4 million procedures, laser hair removal with 1.1 million procedures, and microdermabrasion at 775,000, the ASPS reported.

The total number of minimally invasive procedures was up 3% from the 14.96 million performed in 2015, while onabotulinumtoxinA was up 4%, soft tissue fillers were up 2%, chemical peels were up 4%, laser hair removal was down 1%, and microdermabrasion was down 3%. Larger changes were seen among some less common procedures: injection lipolysis was up 18% (55,660 procedures in 2016), fat injection was up 13% (79,208 procedures in 2016), and acellular dermal matrix procedures were down 18% (7,809 in 2016), according to the ASPS Tracking Operations and Outcomes for Plastic Surgeons database and an annual survey of board-certified dermatologists, otolaryngologists, and plastic surgeons (final sample = 703).

The total number of minimally invasive cosmetic procedures topped 15 million for the first time in 2016, with onabotulinumtoxinA injections leading the way, according to the American Society of Plastic Surgeons.

An estimated 15.4 million minimally invasive cosmetic procedures were performed last year, with onabotulinumtoxinA making up over 45% – approximately 7.1 million anatomic sites injected – of that total, ASPS data show.

Next in popularity was injection of soft tissue fillers, with just over 2.6 million procedures – almost 17% of the procedures performed in 2016 – followed by chemical peels with almost 1.4 million procedures, laser hair removal with 1.1 million procedures, and microdermabrasion at 775,000, the ASPS reported.

The total number of minimally invasive procedures was up 3% from the 14.96 million performed in 2015, while onabotulinumtoxinA was up 4%, soft tissue fillers were up 2%, chemical peels were up 4%, laser hair removal was down 1%, and microdermabrasion was down 3%. Larger changes were seen among some less common procedures: injection lipolysis was up 18% (55,660 procedures in 2016), fat injection was up 13% (79,208 procedures in 2016), and acellular dermal matrix procedures were down 18% (7,809 in 2016), according to the ASPS Tracking Operations and Outcomes for Plastic Surgeons database and an annual survey of board-certified dermatologists, otolaryngologists, and plastic surgeons (final sample = 703).

The total number of minimally invasive cosmetic procedures topped 15 million for the first time in 2016, with onabotulinumtoxinA injections leading the way, according to the American Society of Plastic Surgeons.

An estimated 15.4 million minimally invasive cosmetic procedures were performed last year, with onabotulinumtoxinA making up over 45% – approximately 7.1 million anatomic sites injected – of that total, ASPS data show.

Next in popularity was injection of soft tissue fillers, with just over 2.6 million procedures – almost 17% of the procedures performed in 2016 – followed by chemical peels with almost 1.4 million procedures, laser hair removal with 1.1 million procedures, and microdermabrasion at 775,000, the ASPS reported.

The total number of minimally invasive procedures was up 3% from the 14.96 million performed in 2015, while onabotulinumtoxinA was up 4%, soft tissue fillers were up 2%, chemical peels were up 4%, laser hair removal was down 1%, and microdermabrasion was down 3%. Larger changes were seen among some less common procedures: injection lipolysis was up 18% (55,660 procedures in 2016), fat injection was up 13% (79,208 procedures in 2016), and acellular dermal matrix procedures were down 18% (7,809 in 2016), according to the ASPS Tracking Operations and Outcomes for Plastic Surgeons database and an annual survey of board-certified dermatologists, otolaryngologists, and plastic surgeons (final sample = 703).

Several state regulations governing the sales or use of e-cigarettes and related products were associated with lower proportions of youth trying or regularly using vaping products, a new study found.

Restricting sales of electronic vapor products to minors, however, was not linked to a lower risk of vaping among teens.

Thinkstockphotos

• Statewide prohibition of vaping products on school property or in workplaces, which includes Arizona, New Hampshire, Vermont, and Virginia for schools and North Dakota for workplaces.

• Prohibition of sales to minors under age 18 years, present in 24 states.

• Prohibition or restriction of sales of e-cigarette products from vending machines, present in 17 states.

• Prohibition or restriction of self-service displays of vaping products, present in 11 states.

• Prohibition or restriction of sampling of electronic vapor products, present in Arizona, Delaware, Kentucky, Maryland, New Hampshire, North Carolina, Oklahoma, and South Carolina.

For most of the regulations, teens had a reduced likelihood of trying or currently using vaping products after adjusting for age, ethnicity, grade level, race, region, and sex. Risk of ever trying a vaping product was 12% lower in states that prohibited their use on school grounds or in workplaces, 6% lower in states that barred sales to those under age 18, and 7% lower in states that restricted or prohibited self-service vaping displays.

The risk of youth currently using electronic vapor products was 5% lower in states with the school grounds and workplace restrictions, and 13% lower in states that restricted self-service displays. Laws restricting minor sales were unrelated to the risk of current vaping among youth. Restricting vending machine sales of vaping products had no association with the risk of a teen ever trying vaping, but it was linked to a 7% lower risk of current use of the products among teens. All these associations were statistically significant based on confidence interval values.

Interestingly, a statistically significant risk increase in vaping use occurred for teens in states that restricted or outlawed sampling of vaping products. The risk was 8% higher for ever trying a product and 20% higher for current use. But those findings also could indicate the possibility of reverse causation.

“It’s possible that states that were particularly concerned about sampling had the worst problems – were the ones more likely to institute a ban on that practice, and that would generate the counterintuitive finding,” Dr. Keim said in an interview. “With the data currently available, we can’t look at teen use both before and after the restrictions, just afterwards, but with more data for 2017, it would provide a clearer picture of all of the associations we examined.”

Aside from these laws, other interventions have the potential to reduce vaping among teens as well.

“Restrictions on use in various types of public places and on school grounds may be additional helpful approaches, similar to what has been done with cigarettes,” Dr. Keim said. Although their analysis included laws that prohibited use on school grounds, only four states have one of these laws.

Several state regulations governing the sales or use of e-cigarettes and related products were associated with lower proportions of youth trying or regularly using vaping products, a new study found.

Restricting sales of electronic vapor products to minors, however, was not linked to a lower risk of vaping among teens.

Thinkstockphotos

• Statewide prohibition of vaping products on school property or in workplaces, which includes Arizona, New Hampshire, Vermont, and Virginia for schools and North Dakota for workplaces.

• Prohibition of sales to minors under age 18 years, present in 24 states.

• Prohibition or restriction of sales of e-cigarette products from vending machines, present in 17 states.

• Prohibition or restriction of self-service displays of vaping products, present in 11 states.

• Prohibition or restriction of sampling of electronic vapor products, present in Arizona, Delaware, Kentucky, Maryland, New Hampshire, North Carolina, Oklahoma, and South Carolina.

For most of the regulations, teens had a reduced likelihood of trying or currently using vaping products after adjusting for age, ethnicity, grade level, race, region, and sex. Risk of ever trying a vaping product was 12% lower in states that prohibited their use on school grounds or in workplaces, 6% lower in states that barred sales to those under age 18, and 7% lower in states that restricted or prohibited self-service vaping displays.

The risk of youth currently using electronic vapor products was 5% lower in states with the school grounds and workplace restrictions, and 13% lower in states that restricted self-service displays. Laws restricting minor sales were unrelated to the risk of current vaping among youth. Restricting vending machine sales of vaping products had no association with the risk of a teen ever trying vaping, but it was linked to a 7% lower risk of current use of the products among teens. All these associations were statistically significant based on confidence interval values.

Interestingly, a statistically significant risk increase in vaping use occurred for teens in states that restricted or outlawed sampling of vaping products. The risk was 8% higher for ever trying a product and 20% higher for current use. But those findings also could indicate the possibility of reverse causation.

“It’s possible that states that were particularly concerned about sampling had the worst problems – were the ones more likely to institute a ban on that practice, and that would generate the counterintuitive finding,” Dr. Keim said in an interview. “With the data currently available, we can’t look at teen use both before and after the restrictions, just afterwards, but with more data for 2017, it would provide a clearer picture of all of the associations we examined.”

Aside from these laws, other interventions have the potential to reduce vaping among teens as well.

“Restrictions on use in various types of public places and on school grounds may be additional helpful approaches, similar to what has been done with cigarettes,” Dr. Keim said. Although their analysis included laws that prohibited use on school grounds, only four states have one of these laws.

Several state regulations governing the sales or use of e-cigarettes and related products were associated with lower proportions of youth trying or regularly using vaping products, a new study found.

Restricting sales of electronic vapor products to minors, however, was not linked to a lower risk of vaping among teens.

Thinkstockphotos

• Statewide prohibition of vaping products on school property or in workplaces, which includes Arizona, New Hampshire, Vermont, and Virginia for schools and North Dakota for workplaces.

• Prohibition of sales to minors under age 18 years, present in 24 states.

• Prohibition or restriction of sales of e-cigarette products from vending machines, present in 17 states.

• Prohibition or restriction of self-service displays of vaping products, present in 11 states.

• Prohibition or restriction of sampling of electronic vapor products, present in Arizona, Delaware, Kentucky, Maryland, New Hampshire, North Carolina, Oklahoma, and South Carolina.

For most of the regulations, teens had a reduced likelihood of trying or currently using vaping products after adjusting for age, ethnicity, grade level, race, region, and sex. Risk of ever trying a vaping product was 12% lower in states that prohibited their use on school grounds or in workplaces, 6% lower in states that barred sales to those under age 18, and 7% lower in states that restricted or prohibited self-service vaping displays.

The risk of youth currently using electronic vapor products was 5% lower in states with the school grounds and workplace restrictions, and 13% lower in states that restricted self-service displays. Laws restricting minor sales were unrelated to the risk of current vaping among youth. Restricting vending machine sales of vaping products had no association with the risk of a teen ever trying vaping, but it was linked to a 7% lower risk of current use of the products among teens. All these associations were statistically significant based on confidence interval values.

Interestingly, a statistically significant risk increase in vaping use occurred for teens in states that restricted or outlawed sampling of vaping products. The risk was 8% higher for ever trying a product and 20% higher for current use. But those findings also could indicate the possibility of reverse causation.

“It’s possible that states that were particularly concerned about sampling had the worst problems – were the ones more likely to institute a ban on that practice, and that would generate the counterintuitive finding,” Dr. Keim said in an interview. “With the data currently available, we can’t look at teen use both before and after the restrictions, just afterwards, but with more data for 2017, it would provide a clearer picture of all of the associations we examined.”

Aside from these laws, other interventions have the potential to reduce vaping among teens as well.

“Restrictions on use in various types of public places and on school grounds may be additional helpful approaches, similar to what has been done with cigarettes,” Dr. Keim said. Although their analysis included laws that prohibited use on school grounds, only four states have one of these laws.

Real-time PCR techniques for identifying the pathogens responsible for onychomycosis can offer some advantages over conventional diagnostic approaches but also have their limitations, say the authors of a study published in Mycoses.

Anissa Z. Hafirassou of Frères-Mentouri, Constantine University, Algeria, and colleagues analyzed nail samples from 70 patients with clinical signs of onychomycosis and 15 healthy controls using four different real-time PCR assays – a panfungal, a pandermatophyte, an assay for Candida and one for Aspergillus – and conventional methods.

copyright Metin Cengiz Bar/Thinkstock

Real-time PCR techniques for identifying the pathogens responsible for onychomycosis can offer some advantages over conventional diagnostic approaches but also have their limitations, say the authors of a study published in Mycoses.

Anissa Z. Hafirassou of Frères-Mentouri, Constantine University, Algeria, and colleagues analyzed nail samples from 70 patients with clinical signs of onychomycosis and 15 healthy controls using four different real-time PCR assays – a panfungal, a pandermatophyte, an assay for Candida and one for Aspergillus – and conventional methods.

copyright Metin Cengiz Bar/Thinkstock

Real-time PCR techniques for identifying the pathogens responsible for onychomycosis can offer some advantages over conventional diagnostic approaches but also have their limitations, say the authors of a study published in Mycoses.

Anissa Z. Hafirassou of Frères-Mentouri, Constantine University, Algeria, and colleagues analyzed nail samples from 70 patients with clinical signs of onychomycosis and 15 healthy controls using four different real-time PCR assays – a panfungal, a pandermatophyte, an assay for Candida and one for Aspergillus – and conventional methods.

copyright Metin Cengiz Bar/Thinkstock

The Society for Vascular Surgery has its very own member affinity program, offering members access to best-in-class products and services coupled with special member discounts.

The portfolio includes a number of insurance, financial and private-practice related products that will assist members in their day-to-day lives. The result: a selection of financial and practice solutions to protect and benefit your families, incomes, practices, offices and staff – even your own slice of cyberspace.

For more information, visit vsweb.org/AffinityProgram, call 855-533-1776 or email [email protected].
 

The Society for Vascular Surgery has its very own member affinity program, offering members access to best-in-class products and services coupled with special member discounts.

The portfolio includes a number of insurance, financial and private-practice related products that will assist members in their day-to-day lives. The result: a selection of financial and practice solutions to protect and benefit your families, incomes, practices, offices and staff – even your own slice of cyberspace.

For more information, visit vsweb.org/AffinityProgram, call 855-533-1776 or email [email protected].
 

The Society for Vascular Surgery has its very own member affinity program, offering members access to best-in-class products and services coupled with special member discounts.

The portfolio includes a number of insurance, financial and private-practice related products that will assist members in their day-to-day lives. The result: a selection of financial and practice solutions to protect and benefit your families, incomes, practices, offices and staff – even your own slice of cyberspace.

For more information, visit vsweb.org/AffinityProgram, call 855-533-1776 or email [email protected].
 

CHICAGO – A gluten-free diet is the cornerstone of treatment for celiac disease, but healing of the gut may take longer in some patients than in others.

New findings presented at the annual Digestive Disease Week suggest that, even though patients treated with a gluten-free diet generally experience clinical improvement during the first few weeks or months of making dietary changes, serologic and especially histologic normalization may take longer – and it is not always certain that it will occur.

designer491/Thinkstock

[email protected]

CHICAGO – A gluten-free diet is the cornerstone of treatment for celiac disease, but healing of the gut may take longer in some patients than in others.

New findings presented at the annual Digestive Disease Week suggest that, even though patients treated with a gluten-free diet generally experience clinical improvement during the first few weeks or months of making dietary changes, serologic and especially histologic normalization may take longer – and it is not always certain that it will occur.

designer491/Thinkstock

[email protected]

CHICAGO – A gluten-free diet is the cornerstone of treatment for celiac disease, but healing of the gut may take longer in some patients than in others.

New findings presented at the annual Digestive Disease Week suggest that, even though patients treated with a gluten-free diet generally experience clinical improvement during the first few weeks or months of making dietary changes, serologic and especially histologic normalization may take longer – and it is not always certain that it will occur.

designer491/Thinkstock

[email protected]

CHICAGO – Out-of-pocket costs may present a barrier to colorectal screening, and removing those costs could reduce colorectal cancer deaths, according to new data presented at the annual Digestive Disease Week.

These data imply that removing copayments could result in a 16% decrease in colorectal cancer–related deaths among Medicare beneficiaries, explained lead author Elisabeth Peterse, PhD, of the department of public health, Erasmus Medical Center, Rotterdam, the Netherlands.

The research also demonstrated that waiving copayments is cost effective, she added.

Despite the effectiveness of colorectal cancer screening, only 58% of eligible individuals adhere to current screening recommendations, Dr. Peterse noted. Financial barriers may play a role in the lack of adherence, as studies have found that removing out-of-pocket costs is one of the most effective interventions for increasing screening.

“But despite the fact that the Affordable Care Act has been successful in partially eliminating cost sharing for colorectal screening, Medicare beneficiaries may still face unexpected out-of-pocket liabilities,” said Dr. Peterse.

Out-of-pocket costs can be complicated, given that they can depend largely on how a procedure is coded. A screening colonoscopy or fecal immunochemical test (FIT) is completely covered if it is coded as a screening test, but follow-up colonoscopies come with 20% copayments.

A screening colonoscopy with polypectomy and a follow-up colonoscopy that is done after a positive fecal immunochemical test are coded as diagnostic rather than screening, so the patient has out-of-pocket costs, she explained.

To explore how waiving the cost of screening could impact colorectal cancer–related mortality and cost effectiveness, the researchers conducted an analysis using a microsimulation model for a cohort composed of 65-year-old individuals.

In the simulation, they estimated colorectal cancer–related mortality, quality-adjusted life-years, and total cost of screening and treatment using the current Medicare copayment schedule. These were then compared with outcomes for alternative situations.

The study was conducted in two parts, explained Dr. Peterse. In the first part, the researchers looked at five scenarios: one in which the 20% copayment was intact. In the second, the copayment was waived without having any impact on adherence. In the third, the investigators looked at a 5% increase in adherence but only at diagnostic follow-up.

In the fourth and fifth scenarios, the investigators looked at 5% and 10% increases in adherence, in both first screening and diagnostic follow-up, she added.

In the study’s second part, the researchers also estimated the threshold increase in participation at which copayment removal would be cost effective, using a $50,000 willingness-to-pay threshold.

They found that without screening, the expected mortality would be 25 colorectal deaths per 1,000 people in a population of 65-year-old individuals. With screening, the number was reduced to 12.8 deaths per 1,000 65-year-olds for colonoscopy, and 14.9 deaths per 1,000 for FIT screening. The total associated costs for screening and treatment for the two modalities were $3.02 million and $2.87 million.

If waiving the copayments had no impact in increasing screening levels, the cost of screening was estimated to increase to $3.1 million (2.8% increase) for colonoscopy and $2.9 million (1.6% increase) for FIT.

But if copayments were removed and there were a 5% increase in adherence, colorectal cancer deaths were estimated to decline to 11.7 (–8.3%) and 13.9 (–6.3%) per 1,000 for colonoscopy and FIT, respectively. That would result in cost-effectiveness ratios of $19,288 and $7,894 for no copayment versus having a copayment. Increasing adherence to 10% would result in an even lower ratio, noted Dr. Peterse.

The threshold increase for participating in screening programs – the point where removing a copayment becomes cost effective – was a 1.8% increase in colonoscopy screening and a 0.8% increase for FIT.

The conclusion is that waiving copayments is cost effective, Dr. Peterse said.

Dr. Peterse added that a limitation to the analysis is that the study authors don’t know to what extent patients are even aware of the copayments. “So, we don’t know if it is a barrier, and we didn’t take other insurance scenarios into account,” she said.

Dr. Peterse declared no relevant disclosures.

CHICAGO – Out-of-pocket costs may present a barrier to colorectal screening, and removing those costs could reduce colorectal cancer deaths, according to new data presented at the annual Digestive Disease Week.

These data imply that removing copayments could result in a 16% decrease in colorectal cancer–related deaths among Medicare beneficiaries, explained lead author Elisabeth Peterse, PhD, of the department of public health, Erasmus Medical Center, Rotterdam, the Netherlands.

The research also demonstrated that waiving copayments is cost effective, she added.

Despite the effectiveness of colorectal cancer screening, only 58% of eligible individuals adhere to current screening recommendations, Dr. Peterse noted. Financial barriers may play a role in the lack of adherence, as studies have found that removing out-of-pocket costs is one of the most effective interventions for increasing screening.

“But despite the fact that the Affordable Care Act has been successful in partially eliminating cost sharing for colorectal screening, Medicare beneficiaries may still face unexpected out-of-pocket liabilities,” said Dr. Peterse.

Out-of-pocket costs can be complicated, given that they can depend largely on how a procedure is coded. A screening colonoscopy or fecal immunochemical test (FIT) is completely covered if it is coded as a screening test, but follow-up colonoscopies come with 20% copayments.

A screening colonoscopy with polypectomy and a follow-up colonoscopy that is done after a positive fecal immunochemical test are coded as diagnostic rather than screening, so the patient has out-of-pocket costs, she explained.

To explore how waiving the cost of screening could impact colorectal cancer–related mortality and cost effectiveness, the researchers conducted an analysis using a microsimulation model for a cohort composed of 65-year-old individuals.

In the simulation, they estimated colorectal cancer–related mortality, quality-adjusted life-years, and total cost of screening and treatment using the current Medicare copayment schedule. These were then compared with outcomes for alternative situations.

The study was conducted in two parts, explained Dr. Peterse. In the first part, the researchers looked at five scenarios: one in which the 20% copayment was intact. In the second, the copayment was waived without having any impact on adherence. In the third, the investigators looked at a 5% increase in adherence but only at diagnostic follow-up.

In the fourth and fifth scenarios, the investigators looked at 5% and 10% increases in adherence, in both first screening and diagnostic follow-up, she added.

In the study’s second part, the researchers also estimated the threshold increase in participation at which copayment removal would be cost effective, using a $50,000 willingness-to-pay threshold.

They found that without screening, the expected mortality would be 25 colorectal deaths per 1,000 people in a population of 65-year-old individuals. With screening, the number was reduced to 12.8 deaths per 1,000 65-year-olds for colonoscopy, and 14.9 deaths per 1,000 for FIT screening. The total associated costs for screening and treatment for the two modalities were $3.02 million and $2.87 million.

If waiving the copayments had no impact in increasing screening levels, the cost of screening was estimated to increase to $3.1 million (2.8% increase) for colonoscopy and $2.9 million (1.6% increase) for FIT.

But if copayments were removed and there were a 5% increase in adherence, colorectal cancer deaths were estimated to decline to 11.7 (–8.3%) and 13.9 (–6.3%) per 1,000 for colonoscopy and FIT, respectively. That would result in cost-effectiveness ratios of $19,288 and $7,894 for no copayment versus having a copayment. Increasing adherence to 10% would result in an even lower ratio, noted Dr. Peterse.

The threshold increase for participating in screening programs – the point where removing a copayment becomes cost effective – was a 1.8% increase in colonoscopy screening and a 0.8% increase for FIT.

The conclusion is that waiving copayments is cost effective, Dr. Peterse said.

Dr. Peterse added that a limitation to the analysis is that the study authors don’t know to what extent patients are even aware of the copayments. “So, we don’t know if it is a barrier, and we didn’t take other insurance scenarios into account,” she said.

Dr. Peterse declared no relevant disclosures.

CHICAGO – Out-of-pocket costs may present a barrier to colorectal screening, and removing those costs could reduce colorectal cancer deaths, according to new data presented at the annual Digestive Disease Week.

These data imply that removing copayments could result in a 16% decrease in colorectal cancer–related deaths among Medicare beneficiaries, explained lead author Elisabeth Peterse, PhD, of the department of public health, Erasmus Medical Center, Rotterdam, the Netherlands.

The research also demonstrated that waiving copayments is cost effective, she added.

Despite the effectiveness of colorectal cancer screening, only 58% of eligible individuals adhere to current screening recommendations, Dr. Peterse noted. Financial barriers may play a role in the lack of adherence, as studies have found that removing out-of-pocket costs is one of the most effective interventions for increasing screening.

“But despite the fact that the Affordable Care Act has been successful in partially eliminating cost sharing for colorectal screening, Medicare beneficiaries may still face unexpected out-of-pocket liabilities,” said Dr. Peterse.

Out-of-pocket costs can be complicated, given that they can depend largely on how a procedure is coded. A screening colonoscopy or fecal immunochemical test (FIT) is completely covered if it is coded as a screening test, but follow-up colonoscopies come with 20% copayments.

A screening colonoscopy with polypectomy and a follow-up colonoscopy that is done after a positive fecal immunochemical test are coded as diagnostic rather than screening, so the patient has out-of-pocket costs, she explained.

To explore how waiving the cost of screening could impact colorectal cancer–related mortality and cost effectiveness, the researchers conducted an analysis using a microsimulation model for a cohort composed of 65-year-old individuals.

In the simulation, they estimated colorectal cancer–related mortality, quality-adjusted life-years, and total cost of screening and treatment using the current Medicare copayment schedule. These were then compared with outcomes for alternative situations.

The study was conducted in two parts, explained Dr. Peterse. In the first part, the researchers looked at five scenarios: one in which the 20% copayment was intact. In the second, the copayment was waived without having any impact on adherence. In the third, the investigators looked at a 5% increase in adherence but only at diagnostic follow-up.

In the fourth and fifth scenarios, the investigators looked at 5% and 10% increases in adherence, in both first screening and diagnostic follow-up, she added.

In the study’s second part, the researchers also estimated the threshold increase in participation at which copayment removal would be cost effective, using a $50,000 willingness-to-pay threshold.

They found that without screening, the expected mortality would be 25 colorectal deaths per 1,000 people in a population of 65-year-old individuals. With screening, the number was reduced to 12.8 deaths per 1,000 65-year-olds for colonoscopy, and 14.9 deaths per 1,000 for FIT screening. The total associated costs for screening and treatment for the two modalities were $3.02 million and $2.87 million.

If waiving the copayments had no impact in increasing screening levels, the cost of screening was estimated to increase to $3.1 million (2.8% increase) for colonoscopy and $2.9 million (1.6% increase) for FIT.

But if copayments were removed and there were a 5% increase in adherence, colorectal cancer deaths were estimated to decline to 11.7 (–8.3%) and 13.9 (–6.3%) per 1,000 for colonoscopy and FIT, respectively. That would result in cost-effectiveness ratios of $19,288 and $7,894 for no copayment versus having a copayment. Increasing adherence to 10% would result in an even lower ratio, noted Dr. Peterse.

The threshold increase for participating in screening programs – the point where removing a copayment becomes cost effective – was a 1.8% increase in colonoscopy screening and a 0.8% increase for FIT.

The conclusion is that waiving copayments is cost effective, Dr. Peterse said.

Dr. Peterse added that a limitation to the analysis is that the study authors don’t know to what extent patients are even aware of the copayments. “So, we don’t know if it is a barrier, and we didn’t take other insurance scenarios into account,” she said.

Dr. Peterse declared no relevant disclosures.

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

In this issue of Emergency Medicine (EM), emergency physician (EP) Christopher Hunter, MD, and his colleagues from Orlando Regional Medical Center (ORMC) share their first-person experiences planning for and dealing with the medical issues presented by an estimated 40,000 people attending an annual outdoor electronic dance music festival on each of 2 days in November 2016. Reacting to the overwhelming burden that had been placed on their ED and hospital by the same event the year before, the ORMC EPs demonstrate how a coordinated approach to planning and execution by EPs, the local emergency medical services system, festival organizers, and disaster response groups can accurately anticipate and effectively deal with the myriad of urgent and emergent needs presented by this type of event. In recent years, the number of such events throughout the country has been increasing rapidly.

This same group of skilled and dedicated ORMC EPs authored a first-person account in the August 2016 issue of EM (The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned. Emerg Med. 2016;48(8):348-356), describing how they handled the aftermath of the Pulse Nightclub mass casualty incident (MCI), which also occurred in close proximity to ORMC.

Tragically, as this issue of EM was going to press, the world was shocked by yet another terrorist MCI, this time at a concert venue in Manchester, England. The lethal explosives were detonated in Manchester by a suicide bomber just outside the arena as the exiting crowd was heading to the nearby railroad station. This latest MCI claimed the lives of at least 22 children, parents, and young adults, and is of great concern to all who participate in concerts and large outdoor events: We must now consider the possibility of incidents combining the problems described in both of the first-person accounts mentioned above.

The most recent wave of terrorist MCIs, including the 2016 Orlando Pulse Nightclub shootings (49 deaths, 53 injuries, all but four victims were under the age of 40 years); the November 2015 terrorist incidents in Paris, including the Bataclan theatre rock concert massacre (89 deaths); and the April 15, 2013 Boston Marathon bombing (three deaths—ages 8, 23, 29 years—and 264 injuries), have all targeted mostly children and young adults.

In contrast, the victims of previous terrorist MCIs were mostly working adults. Of the almost 3,000 people who died in the 9/11 World Trade Center (WTC) and Pentagon attacks, almost all were between 35 and 39 years old, with the youngest WTC tower victim 18 years of age and the oldest 79. Terrorist activities in trains such as the March 11, 2004 Madrid commuter train bombings (192 deaths, about 2,000 injuries), and the March 20, 1995 Tokyo subway sarin gas release (12 deaths, over 1,000 severe injuries) also appeared to have targeted adults traveling to work during rush hours.

Clearly, EPs have an important role to play in providing urgent and emergent care at large outdoor gatherings, and emergent care and resuscitation of victims after natural and man-made MCIs. But the prospect of both types of events occurring in rapid succession at the same venue underlines the importance of preserving hospital-based ED resources during large gatherings by treating and releasing the majority of patients with festival-related illnesses and minor injuries on-site, as described in this month’s cover article.

The proliferation of EP-staffed urgent care centers and freestanding EDs (FSEDs) in recent years has demonstrated the ability of EPs to provide expert, needed emergency care outside of the walls of traditional, hospital-based EDs—a healthy trend for the future of emergency medicine. Like “pop-up” seasonal retail stores, the “pop-up FSED” described here by the ORMC EPs will become an increasingly important means of delivering urgent and emergent care in the future. 

Over the past 5 to 10 years, electronic dance music (EDM) festivals have grown in popularity in the United States, developing into massive, multiday events drawing crowds of tens of thousands of attendees.¹ The nature of these events—ie, long outdoor performances attended by a primarily youthful audience in sometimes austere environments¹—presents several unique challenges to local EDs, including the ability to effectively manage mass cases of polysubstance abuse, exposure to extremes of weather, and dehydration.

Since 2011, Orlando, Florida has been host to a popular annual EDM festival—one that has nearly doubled in size since its inception. In 2015, both the volume of 911 calls related to this event and number of attendees seeking care at the city’s first aid stations located at the festival overwhelmed our local emergency medical services (EMS) system and the nearest ED. The acuity of these patient interactions ranged from cases that could have been treated and released on-site to several critical care cases, including two fatalities.

In advance of the November 2016 festival, event staff, EMS, and hospital planners worked together to improve attendee safety and to avoid unnecessary admissions to the area receiving hospital, Orlando Regional Medical Center (ORMC). This cooperative endeavor resulted in the creation of a unique, fully staffed field hospital that was seamlessly integrated with EMS personnel and in constant communication with ORMC. The implementation of a field hospital on-site at the event decreased mortality and provided a reasonable and manageable way to safely treat and release patients who would have otherwise required transportation to the receiving center.

The 2016 Festival: Background

Location and Setup

In November 2016, the EDM festival was held at its usual location in the fields and areas surrounding a large stadium near downtown Orlando. Although the fall season in Florida can be unpredictable, the weather during the day is typically hot and humid, with temperatures averaging 80°F to 90°F. The festival took place over a 2-day period between noon and midnight each day. Unlike similar multiday festivals that run over a consecutive period of 24 to 48 hours, there were no overnight activities at this event.

Whereas other similar festivals often take place in more remote, austere environments such as deserts or forests, the Orlando EDM festival was held within the city but did not have on-site overnight accommodations. While this location eased some of our concerns, overnight closure of the field hospital altered our approach to patient management. When the facility closed, many patients who may have been observed overnight and subsequently released, required transport to the hospital for further observation and monitoring.

Attendees and Layout

The festival drew approximately 30,000 to 40,000 attendees each day, with multiple stages and fairground-type attractions spread over approximately 45 acres. The area was transformed by massive stages and production equipment, including complex lighting, pyrotechnics, expansive sound systems, and carnival rides. There were also dozens of on-site kiosks and pop-up structures selling food, merchandise, and alcoholic and nonalcoholic beverages.

Substance Abuse and Elemental Exposures

Although festival planners expressly prohibit illicit drug use at EDM events, substance use has been and continues to be prevalent at these types of festivals—particularly the use of alcohol, amphetamines such as 3,4-methylenedioxymethamphetamine (MDMA, also known as “ecstasy” and “Molly”), lysergic acid diethylamide (LSD), cocaine, and marijuana (Table).²

Lessons From the 2015 Festival

The 2015 EDM festival in Orlando had taken place without significant coordination between local EMS medical directors and ORMC, and was treated in a similar manner to other mass gatherings held in the area—ie, with extra EMS personnel on-site as well as several first aid stations. However, over the course of the 2015 event, the medics on-site were overwhelmed by the number of attendees seeking care, and felt obligated to transport a large number of these patients to ORMC (many of whom did not require hospital care), or to treat and release patients in a manner that was not in accordance with existing protocol.

As a result, the online medical control doctors at ORMC were overwhelmed by the sudden influx of calls for treat-and-release orders or intravenous (IV) hydration—not a common occurrence at this institution. This resulted in dozens of patient transports to the ED. Many of these patients did not require emergent care but simply needed shelter from the elements, rest because of sleep deprivation, or a place to recover from the effects of alcohol or drugs. Some patients, however, presented to ORMC in critical condition, two of whom died from suspected drug-related causes and/or severe hyperthermia.

After-Action Review

An after-action review of the 2015 EDM festival conducted by the Orlando Fire Department (OFD) concluded that significantly more medical support was needed for this and similar large-scale events in the future. Together with OFD, we examined how other regions in the United States handled similar festivals, and it became clear that a multidisciplinary approach, including a field hospital, EMS, ORMC, and festival planners, would be necessary for the 2016 festival.

Collaborative Planning for the 2016 Festival

Festival planners and promoters worked closely with the City of Orlando and EMS medical directors for months leading up to the 2016 EDM festival. The complexities of stage set-up alone required significant coordination, including the closure of several roads. To set up the field hospital, we first tried to acquire “real estate” on festival grounds. When this proved not to be feasible, we worked with city officials to create a field hospital on a street just outside the festival’s side gate.

Resources

Throughout the process, we worked closely with the festival’s planners, as well as a medical team designated by its parent company, to coordinate shared resources. The medical team provided a significant amount of medical supplies to our field hospital. In addition, the festival obtained and paid for an insurance rider extending coverage to our medical staff while working at the event.

Ground Control Staff

The planners and promoters of the EDM festival host several other festivals each year, including some that are larger and longer than the annual event held in Orlando. A small team from Orlando visited their set-up at a larger festival in Nevada several months prior to the 2016 EDM festival, gathering information on how we could best execute our plans. In addition to equipment and support, the festival also designated ground controllers (GCs) stationed throughout the festival area. These were individuals without medical training who could be easily identified and could guide those in need of medical attention to the nearest first aid station or to the field hospital, or contact us when someone was in need of immediate or emergent care.

Access and Communications

Several areas identified for improvement from 2015 included better ambulance access, radio communication (especially with physicians), and appropriate staffing. To provide additional medical staff for the 2016 EDM festival, the Office of the Medical Director (OMD) and the Central Florida Disaster Coalition (CFDC), a regional nonprofit organization that assists with disaster-health response in the area, utilized this event as a drill for a large-scale disaster that would require a self-sufficient field hospital. Part of this initiative included radio transmission equipment that would allow the routing of all 911 and other emergency calls from the festival grounds directly to on-site medical personnel.

In addition to the CFDC resources, we had dedicated medical control on the radio to answer questions from the paramedics staffing the outer first aid stations. This was separate from our normal medical control base-station process, and allowed our traditional EMS operating structure to continue outside the event without any confusion or added burden from within.

Field Hospital and First Aid Stations

Created just beyond the fencing that surrounded the event, the field hospital was a 3,200-square-foot, enclosed, air-conditioned structure powered by generators. In addition to the field hospital, three first aid stations were strategically placed around the festival grounds, and groups of medical personnel were assigned to walk the grounds.

The field hospital was staffed by physicians, nurses, paramedics, respiratory therapists, administrative staff, and pharmacists, and was divided into three separate color-coded sections based on patient acuity—a “green” section with 16 beds for low-acuity patients; a “yellow” section with 10 beds for medium-acuity patients; and a “red” section with four beds for critical care patients. The critical care area, which was set up as a free-standing ED, had ventilators, ultrasound equipment, an ice bath, and advanced life support equipment. Board-certified emergency physicians were present in each area at all times throughout the event, in addition to several emergency medicine residents and medical students. The field hospital also housed a fully stocked pharmacy.

To direct and manage patients, a registration section was set up in front of the field hospital; intake/triage took place in a separate 15-chair, low-acuity area located beyond the front door. Charting was performed on CFDC charts and maintained for records; however, no patients were billed for care.

Separate command vehicles were set up for operations, radio communication, and storage of the staff’s personal belongings. The festival organizers provided meals to all medical personnel.

Access, Communications, and Transportation

A designated road was closed off to all nonemergency traffic leading from the field hospital to an open access point. Our closed communication system meant that 911 calls inside the event would be dispatched to our personnel stationed on-site.

The field hospital served as a single casualty collection point for the entire event, so any patient transported out would first go to the field hospital for evaluation, then move to a waiting transport vehicle, if necessary. This arrangement not only allowed the on-scene staff to evaluate and, when necessary, stabilize patients before transport, but also permitted us to identify and care for those who could be treated on-scene instead of sending them to the hospital. Routing all patients through one location also allowed the EMS staff to appropriately monitor the exact number of patients being treated. The first aid stations were staffed by paramedics and emergency medical technicians, and stocked with advanced life support and first aid equipment.

Motorized golf carts, “gators,” and hand-held carts were used to convey patients from first aid stations and other parts of the festival grounds to the field hospital. On several occasions, physicians accompanied paramedics responding to calls on the festival grounds.

The 2016 Festival: First-Person Report

An hour before the event began, we arrived at the scene, familiarized ourselves with the layout, and met with incident command, EMS, medical directors, and festival staff to discuss plans and divide the teams up. Prior to the event, a medical toxicologist reviewed with participating medical staff several priority resuscitation measures for patients presenting with drug intoxication. These priorities included control of hyperthermia, management of drug-related arrhythmias, seizures, and agitation, all of which permitted smooth transition of care and mutual understanding about which patients ultimately required transfer to the hospital.

Unexpected Needs

The medical needs were not great during the daytime hours. However, by sunset, a constant stream of attendees visited our field hospital, bringing their own prescription medications, including some requiring refrigeration, and requested that we store these on their behalf. We quickly created a process for safe storage and accountability of these medications.

In addition to requesting an unanticipated storage facility, attendees presented with more expected and typical “urgent care needs,” including headaches, rashes, and blisters. By the late afternoon, we began seeing patients who had been vomiting after riding fair attractions and those with heat-related syncope.

As evening descended, our triage area became busy with a wave of agitated, intoxicated patients presenting via EMS, friends, and GCs. When indicated, benzodiazepines (lorazepam and midazolam) were administered to mild-to-moderately agitated patients after verbal de-escalation attempts were unsuccessful. Severely agitated patients required sedative treatment with an antipsychotic (haloperidol or ziprasidone).

In the low-acuity (green) section, arousable patients whose vital signs were stable rested on cots, as did those requiring oral ondansetron for vomiting and who were able to tolerate oral hydration. The moderate-­acuity (yellow) section housed a large number of dehydrated and/or intoxicated patients who required IV fluid therapy. Patients in the critical care (red) area suffered primarily from behavioral issues and altered mental status requiring chemical or physical restraint; many of these patients were transported to the hospital once they could be safely moved. Other critical care patients with medical emergencies were also housed in this area, including an overdose victim for whom endotracheal intubation was needed for airway protection.

As the evening progressed, we saw more severe overdoses and intoxications, including several cases of alcohol- and drug-induced seizures. Any seizure that occurred on the festival grounds was considered a potential cardiac arrest, requiring physician response. Some of our most difficult patient encounters included seizing or postictal patients presenting in an agitated fashion among crowds of intoxicated people who were attempting to help. We also treated a middle-aged festival employee with cardiac disease who presented with chest pain and acute electrocardiogram changes.

One festival attendee with a history of shoulder dislocation presented with a recurrent dislocation. Without needing to sedate the patient, we successfully reduced the dislocated shoulder at the field hospital. Afterward, the patient refused transport to the hospital and insisted on returning to the festival in a sling. Several patients were seen for complaints of eye pain or irritation attributed to vigorous wind and pyrotechnic displays around the large stages—two underwent ophthalmologic evaluation with a small eye kit (topical anesthetic, fluorescein stain, and a Woods lamp) and were diagnosed with corneal abrasions.

Multiple patients with histories of asthma presented with respiratory complaints ranging from mild to severe. Most of these patients were successfully treated with albuterol, though some required supplemental oxygen and corticosteroid therapy. One patient required transport to ORMC for additional care and treatment.

Nonmedical Presentations

The location of the field hospital beyond the perimeter fence of the event created a slight “disconnect” from the crowds and lights—but not from the sound. Several attendees presented to the field hospital, asking for a place to “chill out.” To accommodate these presentations, several chairs were set up under the cover of a pop-up tent for a place to rest and drink a bottle of water. Some individuals remained in this tent for nearly the entire event—refusing care, but feeling more comfortable being in proximity of the field hospital. Although many of these individuals appeared to be intoxicated, the area remained calm throughout the event. This makeshift rest area also served as cover during a brief rain storm in the late afternoon on day 1, as well as for those seeking shelter from the hot afternoon.

Emergency Medical Services

The OFD contributed substantial resources to the 2016 festival, and their support continued throughout the event. Operations were based on the National Incident Management System’s framework, which was developed in coordination with the OMD, OFD, and other stakeholders within ORMC. Logistics and medical groups were created, and the event was divided geographically into “northern,” “southern,” and “eastern” divisions. The unified command structure included a fire department deputy chief and a liaison officer (the OFD off-duty coordinator) who maintained face-to-face communications with festival operators throughout the event. The medical group was coordinated by the OFD EMS chief in collaboration with the OMD. A communications plan was created and used effectively throughout the event to coordinate patient movement, transfers, and transports to the field hospital and ORMC. Briefings were conducted for each operational period and included all personnel involved in the event.

At least one EMS medical director was on-site at all times, in constant communication with the EMS chief on scene, who functioned primarily at the field hospital to guide throughput of patients. The OFD staffed three first aid stations with advanced and basic life support providers, and had personnel roving the festival grounds. In addition to having advanced life support capabilities, the first aid stations dispensed acetaminophen, adhesive bandages, ear plugs, and bottled water, and responded to nearby calls for help and transported patients to the field hospital as needed.

The OFD was also the primary transport agency. Ambulances were dedicated to the event and stationed at the field hospital to transport patients to ORMC. In total, 32 EMS personnel were on scene, including ambulance personnel, staffing at first aid stations, and personnel circulating among the crowd.

The Orlando Police Department (OPD) was also a constant presence at the event, providing security for both festivalgoers and staff at the field hospital. We did not have our own security personnel at the field hospital, and OPD provided a comfort level for the medical staff as the number of agitated, intoxicated patients increased.

Orlando Regional Medical Center

During the 2015 EDM festival, ORMC had been inundated with festivalgoers. Many required only minor care, but some were in need of critical care, including two cardiac arrest patients. Based on this festival experience, hospital administration at ORMC ensured adequate staffing for the 2016 festival, including nursing, medical technicians, radiology technicians, and respiratory therapists. Communication between familiar colleagues, operating under mutually understood protocols, and the ability to communicate with the field hospital, allowed for very smooth transitions of care throughout the 2016 event.

There was a direct correlation between the time of day and number and severity of patients transported to the hospital. Early in the day, patients presented with heat illness and altered mental status, syncope, and confusion; all were easily managed. By late evening, patients with possible arrhythmias, seizures, hyperthermia, chest pain, and altered mental status began to arrive. While the number of patients with the clinical presentation of intoxication and agitation was not surprising, the outcomes were occasionally unexpected—including several elevated troponin levels and occasional arrhythmias.

The hospital received 68 patients directly from the field hospital at the festival. More than 100 presented to the field hospital with altered mental status, of which dozens resolved with observation and close monitoring. Thirty patients had transient arrhythmias ranging from tachycardia and a slightly widened QRS complex. Six had seizures which responded to benzodiazepine treatment. One patient suffered respiratory failure; he was managed by mechanical ventilation, which was performed at the field hospital, and afterward transported to ORMC with a resident physician. Five patients had hyponatremia, which may have been dilutional from excess free-water intake or mediated by syndrome of inappropriate antidiuretic hormone secretion secondary to MDMA use. Hyperthermic patients were managed with active cooling.

Laboratory evaluation revealed elevated troponin levels in six patients, though none of the patients required emergent cardiac intervention. The elevated troponin levels were possibly secondary to demand ischemia from sympathomimetic toxidromes.

Although many patients admitted to using recreational drugs, few specified the type or amount of drug taken, either because they were too altered to communicate, were unfamiliar with what they ingested, or feared legal repercussions. Ethanol, marijuana, and MDMA were the most commonly reported drugs.

Lessons Learned

Over the 2-day 2016 EDM festival, 235 patients were treated at the field hospital, and 68 were transported to ORMC—almost 100 fewer hospital transports than during the 2015 EDM festival, which lacked a field hospital. Although two attendees at the 2016 event required intensive care at ORMC, there were no deaths. Overall, the field hospital and cooperative approach provided a safer method for treating patients and without overwhelming hospital or EMS resources. 
Successful utilization of a field hospital at the 2016 EDM festival required the coordinated efforts of multiple organizations, including the EMS system, ORMC, festival organizers, and disaster response groups. The deployment of this strategy required a great deal of planning, coordination, and efforts months before the actual event, and included a sufficient number of trained emergency and medical personnel, support staff for equipment set-up, operation, and takedown, and insurance coverage.

In reviewing the medical care model provided for the 2016 EDM festival, we concluded that a more effective and efficient staffing model would have deployed more nurses and fewer physicians. Utilizing the event as training for residents and medical students resulted in a large number of providers on-site, but inadequate support staff.

When planning for this event, we did not anticipate the extent of the primary care and urgent care concerns encountered during the event, though we did anticipate that the most critical medical concerns were sympathomimetic and hallucinogenic toxidromes requiring restraint, benzodiazepines, and antipsychotics.

Over the past 5 to 10 years, electronic dance music (EDM) festivals have grown in popularity in the United States, developing into massive, multiday events drawing crowds of tens of thousands of attendees.¹ The nature of these events—ie, long outdoor performances attended by a primarily youthful audience in sometimes austere environments¹—presents several unique challenges to local EDs, including the ability to effectively manage mass cases of polysubstance abuse, exposure to extremes of weather, and dehydration.

Since 2011, Orlando, Florida has been host to a popular annual EDM festival—one that has nearly doubled in size since its inception. In 2015, both the volume of 911 calls related to this event and number of attendees seeking care at the city’s first aid stations located at the festival overwhelmed our local emergency medical services (EMS) system and the nearest ED. The acuity of these patient interactions ranged from cases that could have been treated and released on-site to several critical care cases, including two fatalities.

In advance of the November 2016 festival, event staff, EMS, and hospital planners worked together to improve attendee safety and to avoid unnecessary admissions to the area receiving hospital, Orlando Regional Medical Center (ORMC). This cooperative endeavor resulted in the creation of a unique, fully staffed field hospital that was seamlessly integrated with EMS personnel and in constant communication with ORMC. The implementation of a field hospital on-site at the event decreased mortality and provided a reasonable and manageable way to safely treat and release patients who would have otherwise required transportation to the receiving center.

The 2016 Festival: Background

Location and Setup

In November 2016, the EDM festival was held at its usual location in the fields and areas surrounding a large stadium near downtown Orlando. Although the fall season in Florida can be unpredictable, the weather during the day is typically hot and humid, with temperatures averaging 80°F to 90°F. The festival took place over a 2-day period between noon and midnight each day. Unlike similar multiday festivals that run over a consecutive period of 24 to 48 hours, there were no overnight activities at this event.

Whereas other similar festivals often take place in more remote, austere environments such as deserts or forests, the Orlando EDM festival was held within the city but did not have on-site overnight accommodations. While this location eased some of our concerns, overnight closure of the field hospital altered our approach to patient management. When the facility closed, many patients who may have been observed overnight and subsequently released, required transport to the hospital for further observation and monitoring.

Attendees and Layout

The festival drew approximately 30,000 to 40,000 attendees each day, with multiple stages and fairground-type attractions spread over approximately 45 acres. The area was transformed by massive stages and production equipment, including complex lighting, pyrotechnics, expansive sound systems, and carnival rides. There were also dozens of on-site kiosks and pop-up structures selling food, merchandise, and alcoholic and nonalcoholic beverages.

Substance Abuse and Elemental Exposures

Although festival planners expressly prohibit illicit drug use at EDM events, substance use has been and continues to be prevalent at these types of festivals—particularly the use of alcohol, amphetamines such as 3,4-methylenedioxymethamphetamine (MDMA, also known as “ecstasy” and “Molly”), lysergic acid diethylamide (LSD), cocaine, and marijuana (Table).²

Lessons From the 2015 Festival

The 2015 EDM festival in Orlando had taken place without significant coordination between local EMS medical directors and ORMC, and was treated in a similar manner to other mass gatherings held in the area—ie, with extra EMS personnel on-site as well as several first aid stations. However, over the course of the 2015 event, the medics on-site were overwhelmed by the number of attendees seeking care, and felt obligated to transport a large number of these patients to ORMC (many of whom did not require hospital care), or to treat and release patients in a manner that was not in accordance with existing protocol.

As a result, the online medical control doctors at ORMC were overwhelmed by the sudden influx of calls for treat-and-release orders or intravenous (IV) hydration—not a common occurrence at this institution. This resulted in dozens of patient transports to the ED. Many of these patients did not require emergent care but simply needed shelter from the elements, rest because of sleep deprivation, or a place to recover from the effects of alcohol or drugs. Some patients, however, presented to ORMC in critical condition, two of whom died from suspected drug-related causes and/or severe hyperthermia.

After-Action Review

An after-action review of the 2015 EDM festival conducted by the Orlando Fire Department (OFD) concluded that significantly more medical support was needed for this and similar large-scale events in the future. Together with OFD, we examined how other regions in the United States handled similar festivals, and it became clear that a multidisciplinary approach, including a field hospital, EMS, ORMC, and festival planners, would be necessary for the 2016 festival.

Collaborative Planning for the 2016 Festival

Festival planners and promoters worked closely with the City of Orlando and EMS medical directors for months leading up to the 2016 EDM festival. The complexities of stage set-up alone required significant coordination, including the closure of several roads. To set up the field hospital, we first tried to acquire “real estate” on festival grounds. When this proved not to be feasible, we worked with city officials to create a field hospital on a street just outside the festival’s side gate.

Resources

Throughout the process, we worked closely with the festival’s planners, as well as a medical team designated by its parent company, to coordinate shared resources. The medical team provided a significant amount of medical supplies to our field hospital. In addition, the festival obtained and paid for an insurance rider extending coverage to our medical staff while working at the event.

Ground Control Staff

The planners and promoters of the EDM festival host several other festivals each year, including some that are larger and longer than the annual event held in Orlando. A small team from Orlando visited their set-up at a larger festival in Nevada several months prior to the 2016 EDM festival, gathering information on how we could best execute our plans. In addition to equipment and support, the festival also designated ground controllers (GCs) stationed throughout the festival area. These were individuals without medical training who could be easily identified and could guide those in need of medical attention to the nearest first aid station or to the field hospital, or contact us when someone was in need of immediate or emergent care.

Access and Communications

Several areas identified for improvement from 2015 included better ambulance access, radio communication (especially with physicians), and appropriate staffing. To provide additional medical staff for the 2016 EDM festival, the Office of the Medical Director (OMD) and the Central Florida Disaster Coalition (CFDC), a regional nonprofit organization that assists with disaster-health response in the area, utilized this event as a drill for a large-scale disaster that would require a self-sufficient field hospital. Part of this initiative included radio transmission equipment that would allow the routing of all 911 and other emergency calls from the festival grounds directly to on-site medical personnel.

In addition to the CFDC resources, we had dedicated medical control on the radio to answer questions from the paramedics staffing the outer first aid stations. This was separate from our normal medical control base-station process, and allowed our traditional EMS operating structure to continue outside the event without any confusion or added burden from within.

Field Hospital and First Aid Stations

Created just beyond the fencing that surrounded the event, the field hospital was a 3,200-square-foot, enclosed, air-conditioned structure powered by generators. In addition to the field hospital, three first aid stations were strategically placed around the festival grounds, and groups of medical personnel were assigned to walk the grounds.

The field hospital was staffed by physicians, nurses, paramedics, respiratory therapists, administrative staff, and pharmacists, and was divided into three separate color-coded sections based on patient acuity—a “green” section with 16 beds for low-acuity patients; a “yellow” section with 10 beds for medium-acuity patients; and a “red” section with four beds for critical care patients. The critical care area, which was set up as a free-standing ED, had ventilators, ultrasound equipment, an ice bath, and advanced life support equipment. Board-certified emergency physicians were present in each area at all times throughout the event, in addition to several emergency medicine residents and medical students. The field hospital also housed a fully stocked pharmacy.

To direct and manage patients, a registration section was set up in front of the field hospital; intake/triage took place in a separate 15-chair, low-acuity area located beyond the front door. Charting was performed on CFDC charts and maintained for records; however, no patients were billed for care.

Separate command vehicles were set up for operations, radio communication, and storage of the staff’s personal belongings. The festival organizers provided meals to all medical personnel.

Access, Communications, and Transportation

A designated road was closed off to all nonemergency traffic leading from the field hospital to an open access point. Our closed communication system meant that 911 calls inside the event would be dispatched to our personnel stationed on-site.

The field hospital served as a single casualty collection point for the entire event, so any patient transported out would first go to the field hospital for evaluation, then move to a waiting transport vehicle, if necessary. This arrangement not only allowed the on-scene staff to evaluate and, when necessary, stabilize patients before transport, but also permitted us to identify and care for those who could be treated on-scene instead of sending them to the hospital. Routing all patients through one location also allowed the EMS staff to appropriately monitor the exact number of patients being treated. The first aid stations were staffed by paramedics and emergency medical technicians, and stocked with advanced life support and first aid equipment.

Motorized golf carts, “gators,” and hand-held carts were used to convey patients from first aid stations and other parts of the festival grounds to the field hospital. On several occasions, physicians accompanied paramedics responding to calls on the festival grounds.

The 2016 Festival: First-Person Report

An hour before the event began, we arrived at the scene, familiarized ourselves with the layout, and met with incident command, EMS, medical directors, and festival staff to discuss plans and divide the teams up. Prior to the event, a medical toxicologist reviewed with participating medical staff several priority resuscitation measures for patients presenting with drug intoxication. These priorities included control of hyperthermia, management of drug-related arrhythmias, seizures, and agitation, all of which permitted smooth transition of care and mutual understanding about which patients ultimately required transfer to the hospital.

Unexpected Needs

The medical needs were not great during the daytime hours. However, by sunset, a constant stream of attendees visited our field hospital, bringing their own prescription medications, including some requiring refrigeration, and requested that we store these on their behalf. We quickly created a process for safe storage and accountability of these medications.

In addition to requesting an unanticipated storage facility, attendees presented with more expected and typical “urgent care needs,” including headaches, rashes, and blisters. By the late afternoon, we began seeing patients who had been vomiting after riding fair attractions and those with heat-related syncope.

As evening descended, our triage area became busy with a wave of agitated, intoxicated patients presenting via EMS, friends, and GCs. When indicated, benzodiazepines (lorazepam and midazolam) were administered to mild-to-moderately agitated patients after verbal de-escalation attempts were unsuccessful. Severely agitated patients required sedative treatment with an antipsychotic (haloperidol or ziprasidone).

In the low-acuity (green) section, arousable patients whose vital signs were stable rested on cots, as did those requiring oral ondansetron for vomiting and who were able to tolerate oral hydration. The moderate-­acuity (yellow) section housed a large number of dehydrated and/or intoxicated patients who required IV fluid therapy. Patients in the critical care (red) area suffered primarily from behavioral issues and altered mental status requiring chemical or physical restraint; many of these patients were transported to the hospital once they could be safely moved. Other critical care patients with medical emergencies were also housed in this area, including an overdose victim for whom endotracheal intubation was needed for airway protection.

As the evening progressed, we saw more severe overdoses and intoxications, including several cases of alcohol- and drug-induced seizures. Any seizure that occurred on the festival grounds was considered a potential cardiac arrest, requiring physician response. Some of our most difficult patient encounters included seizing or postictal patients presenting in an agitated fashion among crowds of intoxicated people who were attempting to help. We also treated a middle-aged festival employee with cardiac disease who presented with chest pain and acute electrocardiogram changes.

One festival attendee with a history of shoulder dislocation presented with a recurrent dislocation. Without needing to sedate the patient, we successfully reduced the dislocated shoulder at the field hospital. Afterward, the patient refused transport to the hospital and insisted on returning to the festival in a sling. Several patients were seen for complaints of eye pain or irritation attributed to vigorous wind and pyrotechnic displays around the large stages—two underwent ophthalmologic evaluation with a small eye kit (topical anesthetic, fluorescein stain, and a Woods lamp) and were diagnosed with corneal abrasions.

Multiple patients with histories of asthma presented with respiratory complaints ranging from mild to severe. Most of these patients were successfully treated with albuterol, though some required supplemental oxygen and corticosteroid therapy. One patient required transport to ORMC for additional care and treatment.

Nonmedical Presentations

The location of the field hospital beyond the perimeter fence of the event created a slight “disconnect” from the crowds and lights—but not from the sound. Several attendees presented to the field hospital, asking for a place to “chill out.” To accommodate these presentations, several chairs were set up under the cover of a pop-up tent for a place to rest and drink a bottle of water. Some individuals remained in this tent for nearly the entire event—refusing care, but feeling more comfortable being in proximity of the field hospital. Although many of these individuals appeared to be intoxicated, the area remained calm throughout the event. This makeshift rest area also served as cover during a brief rain storm in the late afternoon on day 1, as well as for those seeking shelter from the hot afternoon.

Emergency Medical Services

The OFD contributed substantial resources to the 2016 festival, and their support continued throughout the event. Operations were based on the National Incident Management System’s framework, which was developed in coordination with the OMD, OFD, and other stakeholders within ORMC. Logistics and medical groups were created, and the event was divided geographically into “northern,” “southern,” and “eastern” divisions. The unified command structure included a fire department deputy chief and a liaison officer (the OFD off-duty coordinator) who maintained face-to-face communications with festival operators throughout the event. The medical group was coordinated by the OFD EMS chief in collaboration with the OMD. A communications plan was created and used effectively throughout the event to coordinate patient movement, transfers, and transports to the field hospital and ORMC. Briefings were conducted for each operational period and included all personnel involved in the event.

At least one EMS medical director was on-site at all times, in constant communication with the EMS chief on scene, who functioned primarily at the field hospital to guide throughput of patients. The OFD staffed three first aid stations with advanced and basic life support providers, and had personnel roving the festival grounds. In addition to having advanced life support capabilities, the first aid stations dispensed acetaminophen, adhesive bandages, ear plugs, and bottled water, and responded to nearby calls for help and transported patients to the field hospital as needed.

The OFD was also the primary transport agency. Ambulances were dedicated to the event and stationed at the field hospital to transport patients to ORMC. In total, 32 EMS personnel were on scene, including ambulance personnel, staffing at first aid stations, and personnel circulating among the crowd.

The Orlando Police Department (OPD) was also a constant presence at the event, providing security for both festivalgoers and staff at the field hospital. We did not have our own security personnel at the field hospital, and OPD provided a comfort level for the medical staff as the number of agitated, intoxicated patients increased.

Orlando Regional Medical Center

During the 2015 EDM festival, ORMC had been inundated with festivalgoers. Many required only minor care, but some were in need of critical care, including two cardiac arrest patients. Based on this festival experience, hospital administration at ORMC ensured adequate staffing for the 2016 festival, including nursing, medical technicians, radiology technicians, and respiratory therapists. Communication between familiar colleagues, operating under mutually understood protocols, and the ability to communicate with the field hospital, allowed for very smooth transitions of care throughout the 2016 event.

There was a direct correlation between the time of day and number and severity of patients transported to the hospital. Early in the day, patients presented with heat illness and altered mental status, syncope, and confusion; all were easily managed. By late evening, patients with possible arrhythmias, seizures, hyperthermia, chest pain, and altered mental status began to arrive. While the number of patients with the clinical presentation of intoxication and agitation was not surprising, the outcomes were occasionally unexpected—including several elevated troponin levels and occasional arrhythmias.

The hospital received 68 patients directly from the field hospital at the festival. More than 100 presented to the field hospital with altered mental status, of which dozens resolved with observation and close monitoring. Thirty patients had transient arrhythmias ranging from tachycardia and a slightly widened QRS complex. Six had seizures which responded to benzodiazepine treatment. One patient suffered respiratory failure; he was managed by mechanical ventilation, which was performed at the field hospital, and afterward transported to ORMC with a resident physician. Five patients had hyponatremia, which may have been dilutional from excess free-water intake or mediated by syndrome of inappropriate antidiuretic hormone secretion secondary to MDMA use. Hyperthermic patients were managed with active cooling.

Laboratory evaluation revealed elevated troponin levels in six patients, though none of the patients required emergent cardiac intervention. The elevated troponin levels were possibly secondary to demand ischemia from sympathomimetic toxidromes.

Although many patients admitted to using recreational drugs, few specified the type or amount of drug taken, either because they were too altered to communicate, were unfamiliar with what they ingested, or feared legal repercussions. Ethanol, marijuana, and MDMA were the most commonly reported drugs.

Lessons Learned

Over the 2-day 2016 EDM festival, 235 patients were treated at the field hospital, and 68 were transported to ORMC—almost 100 fewer hospital transports than during the 2015 EDM festival, which lacked a field hospital. Although two attendees at the 2016 event required intensive care at ORMC, there were no deaths. Overall, the field hospital and cooperative approach provided a safer method for treating patients and without overwhelming hospital or EMS resources. 
Successful utilization of a field hospital at the 2016 EDM festival required the coordinated efforts of multiple organizations, including the EMS system, ORMC, festival organizers, and disaster response groups. The deployment of this strategy required a great deal of planning, coordination, and efforts months before the actual event, and included a sufficient number of trained emergency and medical personnel, support staff for equipment set-up, operation, and takedown, and insurance coverage.

In reviewing the medical care model provided for the 2016 EDM festival, we concluded that a more effective and efficient staffing model would have deployed more nurses and fewer physicians. Utilizing the event as training for residents and medical students resulted in a large number of providers on-site, but inadequate support staff.

When planning for this event, we did not anticipate the extent of the primary care and urgent care concerns encountered during the event, though we did anticipate that the most critical medical concerns were sympathomimetic and hallucinogenic toxidromes requiring restraint, benzodiazepines, and antipsychotics.

Over the past 5 to 10 years, electronic dance music (EDM) festivals have grown in popularity in the United States, developing into massive, multiday events drawing crowds of tens of thousands of attendees.¹ The nature of these events—ie, long outdoor performances attended by a primarily youthful audience in sometimes austere environments¹—presents several unique challenges to local EDs, including the ability to effectively manage mass cases of polysubstance abuse, exposure to extremes of weather, and dehydration.

Since 2011, Orlando, Florida has been host to a popular annual EDM festival—one that has nearly doubled in size since its inception. In 2015, both the volume of 911 calls related to this event and number of attendees seeking care at the city’s first aid stations located at the festival overwhelmed our local emergency medical services (EMS) system and the nearest ED. The acuity of these patient interactions ranged from cases that could have been treated and released on-site to several critical care cases, including two fatalities.

In advance of the November 2016 festival, event staff, EMS, and hospital planners worked together to improve attendee safety and to avoid unnecessary admissions to the area receiving hospital, Orlando Regional Medical Center (ORMC). This cooperative endeavor resulted in the creation of a unique, fully staffed field hospital that was seamlessly integrated with EMS personnel and in constant communication with ORMC. The implementation of a field hospital on-site at the event decreased mortality and provided a reasonable and manageable way to safely treat and release patients who would have otherwise required transportation to the receiving center.

The 2016 Festival: Background

Location and Setup

In November 2016, the EDM festival was held at its usual location in the fields and areas surrounding a large stadium near downtown Orlando. Although the fall season in Florida can be unpredictable, the weather during the day is typically hot and humid, with temperatures averaging 80°F to 90°F. The festival took place over a 2-day period between noon and midnight each day. Unlike similar multiday festivals that run over a consecutive period of 24 to 48 hours, there were no overnight activities at this event.

Whereas other similar festivals often take place in more remote, austere environments such as deserts or forests, the Orlando EDM festival was held within the city but did not have on-site overnight accommodations. While this location eased some of our concerns, overnight closure of the field hospital altered our approach to patient management. When the facility closed, many patients who may have been observed overnight and subsequently released, required transport to the hospital for further observation and monitoring.

Attendees and Layout

The festival drew approximately 30,000 to 40,000 attendees each day, with multiple stages and fairground-type attractions spread over approximately 45 acres. The area was transformed by massive stages and production equipment, including complex lighting, pyrotechnics, expansive sound systems, and carnival rides. There were also dozens of on-site kiosks and pop-up structures selling food, merchandise, and alcoholic and nonalcoholic beverages.

Substance Abuse and Elemental Exposures

Although festival planners expressly prohibit illicit drug use at EDM events, substance use has been and continues to be prevalent at these types of festivals—particularly the use of alcohol, amphetamines such as 3,4-methylenedioxymethamphetamine (MDMA, also known as “ecstasy” and “Molly”), lysergic acid diethylamide (LSD), cocaine, and marijuana (Table).²

Lessons From the 2015 Festival

The 2015 EDM festival in Orlando had taken place without significant coordination between local EMS medical directors and ORMC, and was treated in a similar manner to other mass gatherings held in the area—ie, with extra EMS personnel on-site as well as several first aid stations. However, over the course of the 2015 event, the medics on-site were overwhelmed by the number of attendees seeking care, and felt obligated to transport a large number of these patients to ORMC (many of whom did not require hospital care), or to treat and release patients in a manner that was not in accordance with existing protocol.

As a result, the online medical control doctors at ORMC were overwhelmed by the sudden influx of calls for treat-and-release orders or intravenous (IV) hydration—not a common occurrence at this institution. This resulted in dozens of patient transports to the ED. Many of these patients did not require emergent care but simply needed shelter from the elements, rest because of sleep deprivation, or a place to recover from the effects of alcohol or drugs. Some patients, however, presented to ORMC in critical condition, two of whom died from suspected drug-related causes and/or severe hyperthermia.

After-Action Review

An after-action review of the 2015 EDM festival conducted by the Orlando Fire Department (OFD) concluded that significantly more medical support was needed for this and similar large-scale events in the future. Together with OFD, we examined how other regions in the United States handled similar festivals, and it became clear that a multidisciplinary approach, including a field hospital, EMS, ORMC, and festival planners, would be necessary for the 2016 festival.

Collaborative Planning for the 2016 Festival

Festival planners and promoters worked closely with the City of Orlando and EMS medical directors for months leading up to the 2016 EDM festival. The complexities of stage set-up alone required significant coordination, including the closure of several roads. To set up the field hospital, we first tried to acquire “real estate” on festival grounds. When this proved not to be feasible, we worked with city officials to create a field hospital on a street just outside the festival’s side gate.

Resources

Throughout the process, we worked closely with the festival’s planners, as well as a medical team designated by its parent company, to coordinate shared resources. The medical team provided a significant amount of medical supplies to our field hospital. In addition, the festival obtained and paid for an insurance rider extending coverage to our medical staff while working at the event.

Ground Control Staff

The planners and promoters of the EDM festival host several other festivals each year, including some that are larger and longer than the annual event held in Orlando. A small team from Orlando visited their set-up at a larger festival in Nevada several months prior to the 2016 EDM festival, gathering information on how we could best execute our plans. In addition to equipment and support, the festival also designated ground controllers (GCs) stationed throughout the festival area. These were individuals without medical training who could be easily identified and could guide those in need of medical attention to the nearest first aid station or to the field hospital, or contact us when someone was in need of immediate or emergent care.

Access and Communications

Several areas identified for improvement from 2015 included better ambulance access, radio communication (especially with physicians), and appropriate staffing. To provide additional medical staff for the 2016 EDM festival, the Office of the Medical Director (OMD) and the Central Florida Disaster Coalition (CFDC), a regional nonprofit organization that assists with disaster-health response in the area, utilized this event as a drill for a large-scale disaster that would require a self-sufficient field hospital. Part of this initiative included radio transmission equipment that would allow the routing of all 911 and other emergency calls from the festival grounds directly to on-site medical personnel.

In addition to the CFDC resources, we had dedicated medical control on the radio to answer questions from the paramedics staffing the outer first aid stations. This was separate from our normal medical control base-station process, and allowed our traditional EMS operating structure to continue outside the event without any confusion or added burden from within.

Field Hospital and First Aid Stations

Created just beyond the fencing that surrounded the event, the field hospital was a 3,200-square-foot, enclosed, air-conditioned structure powered by generators. In addition to the field hospital, three first aid stations were strategically placed around the festival grounds, and groups of medical personnel were assigned to walk the grounds.

The field hospital was staffed by physicians, nurses, paramedics, respiratory therapists, administrative staff, and pharmacists, and was divided into three separate color-coded sections based on patient acuity—a “green” section with 16 beds for low-acuity patients; a “yellow” section with 10 beds for medium-acuity patients; and a “red” section with four beds for critical care patients. The critical care area, which was set up as a free-standing ED, had ventilators, ultrasound equipment, an ice bath, and advanced life support equipment. Board-certified emergency physicians were present in each area at all times throughout the event, in addition to several emergency medicine residents and medical students. The field hospital also housed a fully stocked pharmacy.

To direct and manage patients, a registration section was set up in front of the field hospital; intake/triage took place in a separate 15-chair, low-acuity area located beyond the front door. Charting was performed on CFDC charts and maintained for records; however, no patients were billed for care.

Separate command vehicles were set up for operations, radio communication, and storage of the staff’s personal belongings. The festival organizers provided meals to all medical personnel.

Access, Communications, and Transportation

A designated road was closed off to all nonemergency traffic leading from the field hospital to an open access point. Our closed communication system meant that 911 calls inside the event would be dispatched to our personnel stationed on-site.

The field hospital served as a single casualty collection point for the entire event, so any patient transported out would first go to the field hospital for evaluation, then move to a waiting transport vehicle, if necessary. This arrangement not only allowed the on-scene staff to evaluate and, when necessary, stabilize patients before transport, but also permitted us to identify and care for those who could be treated on-scene instead of sending them to the hospital. Routing all patients through one location also allowed the EMS staff to appropriately monitor the exact number of patients being treated. The first aid stations were staffed by paramedics and emergency medical technicians, and stocked with advanced life support and first aid equipment.

Motorized golf carts, “gators,” and hand-held carts were used to convey patients from first aid stations and other parts of the festival grounds to the field hospital. On several occasions, physicians accompanied paramedics responding to calls on the festival grounds.

The 2016 Festival: First-Person Report

An hour before the event began, we arrived at the scene, familiarized ourselves with the layout, and met with incident command, EMS, medical directors, and festival staff to discuss plans and divide the teams up. Prior to the event, a medical toxicologist reviewed with participating medical staff several priority resuscitation measures for patients presenting with drug intoxication. These priorities included control of hyperthermia, management of drug-related arrhythmias, seizures, and agitation, all of which permitted smooth transition of care and mutual understanding about which patients ultimately required transfer to the hospital.

Unexpected Needs

The medical needs were not great during the daytime hours. However, by sunset, a constant stream of attendees visited our field hospital, bringing their own prescription medications, including some requiring refrigeration, and requested that we store these on their behalf. We quickly created a process for safe storage and accountability of these medications.

In addition to requesting an unanticipated storage facility, attendees presented with more expected and typical “urgent care needs,” including headaches, rashes, and blisters. By the late afternoon, we began seeing patients who had been vomiting after riding fair attractions and those with heat-related syncope.

As evening descended, our triage area became busy with a wave of agitated, intoxicated patients presenting via EMS, friends, and GCs. When indicated, benzodiazepines (lorazepam and midazolam) were administered to mild-to-moderately agitated patients after verbal de-escalation attempts were unsuccessful. Severely agitated patients required sedative treatment with an antipsychotic (haloperidol or ziprasidone).

In the low-acuity (green) section, arousable patients whose vital signs were stable rested on cots, as did those requiring oral ondansetron for vomiting and who were able to tolerate oral hydration. The moderate-­acuity (yellow) section housed a large number of dehydrated and/or intoxicated patients who required IV fluid therapy. Patients in the critical care (red) area suffered primarily from behavioral issues and altered mental status requiring chemical or physical restraint; many of these patients were transported to the hospital once they could be safely moved. Other critical care patients with medical emergencies were also housed in this area, including an overdose victim for whom endotracheal intubation was needed for airway protection.

As the evening progressed, we saw more severe overdoses and intoxications, including several cases of alcohol- and drug-induced seizures. Any seizure that occurred on the festival grounds was considered a potential cardiac arrest, requiring physician response. Some of our most difficult patient encounters included seizing or postictal patients presenting in an agitated fashion among crowds of intoxicated people who were attempting to help. We also treated a middle-aged festival employee with cardiac disease who presented with chest pain and acute electrocardiogram changes.

One festival attendee with a history of shoulder dislocation presented with a recurrent dislocation. Without needing to sedate the patient, we successfully reduced the dislocated shoulder at the field hospital. Afterward, the patient refused transport to the hospital and insisted on returning to the festival in a sling. Several patients were seen for complaints of eye pain or irritation attributed to vigorous wind and pyrotechnic displays around the large stages—two underwent ophthalmologic evaluation with a small eye kit (topical anesthetic, fluorescein stain, and a Woods lamp) and were diagnosed with corneal abrasions.

Multiple patients with histories of asthma presented with respiratory complaints ranging from mild to severe. Most of these patients were successfully treated with albuterol, though some required supplemental oxygen and corticosteroid therapy. One patient required transport to ORMC for additional care and treatment.

Nonmedical Presentations

The location of the field hospital beyond the perimeter fence of the event created a slight “disconnect” from the crowds and lights—but not from the sound. Several attendees presented to the field hospital, asking for a place to “chill out.” To accommodate these presentations, several chairs were set up under the cover of a pop-up tent for a place to rest and drink a bottle of water. Some individuals remained in this tent for nearly the entire event—refusing care, but feeling more comfortable being in proximity of the field hospital. Although many of these individuals appeared to be intoxicated, the area remained calm throughout the event. This makeshift rest area also served as cover during a brief rain storm in the late afternoon on day 1, as well as for those seeking shelter from the hot afternoon.

Emergency Medical Services

The OFD contributed substantial resources to the 2016 festival, and their support continued throughout the event. Operations were based on the National Incident Management System’s framework, which was developed in coordination with the OMD, OFD, and other stakeholders within ORMC. Logistics and medical groups were created, and the event was divided geographically into “northern,” “southern,” and “eastern” divisions. The unified command structure included a fire department deputy chief and a liaison officer (the OFD off-duty coordinator) who maintained face-to-face communications with festival operators throughout the event. The medical group was coordinated by the OFD EMS chief in collaboration with the OMD. A communications plan was created and used effectively throughout the event to coordinate patient movement, transfers, and transports to the field hospital and ORMC. Briefings were conducted for each operational period and included all personnel involved in the event.

At least one EMS medical director was on-site at all times, in constant communication with the EMS chief on scene, who functioned primarily at the field hospital to guide throughput of patients. The OFD staffed three first aid stations with advanced and basic life support providers, and had personnel roving the festival grounds. In addition to having advanced life support capabilities, the first aid stations dispensed acetaminophen, adhesive bandages, ear plugs, and bottled water, and responded to nearby calls for help and transported patients to the field hospital as needed.

The OFD was also the primary transport agency. Ambulances were dedicated to the event and stationed at the field hospital to transport patients to ORMC. In total, 32 EMS personnel were on scene, including ambulance personnel, staffing at first aid stations, and personnel circulating among the crowd.

The Orlando Police Department (OPD) was also a constant presence at the event, providing security for both festivalgoers and staff at the field hospital. We did not have our own security personnel at the field hospital, and OPD provided a comfort level for the medical staff as the number of agitated, intoxicated patients increased.

Orlando Regional Medical Center

During the 2015 EDM festival, ORMC had been inundated with festivalgoers. Many required only minor care, but some were in need of critical care, including two cardiac arrest patients. Based on this festival experience, hospital administration at ORMC ensured adequate staffing for the 2016 festival, including nursing, medical technicians, radiology technicians, and respiratory therapists. Communication between familiar colleagues, operating under mutually understood protocols, and the ability to communicate with the field hospital, allowed for very smooth transitions of care throughout the 2016 event.

There was a direct correlation between the time of day and number and severity of patients transported to the hospital. Early in the day, patients presented with heat illness and altered mental status, syncope, and confusion; all were easily managed. By late evening, patients with possible arrhythmias, seizures, hyperthermia, chest pain, and altered mental status began to arrive. While the number of patients with the clinical presentation of intoxication and agitation was not surprising, the outcomes were occasionally unexpected—including several elevated troponin levels and occasional arrhythmias.

The hospital received 68 patients directly from the field hospital at the festival. More than 100 presented to the field hospital with altered mental status, of which dozens resolved with observation and close monitoring. Thirty patients had transient arrhythmias ranging from tachycardia and a slightly widened QRS complex. Six had seizures which responded to benzodiazepine treatment. One patient suffered respiratory failure; he was managed by mechanical ventilation, which was performed at the field hospital, and afterward transported to ORMC with a resident physician. Five patients had hyponatremia, which may have been dilutional from excess free-water intake or mediated by syndrome of inappropriate antidiuretic hormone secretion secondary to MDMA use. Hyperthermic patients were managed with active cooling.

Laboratory evaluation revealed elevated troponin levels in six patients, though none of the patients required emergent cardiac intervention. The elevated troponin levels were possibly secondary to demand ischemia from sympathomimetic toxidromes.

Although many patients admitted to using recreational drugs, few specified the type or amount of drug taken, either because they were too altered to communicate, were unfamiliar with what they ingested, or feared legal repercussions. Ethanol, marijuana, and MDMA were the most commonly reported drugs.

Lessons Learned

Over the 2-day 2016 EDM festival, 235 patients were treated at the field hospital, and 68 were transported to ORMC—almost 100 fewer hospital transports than during the 2015 EDM festival, which lacked a field hospital. Although two attendees at the 2016 event required intensive care at ORMC, there were no deaths. Overall, the field hospital and cooperative approach provided a safer method for treating patients and without overwhelming hospital or EMS resources. 
Successful utilization of a field hospital at the 2016 EDM festival required the coordinated efforts of multiple organizations, including the EMS system, ORMC, festival organizers, and disaster response groups. The deployment of this strategy required a great deal of planning, coordination, and efforts months before the actual event, and included a sufficient number of trained emergency and medical personnel, support staff for equipment set-up, operation, and takedown, and insurance coverage.

In reviewing the medical care model provided for the 2016 EDM festival, we concluded that a more effective and efficient staffing model would have deployed more nurses and fewer physicians. Utilizing the event as training for residents and medical students resulted in a large number of providers on-site, but inadequate support staff.

When planning for this event, we did not anticipate the extent of the primary care and urgent care concerns encountered during the event, though we did anticipate that the most critical medical concerns were sympathomimetic and hallucinogenic toxidromes requiring restraint, benzodiazepines, and antipsychotics.

Coronary heart disease remains the leading cause of death of US adults aged 35 years and older due to the downstream consequences of arterial occlusion and ensuing myocardial ischemia.^1,2 Among patients with coronary heart disease, 30% to 33% will present with ST-segment elevation myocardial infarction (STEMI).^3-5

For STEMI patients, access to a facility with percutaneous coronary intervention (PCI) capabilities is critical. Door-to-balloon (D2B) time is used as a performance measure to assess the quality of care that STEMI patients are receiving. Data show that decreasing D2B times can improve outcomes of STEMI patients, with lower D2B time associated with lower mortality rates.⁵ To obtain and maintain the lowest D2B times possible, health care systems must adopt best practice models to continually improve patient outcomes.

The current best practice for patients with an acute STEMI involves bypassing non-PCI centers and transporting patients directly to PCI-enabled centers—as long as the patient’s total emergency medical services (EMS) contact-to-balloon time remains low. In a study by Le May et al,⁶ patients directly transported to a PCI-enabled center had a mortality rate of 5% within 180 days compared to 11.5% for those who were first seen at a center without PCI capabilities.

Longer EMS transport time to PCI centers, however, requires earlier cardiac catheterization laboratory (CCL) activation to prevent delays in care. Emergency physicians (EPs) must work with local EMS, PCI and non-PCI centers, and interventional cardiologists to establish protocols to expedite STEMI patient care. Previous studies, however, have shown that paramedics are able to diagnose STEMI patients during transport and can activate the catheterization team from the field, with beneficial patient outcomes.^7-11 Prior to July 2011, all patients with a suspected MI who were transported to our institution via EMS were not diagnosed with STEMI until evaluation by an EP. Because the CCL had no in-house staff after hours, the interventional cardiology team required 30 minutes to respond and prepare. In 2011, our EMS, in conjunction with county hospitals, EPs, and cardiologists, implemented an initiative that empowered paramedics to activate STEMI alerts from the field. This provided advanced notification to the interventional cardiology laboratory team to initiate preparation for patients in need of immediate PCI.

Since the best practice for STEMI patients involves early diagnosis and immediate activation of the cardiac catheterization team, we sought to improve the outcomes for STEMI patients by utilizing prehospital care initiatives to lower D2B times. Other health care systems have utilized EPs to receive the transmitted electrocardiogram (ECG) and to initiate CCL team activation. We found that having both the EP and cardiologist review the ECG delayed the activation process when compared to direct activation by EMS. Our initiatives to improve time to CCL activation included the following:

(1) Training and enabling paramedics to diagnose a STEMI on the ECG;

(2) Bypassing non-PCI centers for PCI centers during STEMI patient transport;

(3) Allowing paramedics to activate the CCL at our institution prior to transmitting an ECG and prior to patient arrival at the hospital; and

(4) Bypassing the ED to go directly to the CCL when the CCL was ready to receive the patient. (When the CCL was not ready, patients were transported to the ED. After reviewing the transmitted ECG, the EPs could cancel the STEMI alert if indicated.)

By empowering EMS to diagnose and activate the CCL, we also measured the rate of unnecessary activations, which was defined as patients who did not present with chest pain and an ECG showing ≥1 mm ST segment elevation in two contiguous limb leads, or ≥2 mm ST segment elevation in two contiguous precordial leads.

Causes of unnecessary activation by EMS included left ventricular hypertrophy, left bundle branch block, early repolarization, non-specific ST segment changes, pericarditis, and ventricular paced rhythms. We recorded and analyzed D2B times and the unnecessary activation rates, and continuously used these data for quality improvement. Our goal was to decrease D2B times and unnecessary activation rates, while maintaining these improvements over time.

Our ED has 93,000 patient visits annually, and our hospital serves as the only PCI center within a county encompassing 1,255 square miles. Our hospital EMS used 12 Lifepak monitors to help interpret patients’ ECG. To study the impact of our initiative, data were collected each year from 2011 to 2015. The 2011 data were recorded before EMS began to activate the CCL and served as the baseline for the D2B times. These data were then compared to postintervention D2B data from 2012 to 2015.

In addition to collecting unnecessary activation rates by EMS paramedics from 2012 to 2015, we continuously used the unnecessary activation data to identify why these activations were occurring and to devise a strategy to improve rates. Emergency physicians have a leadership role regarding EMS training and oversight, ongoing paramedic education, and the quality improvement process.

A Reduction in D2B Time

Our baseline D2B time prior to the intervention was 52.5 minutes. After our intervention, average D2B times for 2012, 2013, 2014, and 2015 were 38.2, 33.5, 39, and 37.25 minutes, respectively. The institution’s baseline rate of unnecessary activation prior to intervention in 2011 was 19.1%. After intervention, the EMS unnecessary activation rates for 2012, 2013, 2014, and 2015 were 30%, 18%, 15%, and 19% respectively, averaging 20.5% over 4 years, or 17.3% for 2013 through 2015.

Emergency medical services averaged approximately 164 STEMI activations each year. We decreased D2B times for patients by over 15 minutes from 2011 compared to 2012 through 2015. These results were sustained, with attention to metrics, over four years. Furthermore, the proportion of STEMI patients receiving immediate PCI within the recommended 90 minutes was 100% of patients in 2014 and 2015, reflecting consistent improvement over 2012 and 2013.

We also demonstrated an overall reduction in the unnecessary CCL activation rate by EMS over the time of our intervention. Our analysis of unnecessary activation causes and EMS education led to improvement in the unnecessary activation rate from 2012-2015, and these rates have been sustained over time. The rate of unnecessary activation by EMS in 2012 to 2015 was 20.5%.

Conclusion

Lower D2B time for STEMI patients is associated with lower mortality following PCI for patients with acute MI, fewer complications, and shorter length of stay in the hospital. We successfully lowered D2B time after empowering EMS to activate our interventional cardiology laboratory prior to arrival at the hospital for patients with acute STEMI, coupled with the ability to bypass the ED for patients with acute STEMI presentations. With rigorous attention to metrics and ongoing aggressive medic education, we were able to achieve consistent, sustained D2B times under 40 minutes over the course of four consecutive years. We present our experience as a potential model of a multifaceted intervention for other systems to consider replicating.

Coronary heart disease remains the leading cause of death of US adults aged 35 years and older due to the downstream consequences of arterial occlusion and ensuing myocardial ischemia.^1,2 Among patients with coronary heart disease, 30% to 33% will present with ST-segment elevation myocardial infarction (STEMI).^3-5

For STEMI patients, access to a facility with percutaneous coronary intervention (PCI) capabilities is critical. Door-to-balloon (D2B) time is used as a performance measure to assess the quality of care that STEMI patients are receiving. Data show that decreasing D2B times can improve outcomes of STEMI patients, with lower D2B time associated with lower mortality rates.⁵ To obtain and maintain the lowest D2B times possible, health care systems must adopt best practice models to continually improve patient outcomes.

The current best practice for patients with an acute STEMI involves bypassing non-PCI centers and transporting patients directly to PCI-enabled centers—as long as the patient’s total emergency medical services (EMS) contact-to-balloon time remains low. In a study by Le May et al,⁶ patients directly transported to a PCI-enabled center had a mortality rate of 5% within 180 days compared to 11.5% for those who were first seen at a center without PCI capabilities.

Longer EMS transport time to PCI centers, however, requires earlier cardiac catheterization laboratory (CCL) activation to prevent delays in care. Emergency physicians (EPs) must work with local EMS, PCI and non-PCI centers, and interventional cardiologists to establish protocols to expedite STEMI patient care. Previous studies, however, have shown that paramedics are able to diagnose STEMI patients during transport and can activate the catheterization team from the field, with beneficial patient outcomes.^7-11 Prior to July 2011, all patients with a suspected MI who were transported to our institution via EMS were not diagnosed with STEMI until evaluation by an EP. Because the CCL had no in-house staff after hours, the interventional cardiology team required 30 minutes to respond and prepare. In 2011, our EMS, in conjunction with county hospitals, EPs, and cardiologists, implemented an initiative that empowered paramedics to activate STEMI alerts from the field. This provided advanced notification to the interventional cardiology laboratory team to initiate preparation for patients in need of immediate PCI.

Since the best practice for STEMI patients involves early diagnosis and immediate activation of the cardiac catheterization team, we sought to improve the outcomes for STEMI patients by utilizing prehospital care initiatives to lower D2B times. Other health care systems have utilized EPs to receive the transmitted electrocardiogram (ECG) and to initiate CCL team activation. We found that having both the EP and cardiologist review the ECG delayed the activation process when compared to direct activation by EMS. Our initiatives to improve time to CCL activation included the following:

(1) Training and enabling paramedics to diagnose a STEMI on the ECG;

(2) Bypassing non-PCI centers for PCI centers during STEMI patient transport;

(3) Allowing paramedics to activate the CCL at our institution prior to transmitting an ECG and prior to patient arrival at the hospital; and

(4) Bypassing the ED to go directly to the CCL when the CCL was ready to receive the patient. (When the CCL was not ready, patients were transported to the ED. After reviewing the transmitted ECG, the EPs could cancel the STEMI alert if indicated.)

By empowering EMS to diagnose and activate the CCL, we also measured the rate of unnecessary activations, which was defined as patients who did not present with chest pain and an ECG showing ≥1 mm ST segment elevation in two contiguous limb leads, or ≥2 mm ST segment elevation in two contiguous precordial leads.

Causes of unnecessary activation by EMS included left ventricular hypertrophy, left bundle branch block, early repolarization, non-specific ST segment changes, pericarditis, and ventricular paced rhythms. We recorded and analyzed D2B times and the unnecessary activation rates, and continuously used these data for quality improvement. Our goal was to decrease D2B times and unnecessary activation rates, while maintaining these improvements over time.

Our ED has 93,000 patient visits annually, and our hospital serves as the only PCI center within a county encompassing 1,255 square miles. Our hospital EMS used 12 Lifepak monitors to help interpret patients’ ECG. To study the impact of our initiative, data were collected each year from 2011 to 2015. The 2011 data were recorded before EMS began to activate the CCL and served as the baseline for the D2B times. These data were then compared to postintervention D2B data from 2012 to 2015.

In addition to collecting unnecessary activation rates by EMS paramedics from 2012 to 2015, we continuously used the unnecessary activation data to identify why these activations were occurring and to devise a strategy to improve rates. Emergency physicians have a leadership role regarding EMS training and oversight, ongoing paramedic education, and the quality improvement process.

A Reduction in D2B Time

Our baseline D2B time prior to the intervention was 52.5 minutes. After our intervention, average D2B times for 2012, 2013, 2014, and 2015 were 38.2, 33.5, 39, and 37.25 minutes, respectively. The institution’s baseline rate of unnecessary activation prior to intervention in 2011 was 19.1%. After intervention, the EMS unnecessary activation rates for 2012, 2013, 2014, and 2015 were 30%, 18%, 15%, and 19% respectively, averaging 20.5% over 4 years, or 17.3% for 2013 through 2015.

Emergency medical services averaged approximately 164 STEMI activations each year. We decreased D2B times for patients by over 15 minutes from 2011 compared to 2012 through 2015. These results were sustained, with attention to metrics, over four years. Furthermore, the proportion of STEMI patients receiving immediate PCI within the recommended 90 minutes was 100% of patients in 2014 and 2015, reflecting consistent improvement over 2012 and 2013.

We also demonstrated an overall reduction in the unnecessary CCL activation rate by EMS over the time of our intervention. Our analysis of unnecessary activation causes and EMS education led to improvement in the unnecessary activation rate from 2012-2015, and these rates have been sustained over time. The rate of unnecessary activation by EMS in 2012 to 2015 was 20.5%.

Conclusion

Lower D2B time for STEMI patients is associated with lower mortality following PCI for patients with acute MI, fewer complications, and shorter length of stay in the hospital. We successfully lowered D2B time after empowering EMS to activate our interventional cardiology laboratory prior to arrival at the hospital for patients with acute STEMI, coupled with the ability to bypass the ED for patients with acute STEMI presentations. With rigorous attention to metrics and ongoing aggressive medic education, we were able to achieve consistent, sustained D2B times under 40 minutes over the course of four consecutive years. We present our experience as a potential model of a multifaceted intervention for other systems to consider replicating.

Coronary heart disease remains the leading cause of death of US adults aged 35 years and older due to the downstream consequences of arterial occlusion and ensuing myocardial ischemia.^1,2 Among patients with coronary heart disease, 30% to 33% will present with ST-segment elevation myocardial infarction (STEMI).^3-5

For STEMI patients, access to a facility with percutaneous coronary intervention (PCI) capabilities is critical. Door-to-balloon (D2B) time is used as a performance measure to assess the quality of care that STEMI patients are receiving. Data show that decreasing D2B times can improve outcomes of STEMI patients, with lower D2B time associated with lower mortality rates.⁵ To obtain and maintain the lowest D2B times possible, health care systems must adopt best practice models to continually improve patient outcomes.

The current best practice for patients with an acute STEMI involves bypassing non-PCI centers and transporting patients directly to PCI-enabled centers—as long as the patient’s total emergency medical services (EMS) contact-to-balloon time remains low. In a study by Le May et al,⁶ patients directly transported to a PCI-enabled center had a mortality rate of 5% within 180 days compared to 11.5% for those who were first seen at a center without PCI capabilities.

Longer EMS transport time to PCI centers, however, requires earlier cardiac catheterization laboratory (CCL) activation to prevent delays in care. Emergency physicians (EPs) must work with local EMS, PCI and non-PCI centers, and interventional cardiologists to establish protocols to expedite STEMI patient care. Previous studies, however, have shown that paramedics are able to diagnose STEMI patients during transport and can activate the catheterization team from the field, with beneficial patient outcomes.^7-11 Prior to July 2011, all patients with a suspected MI who were transported to our institution via EMS were not diagnosed with STEMI until evaluation by an EP. Because the CCL had no in-house staff after hours, the interventional cardiology team required 30 minutes to respond and prepare. In 2011, our EMS, in conjunction with county hospitals, EPs, and cardiologists, implemented an initiative that empowered paramedics to activate STEMI alerts from the field. This provided advanced notification to the interventional cardiology laboratory team to initiate preparation for patients in need of immediate PCI.

Since the best practice for STEMI patients involves early diagnosis and immediate activation of the cardiac catheterization team, we sought to improve the outcomes for STEMI patients by utilizing prehospital care initiatives to lower D2B times. Other health care systems have utilized EPs to receive the transmitted electrocardiogram (ECG) and to initiate CCL team activation. We found that having both the EP and cardiologist review the ECG delayed the activation process when compared to direct activation by EMS. Our initiatives to improve time to CCL activation included the following:

(1) Training and enabling paramedics to diagnose a STEMI on the ECG;

(2) Bypassing non-PCI centers for PCI centers during STEMI patient transport;

(3) Allowing paramedics to activate the CCL at our institution prior to transmitting an ECG and prior to patient arrival at the hospital; and

(4) Bypassing the ED to go directly to the CCL when the CCL was ready to receive the patient. (When the CCL was not ready, patients were transported to the ED. After reviewing the transmitted ECG, the EPs could cancel the STEMI alert if indicated.)

By empowering EMS to diagnose and activate the CCL, we also measured the rate of unnecessary activations, which was defined as patients who did not present with chest pain and an ECG showing ≥1 mm ST segment elevation in two contiguous limb leads, or ≥2 mm ST segment elevation in two contiguous precordial leads.

Causes of unnecessary activation by EMS included left ventricular hypertrophy, left bundle branch block, early repolarization, non-specific ST segment changes, pericarditis, and ventricular paced rhythms. We recorded and analyzed D2B times and the unnecessary activation rates, and continuously used these data for quality improvement. Our goal was to decrease D2B times and unnecessary activation rates, while maintaining these improvements over time.

Our ED has 93,000 patient visits annually, and our hospital serves as the only PCI center within a county encompassing 1,255 square miles. Our hospital EMS used 12 Lifepak monitors to help interpret patients’ ECG. To study the impact of our initiative, data were collected each year from 2011 to 2015. The 2011 data were recorded before EMS began to activate the CCL and served as the baseline for the D2B times. These data were then compared to postintervention D2B data from 2012 to 2015.

In addition to collecting unnecessary activation rates by EMS paramedics from 2012 to 2015, we continuously used the unnecessary activation data to identify why these activations were occurring and to devise a strategy to improve rates. Emergency physicians have a leadership role regarding EMS training and oversight, ongoing paramedic education, and the quality improvement process.

A Reduction in D2B Time

Our baseline D2B time prior to the intervention was 52.5 minutes. After our intervention, average D2B times for 2012, 2013, 2014, and 2015 were 38.2, 33.5, 39, and 37.25 minutes, respectively. The institution’s baseline rate of unnecessary activation prior to intervention in 2011 was 19.1%. After intervention, the EMS unnecessary activation rates for 2012, 2013, 2014, and 2015 were 30%, 18%, 15%, and 19% respectively, averaging 20.5% over 4 years, or 17.3% for 2013 through 2015.

Emergency medical services averaged approximately 164 STEMI activations each year. We decreased D2B times for patients by over 15 minutes from 2011 compared to 2012 through 2015. These results were sustained, with attention to metrics, over four years. Furthermore, the proportion of STEMI patients receiving immediate PCI within the recommended 90 minutes was 100% of patients in 2014 and 2015, reflecting consistent improvement over 2012 and 2013.

We also demonstrated an overall reduction in the unnecessary CCL activation rate by EMS over the time of our intervention. Our analysis of unnecessary activation causes and EMS education led to improvement in the unnecessary activation rate from 2012-2015, and these rates have been sustained over time. The rate of unnecessary activation by EMS in 2012 to 2015 was 20.5%.

Conclusion

Lower D2B time for STEMI patients is associated with lower mortality following PCI for patients with acute MI, fewer complications, and shorter length of stay in the hospital. We successfully lowered D2B time after empowering EMS to activate our interventional cardiology laboratory prior to arrival at the hospital for patients with acute STEMI, coupled with the ability to bypass the ED for patients with acute STEMI presentations. With rigorous attention to metrics and ongoing aggressive medic education, we were able to achieve consistent, sustained D2B times under 40 minutes over the course of four consecutive years. We present our experience as a potential model of a multifaceted intervention for other systems to consider replicating.

Case

A 29-year-old man presented to the ED with a 3-day history of constant left-sided low back pain that radiated to his left buttock and groin. The patient stated the pain worsened with movement, making it difficult for him to walk. He reported lifting heavy boxes at work, but denied any trauma. The patient also denied recent fevers, chills, chest pain, dyspnea, abdominal pain, urinary or fecal incontinence, weakness, numbness, or saddle anesthesia. Regarding his medical history, he had an appendectomy as a child, but reported no other surgeries or medical issues. His social history was significant for narcotic and inhalant use and daily tobacco use. The patient also reported taking heroin intravenously (IV) 6 months prior.

Vital signs at presentation were: heart rate (HR), 92 beats/min; respiratory rate, 15 breaths/min; blood pressure, 118/80 mm Hg; and temperature, 98.2°F. Oxygen saturation was 98% on room air.

The patient was a well-developed young man in no apparent distress. Dermatological examination showed bilateral track marks in the antecubital fossa. The musculoskeletal (MSK) examination demonstrated left gluteal tenderness to palpation and decreased active and passive range of motion of the left hip, especially with internal rotation and flexion. He had no midline tenderness, and the lower extremities had normal pulses and no motor or sensory deficits.

The patient’s pain improved with IV fluids, diazepam, and ketorolac, and he was able to ambulate with assistance. He was clinically diagnosed with sciatica, and discharged home with prescriptions for diazepam and ibuprofen. He was also instructed to follow-up with an orthopedist within 7 days from discharge.

The patient returned to the ED the following day with similar complaints of unabating left-sided pain and difficulty ambulating. His vital signs were notable for an elevated HR of 106 beats/min. Physical examination findings were unchanged from his presentation the previous day, and an X-ray of the lumbar spine showed no abnormalities.

After receiving IV analgesics, the patient’s pain improved and his tachycardia resolved. He was discharged home with instructions to continue taking diazepam, and was also given prescriptions for prednisone and oxycodone/acetaminophen. He was instructed to follow-up with an orthopedist within 24 hours.

Over the next 9 days, the patient was seen twice by an orthopedist, who ordered imaging of the lumbar spine, including a repeat X-ray and contrast-enhanced magnetic resonance imaging (MRI), both of which were unremarkable. The patient completed the prescribed course of diclofenac, oxycodone/acetaminophen, and prednisone, but experienced only minimal pain relief. The orthopedist prescribed the diclofenac to supplement the medication regimen that he was already on.

At the second follow-up visit, the orthopedist ordered an MRI of the patient’s left hip, which demonstrated inflammation of the left sacroiliac joint (SIJ) with effusion, and a 1-cm by 1-cm collection adjacent to the left psoas muscle; these findings were concerning for septic arthritis (Figure). Based on the MRI study, a computed tomography (CT)-guided arthrocentesis of the left SIJ was performed by an interventional radiologist.

Discussion

Infectious sacroiliitis (ISI) is a rare form of infectious arthritis affecting the SIJ, with an incidence of 1 to 2 reported cases per year.¹ The literature on ISI currently consists only of case reports and case series. This infection is often diagnosed after the disease has progressed, with a mean time to diagnosis of 43.3 days.²

Infectious arthritis of any joint has a prevalence of 2 to 10 per 100,000 people. In 50% of cases, the knee is the joint most commonly affected, followed by the hip, shoulder, and elbow.³ Regardless of location, infectious arthritis is associated with significant morbidity and mortality due to sepsis and irreversible loss of joint function.⁴

Risk factors for ISI include IV drug use, pregnancy, trauma, endocarditis, and immunosuppression.¹ The decision to initiate the workup for ISI can be difficult to make because the condition may present without signs of an infectious etiology, such as toxic appearance, inflammatory changes surrounding the joint, or even fever—only 41% of affected patients in one case series were febrile.² The workup is often time-consuming, invasive, and expensive.

Although delayed diagnosis and treatment of septic arthritis is associated with significant adverse effects, there is unfortunately no consensus to guide the workup for ISI. As opposed to Kocher’s criteria for the differentiation of septic hip arthritis from transient synovitis in pediatric patients or well-known red-flags for further evaluation of low back pain, physicians are left without much guidance when considering laboratory workup or imaging decisions to evaluate for ISI.

Sacroiliac Joint

As previously noted, the SIJ is not commonly affected by infection. It is a diarthrodial, L-shaped joint comprised of the posterior ilium and sacrum, and is a near-rigid structure with very limited movement that provides stability to the axial skeleton.⁵ The SIJ is often overlooked as a secondary cause of low back pain in younger patients with rheumatologic conditions (eg, ankylosing spondylitis, Reiter syndrome), pregnancy-associated ligamentous laxity, and osteoarthritis in elderly patients. In one study, 88.2% of sacroiliitis cases were inflammatory, 8.8% infectious, and 2.9% degenerative.⁶

Signs and Symptoms

As our case illustrates, ISI often presents with nonspecific symptoms and physical findings.⁷ Patients typically present with fever, painful manipulation of the SIJ, and unilateral lumbo-gluteal pain.² The components of the history and physical examination suspicious for an infectious etiology include the subacute presentation; unresolved pain despite treatment; tenderness to palpation; decreased range of motion; and recent IV drug use, which increases the risk of infectious disease due to unsterile practices and direct inoculation of pathogens into the bloodstream⁸ and a further predilection into the axial skeleton. ⁹ It is important to obtain an accurate social history; however, patients may not be forthright about disclosing sensitive information such as sexual history and illicit drug use.

Physical Assessment

The SIJ is best appreciated in the seated patient by palpating one fingerbreadth medial to the posterior superior iliac spine as he or she slowly bends forward.¹⁰ Tenderness elicited while in this position is suggestive of SIJ inflammation. The area of tenderness may be lower than anticipated and lateral to the gluteal cleft, as synovial fluid is typically relegated to the lower half of the joint.

Several adjunctive physical examination maneuvers, such as the Gaenslen test and Flexion Abduction External Rotation test (FABER test or Patrick’s test) can isolate SIJ pathology or dysfunction. The Gaenslen test is performed by asking the patient to lie supine and flex the affected hip and knee, with the lumbar spine flat against the examination table. Hyperextending the contralateral thigh downward will reproduce pain in the affected SIJ.

The FABER test is a simple but less specific examination technique to assess joint pain in the hip, lumbar, and sacroiliac joints.¹¹ In this assessment, the clinician flexes the patient’s affected knee to 90°, externally rotates the hip, and applies downward pressure on the knee. Pain reproduced in the affected SI region is sensitive for joint inflammation.

Laboratory and Imaging Studies

Laboratory studies typically show inconsistent and nonspecific findings, such as the elevated ESR and CRP levels seen in our patient.^2,12 Imaging studies to assess the SIJ for signs of infection are therefore essential for confirming infection.

Magnetic resonance imaging is the preferred imaging modality to assess for ISI, since it has the highest sensitivity in visualizing joint effusion and bone marrow edema compared to other modalities. Computed tomography, however, can be helpful in visualizing associated abscesses and guiding arthrocentesis.¹² Plain X-ray may not demonstrate early changes in bone.¹³ The confirmatory study for ISI is synovial fluid analysis and culture.⁷

Treatment

Infectious sacroiliitis secondary to P aeruginosa, a gram-negative bacillus, is difficult to treat because of the glycocalyx and slime production that protects the pathogen from antibiotics, the development of multiple-antimicrobial resistance, and poor drug penetration into bones and abscesses.¹⁴ Antibiotic treatment should cover Staphylococcus aureus and may be broadened to cover gram-negative bacilli. The recommended duration of treatment is at least a 2-week course of IV antibiotics, followed by a 6-week course of oral antibiotics.² Therapy also includes pain control and surgical intervention for abscesses, osteomyelitis, and refractory cases.⁷

Complications

Complications and long-term sequelae are common in ISI, often due to late diagnosis of the condition. Our case illustrates the delayed diagnosis of Pseudomonas ISI with candidemia in a young man with a history of IV drug use presenting with atraumatic low back pain. His clinical course was complicated by a thromboembolic event, likely secondary to immobility and a hypercoagulable state from infection and inflammation.¹⁵ Infectious sacroiliitis secondary to P aeruginosa is most commonly seen in patients with immunosuppression, hospitalization, and IV drug use.²

Summary

Infectious sacroiliitis remains a diagnostic challenge for physicians due to its rare incidence and nonspecific clinical manifestations. Our case illustrates the importance of maintaining a high level of clinical suspicion for infectious arthritis in young patients presenting with common MSK complaints in the presence of infectious risk factors. Emergency physicians should consider red flags, abnormal vital signs, and patient recidivism when deciding on the most appropriate workup.

Case

A 29-year-old man presented to the ED with a 3-day history of constant left-sided low back pain that radiated to his left buttock and groin. The patient stated the pain worsened with movement, making it difficult for him to walk. He reported lifting heavy boxes at work, but denied any trauma. The patient also denied recent fevers, chills, chest pain, dyspnea, abdominal pain, urinary or fecal incontinence, weakness, numbness, or saddle anesthesia. Regarding his medical history, he had an appendectomy as a child, but reported no other surgeries or medical issues. His social history was significant for narcotic and inhalant use and daily tobacco use. The patient also reported taking heroin intravenously (IV) 6 months prior.

Vital signs at presentation were: heart rate (HR), 92 beats/min; respiratory rate, 15 breaths/min; blood pressure, 118/80 mm Hg; and temperature, 98.2°F. Oxygen saturation was 98% on room air.

The patient was a well-developed young man in no apparent distress. Dermatological examination showed bilateral track marks in the antecubital fossa. The musculoskeletal (MSK) examination demonstrated left gluteal tenderness to palpation and decreased active and passive range of motion of the left hip, especially with internal rotation and flexion. He had no midline tenderness, and the lower extremities had normal pulses and no motor or sensory deficits.

The patient’s pain improved with IV fluids, diazepam, and ketorolac, and he was able to ambulate with assistance. He was clinically diagnosed with sciatica, and discharged home with prescriptions for diazepam and ibuprofen. He was also instructed to follow-up with an orthopedist within 7 days from discharge.

The patient returned to the ED the following day with similar complaints of unabating left-sided pain and difficulty ambulating. His vital signs were notable for an elevated HR of 106 beats/min. Physical examination findings were unchanged from his presentation the previous day, and an X-ray of the lumbar spine showed no abnormalities.

After receiving IV analgesics, the patient’s pain improved and his tachycardia resolved. He was discharged home with instructions to continue taking diazepam, and was also given prescriptions for prednisone and oxycodone/acetaminophen. He was instructed to follow-up with an orthopedist within 24 hours.

Over the next 9 days, the patient was seen twice by an orthopedist, who ordered imaging of the lumbar spine, including a repeat X-ray and contrast-enhanced magnetic resonance imaging (MRI), both of which were unremarkable. The patient completed the prescribed course of diclofenac, oxycodone/acetaminophen, and prednisone, but experienced only minimal pain relief. The orthopedist prescribed the diclofenac to supplement the medication regimen that he was already on.

At the second follow-up visit, the orthopedist ordered an MRI of the patient’s left hip, which demonstrated inflammation of the left sacroiliac joint (SIJ) with effusion, and a 1-cm by 1-cm collection adjacent to the left psoas muscle; these findings were concerning for septic arthritis (Figure). Based on the MRI study, a computed tomography (CT)-guided arthrocentesis of the left SIJ was performed by an interventional radiologist.

Discussion

Infectious sacroiliitis (ISI) is a rare form of infectious arthritis affecting the SIJ, with an incidence of 1 to 2 reported cases per year.¹ The literature on ISI currently consists only of case reports and case series. This infection is often diagnosed after the disease has progressed, with a mean time to diagnosis of 43.3 days.²

Infectious arthritis of any joint has a prevalence of 2 to 10 per 100,000 people. In 50% of cases, the knee is the joint most commonly affected, followed by the hip, shoulder, and elbow.³ Regardless of location, infectious arthritis is associated with significant morbidity and mortality due to sepsis and irreversible loss of joint function.⁴

Risk factors for ISI include IV drug use, pregnancy, trauma, endocarditis, and immunosuppression.¹ The decision to initiate the workup for ISI can be difficult to make because the condition may present without signs of an infectious etiology, such as toxic appearance, inflammatory changes surrounding the joint, or even fever—only 41% of affected patients in one case series were febrile.² The workup is often time-consuming, invasive, and expensive.

Although delayed diagnosis and treatment of septic arthritis is associated with significant adverse effects, there is unfortunately no consensus to guide the workup for ISI. As opposed to Kocher’s criteria for the differentiation of septic hip arthritis from transient synovitis in pediatric patients or well-known red-flags for further evaluation of low back pain, physicians are left without much guidance when considering laboratory workup or imaging decisions to evaluate for ISI.

Sacroiliac Joint

As previously noted, the SIJ is not commonly affected by infection. It is a diarthrodial, L-shaped joint comprised of the posterior ilium and sacrum, and is a near-rigid structure with very limited movement that provides stability to the axial skeleton.⁵ The SIJ is often overlooked as a secondary cause of low back pain in younger patients with rheumatologic conditions (eg, ankylosing spondylitis, Reiter syndrome), pregnancy-associated ligamentous laxity, and osteoarthritis in elderly patients. In one study, 88.2% of sacroiliitis cases were inflammatory, 8.8% infectious, and 2.9% degenerative.⁶

Signs and Symptoms

As our case illustrates, ISI often presents with nonspecific symptoms and physical findings.⁷ Patients typically present with fever, painful manipulation of the SIJ, and unilateral lumbo-gluteal pain.² The components of the history and physical examination suspicious for an infectious etiology include the subacute presentation; unresolved pain despite treatment; tenderness to palpation; decreased range of motion; and recent IV drug use, which increases the risk of infectious disease due to unsterile practices and direct inoculation of pathogens into the bloodstream⁸ and a further predilection into the axial skeleton. ⁹ It is important to obtain an accurate social history; however, patients may not be forthright about disclosing sensitive information such as sexual history and illicit drug use.

Physical Assessment

The SIJ is best appreciated in the seated patient by palpating one fingerbreadth medial to the posterior superior iliac spine as he or she slowly bends forward.¹⁰ Tenderness elicited while in this position is suggestive of SIJ inflammation. The area of tenderness may be lower than anticipated and lateral to the gluteal cleft, as synovial fluid is typically relegated to the lower half of the joint.

Several adjunctive physical examination maneuvers, such as the Gaenslen test and Flexion Abduction External Rotation test (FABER test or Patrick’s test) can isolate SIJ pathology or dysfunction. The Gaenslen test is performed by asking the patient to lie supine and flex the affected hip and knee, with the lumbar spine flat against the examination table. Hyperextending the contralateral thigh downward will reproduce pain in the affected SIJ.

The FABER test is a simple but less specific examination technique to assess joint pain in the hip, lumbar, and sacroiliac joints.¹¹ In this assessment, the clinician flexes the patient’s affected knee to 90°, externally rotates the hip, and applies downward pressure on the knee. Pain reproduced in the affected SI region is sensitive for joint inflammation.

Laboratory and Imaging Studies

Laboratory studies typically show inconsistent and nonspecific findings, such as the elevated ESR and CRP levels seen in our patient.^2,12 Imaging studies to assess the SIJ for signs of infection are therefore essential for confirming infection.

Magnetic resonance imaging is the preferred imaging modality to assess for ISI, since it has the highest sensitivity in visualizing joint effusion and bone marrow edema compared to other modalities. Computed tomography, however, can be helpful in visualizing associated abscesses and guiding arthrocentesis.¹² Plain X-ray may not demonstrate early changes in bone.¹³ The confirmatory study for ISI is synovial fluid analysis and culture.⁷

Treatment

Infectious sacroiliitis secondary to P aeruginosa, a gram-negative bacillus, is difficult to treat because of the glycocalyx and slime production that protects the pathogen from antibiotics, the development of multiple-antimicrobial resistance, and poor drug penetration into bones and abscesses.¹⁴ Antibiotic treatment should cover Staphylococcus aureus and may be broadened to cover gram-negative bacilli. The recommended duration of treatment is at least a 2-week course of IV antibiotics, followed by a 6-week course of oral antibiotics.² Therapy also includes pain control and surgical intervention for abscesses, osteomyelitis, and refractory cases.⁷

Complications

Complications and long-term sequelae are common in ISI, often due to late diagnosis of the condition. Our case illustrates the delayed diagnosis of Pseudomonas ISI with candidemia in a young man with a history of IV drug use presenting with atraumatic low back pain. His clinical course was complicated by a thromboembolic event, likely secondary to immobility and a hypercoagulable state from infection and inflammation.¹⁵ Infectious sacroiliitis secondary to P aeruginosa is most commonly seen in patients with immunosuppression, hospitalization, and IV drug use.²

Summary

Infectious sacroiliitis remains a diagnostic challenge for physicians due to its rare incidence and nonspecific clinical manifestations. Our case illustrates the importance of maintaining a high level of clinical suspicion for infectious arthritis in young patients presenting with common MSK complaints in the presence of infectious risk factors. Emergency physicians should consider red flags, abnormal vital signs, and patient recidivism when deciding on the most appropriate workup.

Case

A 29-year-old man presented to the ED with a 3-day history of constant left-sided low back pain that radiated to his left buttock and groin. The patient stated the pain worsened with movement, making it difficult for him to walk. He reported lifting heavy boxes at work, but denied any trauma. The patient also denied recent fevers, chills, chest pain, dyspnea, abdominal pain, urinary or fecal incontinence, weakness, numbness, or saddle anesthesia. Regarding his medical history, he had an appendectomy as a child, but reported no other surgeries or medical issues. His social history was significant for narcotic and inhalant use and daily tobacco use. The patient also reported taking heroin intravenously (IV) 6 months prior.

Vital signs at presentation were: heart rate (HR), 92 beats/min; respiratory rate, 15 breaths/min; blood pressure, 118/80 mm Hg; and temperature, 98.2°F. Oxygen saturation was 98% on room air.

The patient was a well-developed young man in no apparent distress. Dermatological examination showed bilateral track marks in the antecubital fossa. The musculoskeletal (MSK) examination demonstrated left gluteal tenderness to palpation and decreased active and passive range of motion of the left hip, especially with internal rotation and flexion. He had no midline tenderness, and the lower extremities had normal pulses and no motor or sensory deficits.

The patient’s pain improved with IV fluids, diazepam, and ketorolac, and he was able to ambulate with assistance. He was clinically diagnosed with sciatica, and discharged home with prescriptions for diazepam and ibuprofen. He was also instructed to follow-up with an orthopedist within 7 days from discharge.

The patient returned to the ED the following day with similar complaints of unabating left-sided pain and difficulty ambulating. His vital signs were notable for an elevated HR of 106 beats/min. Physical examination findings were unchanged from his presentation the previous day, and an X-ray of the lumbar spine showed no abnormalities.

After receiving IV analgesics, the patient’s pain improved and his tachycardia resolved. He was discharged home with instructions to continue taking diazepam, and was also given prescriptions for prednisone and oxycodone/acetaminophen. He was instructed to follow-up with an orthopedist within 24 hours.

Over the next 9 days, the patient was seen twice by an orthopedist, who ordered imaging of the lumbar spine, including a repeat X-ray and contrast-enhanced magnetic resonance imaging (MRI), both of which were unremarkable. The patient completed the prescribed course of diclofenac, oxycodone/acetaminophen, and prednisone, but experienced only minimal pain relief. The orthopedist prescribed the diclofenac to supplement the medication regimen that he was already on.

At the second follow-up visit, the orthopedist ordered an MRI of the patient’s left hip, which demonstrated inflammation of the left sacroiliac joint (SIJ) with effusion, and a 1-cm by 1-cm collection adjacent to the left psoas muscle; these findings were concerning for septic arthritis (Figure). Based on the MRI study, a computed tomography (CT)-guided arthrocentesis of the left SIJ was performed by an interventional radiologist.

Discussion

Infectious sacroiliitis (ISI) is a rare form of infectious arthritis affecting the SIJ, with an incidence of 1 to 2 reported cases per year.¹ The literature on ISI currently consists only of case reports and case series. This infection is often diagnosed after the disease has progressed, with a mean time to diagnosis of 43.3 days.²

Infectious arthritis of any joint has a prevalence of 2 to 10 per 100,000 people. In 50% of cases, the knee is the joint most commonly affected, followed by the hip, shoulder, and elbow.³ Regardless of location, infectious arthritis is associated with significant morbidity and mortality due to sepsis and irreversible loss of joint function.⁴

Risk factors for ISI include IV drug use, pregnancy, trauma, endocarditis, and immunosuppression.¹ The decision to initiate the workup for ISI can be difficult to make because the condition may present without signs of an infectious etiology, such as toxic appearance, inflammatory changes surrounding the joint, or even fever—only 41% of affected patients in one case series were febrile.² The workup is often time-consuming, invasive, and expensive.

Although delayed diagnosis and treatment of septic arthritis is associated with significant adverse effects, there is unfortunately no consensus to guide the workup for ISI. As opposed to Kocher’s criteria for the differentiation of septic hip arthritis from transient synovitis in pediatric patients or well-known red-flags for further evaluation of low back pain, physicians are left without much guidance when considering laboratory workup or imaging decisions to evaluate for ISI.

Sacroiliac Joint

As previously noted, the SIJ is not commonly affected by infection. It is a diarthrodial, L-shaped joint comprised of the posterior ilium and sacrum, and is a near-rigid structure with very limited movement that provides stability to the axial skeleton.⁵ The SIJ is often overlooked as a secondary cause of low back pain in younger patients with rheumatologic conditions (eg, ankylosing spondylitis, Reiter syndrome), pregnancy-associated ligamentous laxity, and osteoarthritis in elderly patients. In one study, 88.2% of sacroiliitis cases were inflammatory, 8.8% infectious, and 2.9% degenerative.⁶

Signs and Symptoms

As our case illustrates, ISI often presents with nonspecific symptoms and physical findings.⁷ Patients typically present with fever, painful manipulation of the SIJ, and unilateral lumbo-gluteal pain.² The components of the history and physical examination suspicious for an infectious etiology include the subacute presentation; unresolved pain despite treatment; tenderness to palpation; decreased range of motion; and recent IV drug use, which increases the risk of infectious disease due to unsterile practices and direct inoculation of pathogens into the bloodstream⁸ and a further predilection into the axial skeleton. ⁹ It is important to obtain an accurate social history; however, patients may not be forthright about disclosing sensitive information such as sexual history and illicit drug use.

Physical Assessment

The SIJ is best appreciated in the seated patient by palpating one fingerbreadth medial to the posterior superior iliac spine as he or she slowly bends forward.¹⁰ Tenderness elicited while in this position is suggestive of SIJ inflammation. The area of tenderness may be lower than anticipated and lateral to the gluteal cleft, as synovial fluid is typically relegated to the lower half of the joint.

Several adjunctive physical examination maneuvers, such as the Gaenslen test and Flexion Abduction External Rotation test (FABER test or Patrick’s test) can isolate SIJ pathology or dysfunction. The Gaenslen test is performed by asking the patient to lie supine and flex the affected hip and knee, with the lumbar spine flat against the examination table. Hyperextending the contralateral thigh downward will reproduce pain in the affected SIJ.

The FABER test is a simple but less specific examination technique to assess joint pain in the hip, lumbar, and sacroiliac joints.¹¹ In this assessment, the clinician flexes the patient’s affected knee to 90°, externally rotates the hip, and applies downward pressure on the knee. Pain reproduced in the affected SI region is sensitive for joint inflammation.

Laboratory and Imaging Studies

Laboratory studies typically show inconsistent and nonspecific findings, such as the elevated ESR and CRP levels seen in our patient.^2,12 Imaging studies to assess the SIJ for signs of infection are therefore essential for confirming infection.

Magnetic resonance imaging is the preferred imaging modality to assess for ISI, since it has the highest sensitivity in visualizing joint effusion and bone marrow edema compared to other modalities. Computed tomography, however, can be helpful in visualizing associated abscesses and guiding arthrocentesis.¹² Plain X-ray may not demonstrate early changes in bone.¹³ The confirmatory study for ISI is synovial fluid analysis and culture.⁷

Treatment

Infectious sacroiliitis secondary to P aeruginosa, a gram-negative bacillus, is difficult to treat because of the glycocalyx and slime production that protects the pathogen from antibiotics, the development of multiple-antimicrobial resistance, and poor drug penetration into bones and abscesses.¹⁴ Antibiotic treatment should cover Staphylococcus aureus and may be broadened to cover gram-negative bacilli. The recommended duration of treatment is at least a 2-week course of IV antibiotics, followed by a 6-week course of oral antibiotics.² Therapy also includes pain control and surgical intervention for abscesses, osteomyelitis, and refractory cases.⁷

Complications

Complications and long-term sequelae are common in ISI, often due to late diagnosis of the condition. Our case illustrates the delayed diagnosis of Pseudomonas ISI with candidemia in a young man with a history of IV drug use presenting with atraumatic low back pain. His clinical course was complicated by a thromboembolic event, likely secondary to immobility and a hypercoagulable state from infection and inflammation.¹⁵ Infectious sacroiliitis secondary to P aeruginosa is most commonly seen in patients with immunosuppression, hospitalization, and IV drug use.²

Summary

Infectious sacroiliitis remains a diagnostic challenge for physicians due to its rare incidence and nonspecific clinical manifestations. Our case illustrates the importance of maintaining a high level of clinical suspicion for infectious arthritis in young patients presenting with common MSK complaints in the presence of infectious risk factors. Emergency physicians should consider red flags, abnormal vital signs, and patient recidivism when deciding on the most appropriate workup.