Laleh Gharahbaghian

All Publications

• Protecting the emergency physician workforce during the coronavirus disease 2019 pandemic through precision scheduling at an academic tertiary care trauma center. Journal of the American College of Emergency Physicians open Lee, M. O., Ribeira, R., Fang, A., Cantwell, L., Khanna, K., Smith, C., Gharahbaghian, L. 2021; 2 (1): e12221

  Abstract

  The coronavirus disease 2019 (COVID-19) pandemic created new emergency physician staffing challenges. Emergency physicians may be taken out of the workforce because of respiratory symptoms or pending severe acute respiratory syndrome coronavirus 2 test results. Vulnerable emergency physician populations with increased risk of serious disease and death from COVID-19 include physicians at older ages; those with chronic medical conditions, including cardiac and pulmonary diseases and immunosuppression; and potentially pregnancy. We present our approach to planning for staffing issues through precision scheduling. We describe the actions taken to protect our vulnerable physicians and maximize our physician coverage. Measures include optimizing workforce; increasing backup call system; adjusting shifts based on patient arrival times, volume, and surge predictions; minimizing exposure to COVID-19 and reduce personal protective equipment use through telemedicine, huddles, and, creating lower risk emergency department care areas; and standardizing intubations to limit exposure.

  View details for DOI 10.1002/emp2.12221

  View details for PubMedID 33615307

• The Utility of Color Doppler to Confirm Endotracheal Tube Placement: A Pilot Study. The western journal of emergency medicine Gildea, T. H., Anderson, K. L., Niknam, K. R., Gharahbaghian, L., Williams, S. R., Angelotti, T., Auerbach, P. S., Lobo, V. 2020; 21 (4): 871–76

  Abstract

  INTRODUCTION: Grayscale ultrasound (US) imaging has been used as an adjunct for confirming endotracheal tube (ETT) placement in recent years. The addition of color Doppler imaging (CDI) has been proposed to improve identification but has not been well studied. The aim of this study was to assess whether CDI improves correct localization of ETT placement.METHODS: A convenience sample of emergency and critical care physicians at various levels of training and experience participated in an online assessment. Participants viewed US video clips of patients, which included either tracheal or esophageal intubations captured in grayscale or with CDI; there were five videos of each for a total of 20 videos. Participants were asked to watch each clip and then assess the location of the ETT.RESULTS: Thirty-eight subjects participated in the online assessment. Levels of training included medical students (13%), emergency medicine (EM) residents (50%), EM attendings (32%), and critical care attendings (5%). The odds ratio of properly assessing tracheal placement using color relative to a grayscale imaging technique was 1.5 (p = 0.21). Regarding the correct assessment of esophageal placement, CDI had 1.4 times the odds of being correctly assessed relative to grayscale (p = 0.26). The relationship between training level and correct assessments was not significant for either tracheal or esophageal placements.CONCLUSION: In this pilot study we found no significant improvement in correct identification of ETT placement using color Doppler compared to grayscale ultrasound; however, there was a trend toward improvement that might be better elucidated in a larger study.

  View details for DOI 10.5811/westjem.2020.5.45588

  View details for PubMedID 32726258

• Patient Age, Race and Emergency Department Treatment Area Associated with "Topbox" Press Ganey Scores. The western journal of emergency medicine Lee, M. O., Altamirano, J., Garcia, L. C., Gisondi, M. A., Wang, N. E., Lippert, S., Maldonado, Y., Gharahbaghian, L., Ribeira, R., Fassiotto, M. 2020; 21 (6): 117–24

  Abstract

  Hospitals commonly use Press Ganey (PG) patient satisfaction surveys for benchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest, which is known as the "topbox" score. Our objective was to identify patient and physician factors associated with topbox PG scores in the emergency department (ED).We looked at PG surveys from January 2015-December 2017 at an academic, urban hospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions: "Likelihood of your recommending our ED to others"; and "Courtesy of the doctor." We analyzed topbox scores using generalized estimating equation models clustered by physician and adjusted for patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED area where patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical (urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physician factors included age, gender, race, ethnicity, and number of years at current institution.We analyzed a total of 3,038 surveys. For "Likelihood of your recommending our ED to others," topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.12); less likely among female compared to male patients (OR 0.81; 95% CI, 0.70-0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60-0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54-0.93) and vertical areas (OR 0.71; 95% CI 0.53-0.95) compared to fast track. For "Courtesy of the doctor," topbox scores were more likely with increasing patient age (OR 1.1; CI, 1.06-1.14); less likely among Asian (OR 0.70; 95% CI, 0.58-0.84), Black (OR 0.66; 95% CI, 0.45-0.96), and Hispanic patients (OR 0.68; 95% CI, 0.55-0.83) compared to White patients; and less likely in urgent area (OR 0.69; 95% CI, 0.50-0.95) compared to fast track.Increasing patient age was associated with increased likelihood of topbox scores, while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. We encourage hospitals that use PG topbox scores as financial incentives to understand the contribution of non-service factors to these scores.

  View details for DOI 10.5811/westjem.2020.8.47277

  View details for PubMedID 33207156

• Cardiac Standstill With Intracardiac Clot Formation. Clinical practice and cases in emergency medicine Sakamoto, J. T., Storch, I., Gharahbaghian, L. 2019; 3 (4): 430–31

  Abstract

  This case describes and depicts cardiac standstill with thrombosed blood within the chambers of the heart. This was likely due to stasis of blood from a prolonged no-flow state. After viewing this ultrasound finding, the decision was made to halt resuscitative efforts in this case of a patient in cardiac arrest.

  View details for DOI 10.5811/cpcem.2019.7.42932

  View details for PubMedID 31763607

• Detection of Type B Aortic Dissection in the Emergency Department with Point-of-Care Ultrasound. Clinical practice and cases in emergency medicine Earl-Royal, E., Nguyen, P. D., Alvarez, A., Gharahbaghian, L. 2019; 3 (3): 202–7

  Abstract

  Aortic dissection (AD) is a rare, time-sensitive, and potentially fatal condition that can present with subtle signs requiring timely diagnosis and intervention. Although definitive diagnosis is most accurately made through computed tomography angiography, this can be a time-consuming study and the patient may be unstable, thus preventing the study's completion. Chest radiography (CXR) signs of AD are classically taught yet have poor diagnostic reliability. Point-of-care ultrasound (POCUS) is increasingly used by emergency physicians for the rapid diagnosis of emergent conditions, with multiple case reports illustrating the sonographic signs of AD. We present a case of Stanford type B AD diagnosed by POCUS in the emergency department in a patient with vague symptoms, normal CXR, and without aorta dilation. A subsequent review of CXR versus sonographic signs of AD is described.

  View details for DOI 10.5811/cpcem.2019.5.42928

  View details for PubMedID 31404375

• Point-of-care Ultrasonography for Detecting the Etiology of Unexplained Acute Respiratory and Chest Complaints in the Emergency Department: A Prospective Analysis. Cureus Lamsam, L., Gharahbaghian, L., Lobo, V. 2018; 10 (8): e3218

  Abstract

  Introduction Point-of-care ultrasound (POCUS) is increasingly used as a diagnostic tool in emergency departments. As the number and type of POCUS protocols expand, there is a need to validate their efficacy in comparison with current diagnostic standards. This study compares POCUS to chest radiography in patients with undifferentiated respiratory or chest complaints. Methods A prospective convenience sample of 59 adult patients were enrolled from those presenting with unexplained acute respiratory or chest complaints (and having orders for chest radiography) to a single emergency department in an academic tertiary-care hospital. After a brief educational session, a medical student, blinded to chest radiograph results, performed and interpreted images from the modified Rapid Assessment of Dyspnea in Ultrasound (RADiUS) protocol. The images were reviewed by a blinded ultrasound fellowship-trained emergency physician and compared to chest radiography upon chart review. The primary "gold standard" endpoint diagnosis was the diagnosis at discharge. A secondary analysis was performed using the chest computed tomography (CT) diagnosis as the endpoint diagnosis in the subset of patients with chest CTs. Results When using diagnosis at discharge as the endpoint diagnosis, the modified RADiUS protocol had a higher sensitivity (79% vs. 67%) and lower specificity (71% vs. 83%) than chest radiography. When using chest CT diagnosis as the endpoint diagnosis (in the subset of patients with chest CTs), the modified RADiUS protocol had a higher sensitivity (76% vs. 65%) and lower specificity (71% vs. 100%) than chest radiography. The medical student performed and interpreted the 59 POCUS scans with 92% accuracy. Conclusion The sensitivity and specificity of POCUS using the modified RADiUS protocol was not significantly different than chest radiography. In addition, a medical student was able to perform the protocol and interpret scans with a high level of accuracy. POCUS has potential value for diagnosing the etiology of undifferentiated acute respiratory and chest complaints in adult patients presenting to the emergency department, but larger clinical validation studies are required.

  View details for PubMedID 30405993

• The Social Media Index as an Indicator of Quality for Emergency Medicine Blogs: A METRIQ Study. Annals of emergency medicine Thoma, B., Chan, T. M., Kapur, P., Sifford, D., Siemens, M., Paddock, M., Ankel, F., Grock, A., Lin, M. 2018

  Abstract

  Online educational resources such as blogs are increasingly used for education by emergency medicine clinicians. The Social Media Index was developed to quantify their relative impact. The Medical Education Translational Resources: Indicators of Quality (METRIQ) study was conducted in part to determine the association between the Social Media Index score and quality as measured by gestalt and previously derived quality instruments.Ten blogs were randomly selected from a list of emergency medicine and critical care Web sites. The 2 most recent clinically oriented blog posts published on these blogs were evaluated with gestalt, the Academic Life in Emergency Medicine Approved Instructional Resources (ALiEM AIR) score, and the METRIQ-8 score. Volunteer raters (including medical students, emergency medicine residents, and emergency medicine attending physicians) were identified with a multimodal recruitment methodology. The Social Media Index was calculated in February 2016, November 2016, April 2017, and December 2017. Pearson's correlations were calculated between the Social Media Index and the average rater gestalt, ALiEM AIR score, and METRIQ-8 score.A total of 309 of 330 raters completed all ratings (93.6%). The Social Media Index correlated moderately to strongly with the mean rater gestalt ratings (range 0.69 to 0.76) and moderately with the mean rater ALiEM AIR score (range 0.55 to 0.61) and METRIQ-8 score (range 0.53 to 0.57) during the month of the blog post's selection and for 2 years after.The Social Media Index's correlation with multiple quality evaluation instruments over time supports the hypothesis that it is associated with overall Web site quality. It can play a role in guiding individuals to high-quality resources that can be reviewed with critical appraisal techniques.

  View details for DOI 10.1016/j.annemergmed.2018.05.003

  View details for PubMedID 29980461

• TRAINING NURSES TO ASSESS FLUID STATUS USING POINT-OF-CARE ULTRASOUND Crager, S., Cinkowski, C., Gharahbaghian, L. LIPPINCOTT WILLIAMS & WILKINS. 2018: 179

  View details for DOI 10.1097/01.ccm.0000528409.08831.b0

  View details for Web of Science ID 000436794300356

• Point-of-Care Ultrasound in Austere Environments A Complete Review of Its Utilization, Pitfalls, and Technique for Common Applications in Austere Settings EMERGENCY MEDICINE CLINICS OF NORTH AMERICA Gharahbaghian, L., Anderson, K. L., Lobo, V., Huang, R., Poffenberger, C. M., Nguyen, D. 2017; 35 (2): 409-?

  Abstract

  With the advent of portable ultrasound machines, point-of-care ultrasound (POCUS) has proven to be adaptable to a myriad of environments, including remote and austere settings, where other imaging modalities cannot be carried. Austere environments continue to pose special challenges to ultrasound equipment, but advances in equipment design and environment-specific care allow for its successful use. This article describes the technique and illustrates pathology of common POCUS applications in austere environments. A brief description of common POCUS-guided procedures used in austere environments is also provided.

  View details for DOI 10.1016/j.emc.2016.12.007

  View details for PubMedID 28411935

• Caudal Edge of the Liver in the Right Upper Quadrant (RUQ) View Is the Most Sensitive Area for Free Fluid on the FAST Exam. The western journal of emergency medicine Lobo, V., Hunter-Behrend, M., Cullnan, E., Higbee, R., Phillips, C., Williams, S., Perera, P., Gharahbaghian, L. 2017; 18 (2): 270-280

  Abstract

  The focused assessment with sonography in trauma (FAST) exam is a critical diagnostic test for intraperitoneal free fluid (FF). Current teaching is that fluid accumulates first in Morison's pouch. The goal of this study was to evaluate the "sub-quadrants" of traditional FAST views to determine the most sensitive areas for FF accumulation.We analyzed a retrospective cohort of all adult trauma patients who had a recorded FAST exam by emergency physicians at a Level I trauma center from January 2012 - June 2013. Ultrasound fellowship-trained faculty with three emergency medicine residents reviewed all FAST exams. We excluded studies if they were incomplete, of poor image quality, or with incorrect medical record information. Positive studies were assessed for FF localization, comparing the traditional abdominal views and on a sub-quadrant basis: right upper quadrant (RUQ)1 - hepato-diaphragmatic; RUQ2 - Morison's pouch; RUQ3 - caudal liver edge and superior paracolic gutter; left upper quadrant (LUQ)1 - splenic-diaphragmatic; LUQ2 - spleno-renal; LUQ3 - around inferior pole of kidney; suprapubic area (SP)1 - bilateral to bladder; SP2 - posterior to bladder; SP3 - posterior to uterus (females). FAST results were confirmed by chart review of computed tomography results or operative findings.Of the included 1,008 scans, 48 (4.8%) were positive. The RUQ was the most positive view with 32/48 (66.7%) positive. In the RUQ sub-quadrant analysis, the most positive view was the RUQ3 with 30/32 (93.8%) positive.The RUQ is most sensitive for FF assessment, with the superior paracolic gutter area around the caudal liver edge (RUQ3) being the most positive sub-quadrant within the RUQ.

  View details for DOI 10.5811/westjem.2016.11.30435

  View details for PubMedID 28210364

• Ultrasound Detection of Patellar Fracture and Evaluation of the Knee Extensor Mechanism in the Emergency Department. The western journal of emergency medicine Carter, K., Nesper, A., Gharahbaghian, L., Perera, P. 2016; 17 (6): 814-816

  Abstract

  Traumatic injuries to the knee are common in emergency medicine. Bedside ultrasound (US) has benefits in the rapid initial detection of injuries to the patella. In addition, US can also quickly detect injuries to the entire knee extensor mechanism, including the quadriceps tendon and inferior patellar ligament, which may be difficult to diagnose with plain radiographs. While magnetic resonance imaging remains the gold standard for diagnostic evaluation of the knee extensor mechanism, this can be difficult to obtain from the emergency department. Clinicians caring for patients with orthopedic injuries of the knee would benefit from incorporating bedside musculoskeletal US into their clinical skills set.

  View details for PubMedID 27833696

• Integration of Ultrasound in Undergraduate Medical Education at the California Medical Schools: A Discussion of Common Challenges and Strategies From the UMeCali Experience. Journal of ultrasound in medicine Chiem, A. T., Soucy, Z., Dinh, V. A., Chilstrom, M., Gharahbaghian, L., Shah, V., Medak, A., Nagdev, A., Jang, T., Stark, E., Hussain, A., Lobo, V., Pera, A., Fox, J. C. 2016; 35 (2): 221-233

  Abstract

  Since the first medical student ultrasound electives became available more than a decade ago, ultrasound in undergraduate medical education has gained increasing popularity. More than a dozen medical schools have fully integrated ultrasound education in their curricula, with several dozen more institutions planning to follow suit. Starting in June 2012, a working group of emergency ultrasound faculty at the California medical schools began to meet to discuss barriers as well as innovative approaches to implementing ultrasound education in undergraduate medical education. It became clear that an ongoing collaborative could be formed to discuss barriers, exchange ideas, and lend support for this initiative. The group, termed Ultrasound in Medical Education, California (UMeCali), was formed with 2 main goals: to exchange ideas and resources in facilitating ultrasound education and to develop a white paper to discuss our experiences. Five common themes integral to successful ultrasound education in undergraduate medical education are discussed in this article: (1) initiating an ultrasound education program; (2) the role of medical student involvement; (3) integration of ultrasound in the preclinical years; (4) developing longitudinal ultrasound education; and (5) addressing competency.

  View details for DOI 10.7863/ultra.15.05006

  View details for PubMedID 26764278

• Thymic Tumor Extension into the Heart, a Rare Finding Found by Point-of-Care Ultrasound. Cure¯us Kaufman, E., Hunter-Behrend, M., Leroux, E., Gharahbaghian, L., Lobo, V. 2016; 8 (8)

  Abstract

  We report a cardiac mass detected by point-of-care ultrasound performed within the emergency department on a 65-year-old male with thymic cancer who presented with chronic cough and fever. Results from the initial emergency workup, which included blood tests, urinalysis, and a computerized tomography with angiography scan with venous phasing of the chest, did not result in a definitive diagnosis. A point-of-care echocardiogram was performed to evaluate for possible infective endocarditis, but alternatively identified a large mass in the right atria and ventricle. The mass was later confirmed to be metastatic tumor from the patient's known thymic cancer. This case emphasizes the vital role ultrasound can play in the acute care setting.

  View details for DOI 10.7759/cureus.724

  View details for PubMedID 27625910

  View details for PubMedCentralID PMC5010378

• Splenic Rupture Diagnosed with Bedside Ultrasound in a Patient with Shock in the Emergency Department Following Colonoscopy. The western journal of emergency medicine Mulkerin, W., Mitarai, T., Gharahbaghian, L., Perera, P. 2015; 16 (5): 758-759

  View details for DOI 10.5811/westjem.2015.6.27548

  View details for PubMedID 26587104

• Prehospital Evaluation of Effusion, Pneumothorax, and Standstill (PEEPS): Point-of-care Ultrasound in Emergency Medical Services. The western journal of emergency medicine Bhat, S. R., Johnson, D. A., Pierog, J. E., Zaia, B. E., Williams, S. R., Gharahbaghian, L. 2015; 16 (4): 503-509

  Abstract

  In the United States, there are limited studies regarding use of prehospital ultrasound (US) by emergency medical service (EMS) providers. Field diagnosis of life-threatening conditions using US could be of great utility. This study assesses the ability of EMS providers and students to accurately interpret heart and lung US images.We tested certified emergency medical technicians (EMT-B) and paramedics (EMT-P) as well as EMT-B and EMT-P students enrolled in prehospital training programs within two California counties. Participants completed a pre-test of sonographic imaging of normal findings and three pathologic findings: pericardial effusion, pneumothorax, and cardiac standstill. A focused one-hour lecture on emergency US imaging followed. Post-tests were given to all EMS providers immediately following the lecture and to a subgroup one week later.We enrolled 57 prehospital providers (19 EMT-B students, 16 EMT-P students, 18 certified EMT-B, and 4 certified EMT-P). The mean pre-test score was 65.2%±12.7% with mean immediate post-test score of 91.1%±7.9% (95% CI [22%-30%], p<0.001). Scores significantly improved for all three pathologic findings. Nineteen subjects took the one-week post-test. Their mean score remained significantly higher: pre-test 65.8%±10.7%; immediate post-test 90.5%±7.0% (95% CI [19%-31%], p<0.001), one-week post-test 93.1%±8.3% (95% CI [21%-34%], p<0.001).Using a small sample of EMS providers and students, this study shows the potential feasibility for educating prehospital providers to accurately identify images of pericardial effusion, pneumothorax, and cardiac standstill after a focused lecture.

  View details for DOI 10.5811/westjem.2015.5.25414

  View details for PubMedID 26265961

• Diagnosis of pneumoperitoneum with bedside ultrasound. The western journal of emergency medicine Chao, A., Gharahbaghian, L., Perera, P. 2015; 16 (2): 302-?

  View details for DOI 10.5811/westjem.2014.12.24945

  View details for PubMedID 25834673

  View details for PubMedCentralID PMC4380382

• Spontaneous pneumomediastinum on bedside ultrasound: case report and review of the literature. The western journal of emergency medicine Zachariah, S., Gharahbaghian, L., Perera, P., Joshi, N. 2015; 16 (2): 321-324

  Abstract

  Spontaneous pneumomediastinum is a rare disease process with no clear etiology, although it is thought to be related to changes in intrathoracic pressure causing chest pain and dyspnea. We present a case of a 17-year-old male with acute chest pain evaluated initially by bedside ultrasound, which showed normal lung sliding but poor visualization of the parasternal and apical cardiac views due to significant air artifact, representing air in the thoracic cavity. The diagnosis was later verified by chest radiograph. We present a case report on ultrasound-diagnosed pneumomediastinum, and we review the diagnostic modalities to date.

  View details for DOI 10.5811/westjem.2015.1.24514

  View details for PubMedID 25834681

  View details for PubMedCentralID PMC4380390

• Clinical Correlation Needed: What Do Emergency Physicians Do After an Equivocal Ultrasound for Pediatric Acute Appendicitis? JOURNAL OF CLINICAL ULTRASOUND Ramarajan, N., Krishnamoorthi, R., Gharahbaghian, L., Pirrotta, E., Barth, R. A., Wang, N. E. 2014; 42 (7): 385-394

  Abstract

  Although follow-up CT is recommended for pediatric appendicitis if initial ultrasound (US) is equivocal, many physicians observe the patient at home. There are limited data to understand currently how common or safe this practice is. Our objectives are to assess prevalence of acute appendicitis and outcomes in patients with equivocal US with and without follow-up CT and to identify variables associated with ordering a follow-up CT.Retrospective analysis of the prevalence of appendicitis and outcomes of patients 1-18 years old with an equivocal US at a pediatric emergency department from 2003 to 2008. Recursive partitioning analysis and multivariate logistic regression were used to identify variables associated with ordering follow-up CT.Fifty-five percent (340/620) of children with equivocal US did not receive CT, none of whom returned with a missed appendicitis. The prevalence of appendicitis in children with equivocal US was 12.5% (78/620). In children with follow-up CT, the prevalence was 22.1% (62/280); in those without follow-up CT, the prevalence was 4.7% (16/340). Recursive partitioning identified age >11 years, leukocytosis >15,000 cells/ml, and secondary signs predisposing toward acute appendicitis on US as significant predictors of CT.We view our study as a fundamental part of the incremental progress to understand how best to use US and CT imaging to diagnose pediatric appendicitis while minimizing ionizing radiation. Children at low risk for appendicitis with equivocal US are amenable to observation and reassessment prior to reimaging with US or CT.

  View details for DOI 10.1002/jcu.22153

  View details for Web of Science ID 000340536300001

  View details for PubMedID 24700515

• Ultrasound for Detection of Ascites and for Guidance of the Paracentesis Procedure: Technique and Review of the Literature International Journal of Clinical Medicine Ennis, J., Schultz, G., Perera, P., Williams, S. R., Gharahbaghian, L., Mandavia, D. 2014; 5: 1277-1293

  View details for DOI 10.4236/ijcm.2014.520163.

• Resuscitation Ultrasound and Rapid Ultrasound in Shock in the Critically Ill Patient (The RUSH Exam). Decision Making in Emergency Critical Care: An Evidence-Based Handbook Perera, P., Gharahbaghian, L., Mailhot, T., Williams, S. R., Mandavia, D. Arbo J, Ruoss J, Lightall G and Jones M (Editors) Wolters-Kluwer Publications. 2014: 62–93
• Ultrasound for the Evaluation of Acute Cardiac Conditions and in the Resuscitation of the Critically Ill Patient Cardiac Emergencies-American College of Emergency Physicians Perera, P., Williams, S. R., Gharahbaghian, L. Bresler M, Mattu A (Editors). Dallas, Tx: American College of Emergency Physicians. 2014: 53–89
• Interstitial Neuritis Masquerading as Acute Appendicitis: A Case Report Emergency Medicine-Open Access Lindquist, B., Gharahbaghian, L. 2014; 4 (4)
• Thoracic Ultrasonography CRITICAL CARE CLINICS Lobo, V., Weingrow, D., Perera, P., Williams, S. R., Gharahbaghian, L. 2014; 30 (1): 93-?

  Abstract

  Thoracic ultrasonography (US) has proved to be a valuable tool in the evaluation of the patient with shortness of breath, chest pain, hypoxia, or after chest trauma. Its sensitivity and specificity for detecting disease is higher than that of a chest radiograph, and it can expedite the diagnosis for many emergent conditions. This article describes the technique of each thoracic US application, illustrating both normal and abnormal findings, as well as discussing the literature. Bedside thoracic US has defined imaging benefits in a wide range of thoracic disease, and US guidance has been shown to facilitate thoracic and airway procedures.

  View details for DOI 10.1016/j.ccc.2013.08.002

  View details for PubMedID 24295842

• The FAST and E-FAST in 2013: Trauma Ultrasonography Overview, Practical Techniques, Controversies, and New Frontiers CRITICAL CARE CLINICS Williams, S. R., Perera, P., Gharahbaghian, L. 2014; 30 (1): 119-?

  Abstract

  This article reviews important literature on the FAST and E-FAST examinations in adults. It also reviews key pitfalls, limitations, and controversies. A practical "how-to" guide is presented. Lastly, new frontiers are explored.

  View details for DOI 10.1016/j.ccc.2013.08.005

  View details for PubMedID 24295843

• Cardiac Echocardiography CRITICAL CARE CLINICS Perera, P., Lobo, V., Williams, S. R., Gharahbaghian, L. 2014; 30 (1): 47-?

  Abstract

  Focused cardiac echocardiography has become a critical diagnostic tool for the emergency physician and critical care physician caring for patients in shock and following trauma to the chest, and those presenting with chest pain and shortness of breath,. Cardiac echocardiography allows for immediate diagnosis of pericardial effusions and cardiac tamponade, evaluation of cardiac contractility and volume status, and detection of right ventricular strain possibly seen with a significant pulmonary embolus. This article addresses how to perform cardiac echocardiography using the standard windows, how to interpret a focused goal-directed examination, and how to apply this information clinically at the bedside.

  View details for DOI 10.1016/j.ccc.2013.08.003

  View details for PubMedID 24295841

• FOCUSED CARDIAC ULTRASOUND TRAINING: HOW MUCH IS ENOUGH? JOURNAL OF EMERGENCY MEDICINE Chisholm, C. B., Dodge, W. R., Balise, R. R., Williams, S. R., Gharahbaghian, L., Beraud, A. 2013; 44 (4): 818-822

  Abstract

  Focused transthoracic echocardiography (F-TTE) is an important tool to assess hemodynamically unstable patients in the Emergency Department. Although its scope has been defined by the American College of Emergency Physicians, more research is needed to define an optimal F-TTE training program, including assessment of proficiency.The goal of this study was to determine the effectiveness of current standards in post-residency training to reach proficiency in F-TTE.Fourteen staff Emergency Physicians were enrolled in a standardized teaching curriculum specifically designed to meet the 2008 American College of Emergency Physicians' guidelines for general ultrasound training applied to echocardiography. This training program consisted of 6 h of didactics and 6 h of scanning training, followed by independent scanning over a 5-month period. Acquisition of echocardiographic knowledge was assessed by an online pre- and post-test. At the conclusion of the study, a hands-on skills test assessed the trainees' ability to perform and interpret F-TTE.Ninety percent of trainees passed the written post-test. Two views, the parasternal long and short axis, were easily obtainable, regardless of the level of training or the number of ultrasounds completed. Other views were more difficult to master, but strong trends toward increased competency were evident after 10 h of mixed didactic and scanning training and > 45 ultrasounds.A short, 12-h didactic training in F-TTE provided proficiency in image interpretation and in obtaining adequate images from the parasternal window. More extensive training is needed to master the apical and subcostal windows in a timely manner.

  View details for DOI 10.1016/j.jemermed.2012.07.092

  View details for PubMedID 23351569

• Ultrasound Guided Peripheral Nerve Blocks Introduction to Bedside Ultrasound Lobo, V., Gharahbaghian, L. Dawson M., Mallin M (Editors) Emergency Ultrasund Solutions. 2013
• USE OF CADAVER MODELS IN POINT-OF-CARE EMERGENCY ULTRASOUND EDUCATION FOR DIAGNOSTIC APPLICATIONS JOURNAL OF EMERGENCY MEDICINE Zaia, B. E., Briese, B., Williams, S. R., Gharahbaghian, L. 2012; 43 (4): 683-691

  Abstract

  As the use of bedside emergency ultrasound (US) increases, so does the need for effective US education.To determine 1) what pathology can be reliably simulated and identified by US in human cadavers, and 2) feasibility of using cadavers to improve the comfort of emergency medicine (EM) residents with specific US applications.This descriptive, cross-sectional survey study assessed utility of cadaver simulation to train EM residents in diagnostic US. First, the following pathologies were simulated in a cadaver: orbital foreign body (FB), retrobulbar (RB) hematoma, bone fracture, joint effusion, and pleural effusion. Second, we assessed residents' change in comfort level with US after using this cadaver model. Residents were surveyed regarding their comfort level with various US applications. After brief didactic sessions on the study's US applications, participants attempted to identify the simulated pathology using US. A post-lab survey assessed for change in comfort level after the training.Orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion were readily modeled in a cadaver in ways typical of a live patient. Twenty-two residents completed the pre- and post-lab surveys. After training with cadavers, residents' comfort improved significantly for orbital FB and RB hematoma (mean increase 1.6, p<0.001), bone fracture (mean increase 2.12, p<0.001), and joint effusion (1.6, p<0.001); 100% of residents reported that they found US education using cadavers helpful.Cadavers can simulate orbital FB, RB hematoma, bone fracture, joint effusion, and pleural effusion, and in our center improved the comfort of residents in identifying all but pleural effusion.

  View details for DOI 10.1016/j.jemermed.2012.01.057

  View details for PubMedID 22504086

• Midaxillary Option for Measuring IVC: Prospective Comparison of the Right Midaxillary and Subxiphold IVC Measurements Howard, Z. D., Gharahbaghian, L., Steele, B. J., Foy, S., Williams, S. R. MOSBY-ELSEVIER. 2012: S78–S79

  View details for DOI 10.1016/j.annemergmed.2012.06.195

  View details for Web of Science ID 000309636100216

• Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement. The western journal of emergency medicine Jenkins, J. A., Gharahbaghian, L., Doniger, S. J., Bradley, S., Crandall, S., Spain, D. A., Williams, S. R. 2012; 13 (4): 305-311

  Abstract

  Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement.Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.

  View details for DOI 10.5811/westjem.2011.10.6680

  View details for PubMedID 22942927

  View details for PubMedCentralID PMC3421967

• Anorexia Nervosa A Case Report of a Teenager Presenting With Bradycardia, General Fatigue, and Weakness PEDIATRIC EMERGENCY CARE Grover, C. A., Robin, J. K., Gharahbaghian, L. 2012; 28 (2): 174-177

  Abstract

  Anorexia nervosa is a disease with high prevalence in adolescents and carries the highest mortality of any psychiatric disorder.We present a case of a 17-year-old female presenting to the emergency department with bradycardia that was subsequently diagnosed with anorexia nervosa. We also review the clinical features, diagnosis, complications, and emergency department management of this disease.Patients with anorexia may present with multiple medical complaints, and it is imperative that the emergency physician be familiar with the syndrome so as to correctly identify and treat patients with this disease.

  View details for Web of Science ID 000300339500018

  View details for PubMedID 22307188

• Is It a Pericardial Effusion or is it not? Pitfalls in the Use of Limited Bedside Echocardiography Avoiding Common Errors in the Emergency Department Rossi, J., Crandall, S., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 841–843
• : If Only Joint Disease was Crystal Clear - Crystal Arthropathies do not Preclude a Septic Joint Avoiding Common Errors in the Emergency Department Raghunathan, A., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 409–411
• Cholecystitis: Don’t rely on your physical exam, but rely on your ultrasound Avoiding Common Errors in the Emergency Department Bass, A., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 839–841
• Emergency Echocardiography and IVC Evaluation (Appendix) An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department Williams, S. R., Gharahbaghian, L. Mahadevan & Garmel (eds), Cambridge University Press. 2012; 2
• . It’s Not the Machine’s Fault! Using Basic System Controls to Improve your Ultrasound Images Avoiding Common Errors in the Emergency Department Robin, J. K., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 861–863
• Know the Causes of Back Pain that Kill Patients Avoiding Common Errors in the Emergency Department Kassel, M., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 412–414
• Chest Ultrasound for Pneumothorax (Appendix) An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department Williams, S. R., Gharahbaghian, L. Mahadevan & Garmel (eds); Cambridge University Press. 2012; 2
• Ultrasound Evaluation for Abdominal Aortic Aneurysm (Appendix) An Introduction to Clinical Emergency Medicine: Guide for Practitioners in the Emergency Department Williams, S. R., Gharahbaghian, L. Mahadevan & Garmel (eds), Cambridge University Press. 2012; 2
• Just the Facts: Emergency Ultrasound Applications (Appendix) An Introduction to Clinical Emergency Medicine Williams, S. R., Gharahbaghian, L. Mahadevan SV, Garmel GM (eds): Cambridge University Press. 2012; 2
• Do Not Assume that Synovial Fluid Analysis in 100% Accurate the Diagnosis of Septic Arthritis Avoiding Common Errors in the Emergency Department Baine, J., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 407–408
• Where is the fetal heartbeat? Pearls and Pitfalls for Bedside Ultrasound in Early Pregnancy Avoiding Common Errors in the Emergency Department Lin, B., Gharahbaghian, L. Lippincott Williams & Wilkins. 2012; 1: 852–854
• Unilateral facial swelling with fever. Parotitis. Annals of emergency medicine Grover, C. A., Gharahbaghian, L. 2011; 58 (6): e5-6

  View details for DOI 10.1016/j.annemergmed.2011.06.017

  View details for PubMedID 22099003

• Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Academic emergency medicine Fox, J. C., Boysen, M., Gharahbaghian, L., Cusick, S., Ahmed, S. S., Anderson, C. L., Lekawa, M., Langdorf, M. I. 2011; 18 (5): 477-482

  Abstract

  Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT.This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery.The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%).In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

  View details for DOI 10.1111/j.1553-2712.2011.01071.x

  View details for PubMedID 21569167

• Test Characteristics of Focused Assessment of Sonography for Trauma for Clinically Significant Abdominal Free Fluid in Pediatric Blunt Abdominal Trauma ACADEMIC EMERGENCY MEDICINE Fox, J. C., Boysen, M., Gharahbaghian, L., Cusick, S., Ahmed, S. S., Anderson, C. L., Lekawa, M., Langdorf, M. I. 2011; 18 (5): 476-481

  Abstract

  Focused assessment of sonography in trauma (FAST) has been shown useful to detect clinically significant hemoperitoneum in adults, but not in children. The objectives were to determine test characteristics for clinically important intraperitoneal free fluid (FF) in pediatric blunt abdominal trauma (BAT) using computed tomography (CT) or surgery as criterion reference and, second, to determine the test characteristics of FAST to detect any amount of intraperitoneal FF as detected by CT.This was a prospective observational study of consecutive children (0-17 years) who required trauma team activation for BAT and received either CT or laparotomy between 2004 and 2007. Experienced physicians performed and interpreted FAST. Clinically important FF was defined as moderate or greater amount of intraperitoneal FF per the radiologist CT report or surgery.The study enrolled 431 patients, excluded 74, and analyzed data on 357. For the first objective, 23 patients had significant hemoperitoneum (22 on CT and one at surgery). Twelve of the 23 had true-positive FAST (sensitivity = 52%; 95% confidence interval [CI] = 31% to 73%). FAST was true negative in 321 of 334 (specificity = 96%; 95% CI = 93% to 98%). Twelve of 25 patients with positive FAST had significant FF on CT (positive predictive value [PPV] = 48%; 95% CI = 28% to 69%). Of 332 patients with negative FAST, 321 had no significant fluid on CT (negative predictive value [NPV] = 97%; 95% CI = 94% to 98%). Positive likelihood ratio (LR) for FF was 13.4 (95% CI = 6.9 to 26.0) while the negative LR was 0.50 (95% CI = 0.32 to 0.76). Accuracy was 93% (333 of 357, 95% CI = 90% to 96%). For the second objective, test characteristics were as follows: sensitivity = 20% (95% CI = 13% to 30%), specificity = 98% (95% CI = 95% to 99%), PPV = 76% (95% CI = 54% to 90%), NPV = 78% (95% CI = 73% to 82%), positive LR = 9.0 (95% CI = 3.7 to 21.8), negative LR = 0.81 (95% CI = 0.7 to 0.9), and accuracy = 78% (277 of 357, 95% CI = 73% to 82%).In this population of children with BAT, FAST has a low sensitivity for clinically important FF but has high specificity. A positive FAST suggests hemoperitoneum and abdominal injury, while a negative FAST aids little in decision-making.

  View details for DOI 10.1111/j.1553-2712.2011.01071.x

  View details for Web of Science ID 000290579700004

• THE EFFECT OF EMERGENCY DEPARTMENT OBSERVATIONAL EXPERIENCE ON MEDICAL STUDENT INTEREST IN EMERGENCY MEDICINE JOURNAL OF EMERGENCY MEDICINE Gharahbaghian, L., Hindiyeh, R., Langdorf, M. I., Vaca, F., Anderson, C. L., Kahn, J. A., Wiechmann, W., Lotfipour, S. 2011; 40 (4): 458-461

  Abstract

  In many different health care educational models, shadowing, or observational experience, is accepted as integral to introducing students to the specifics of medical specialties.We investigated whether emergency department (ED) observational experiences (EDOs) affect medical students' (MSs') interest in emergency medicine (EM). Additionally, we examined how the subjective quality of clinical exposures influences this interest and the decision to recommend EDOs to other students.This is a survey of MSs at a Level 1 tertiary care university hospital during a 2-year period. The study focused on assessing perception of ED exposure, post-EDO change in EM interest, and decision to recommend EDOs to others.The majority of MSs had a change in EM interest post-EDO and recommended EDOs. Both variables correlated to ED exposure ratings.The EDO significantly influenced MS interest in EM by providing exposure to various aspects of the ED.

  View details for DOI 10.1016/j.jemermed.2010.02.020

  View details for Web of Science ID 000289828600024

  View details for PubMedID 20381989

• Patellar tendonitis. The western journal of emergency medicine Zaia, B., Gharahbaghian, L. 2011; 12 (1): 139-140

  View details for PubMedID 21691492

• Cardiac tamponade after minimally invasive coronary artery bypass graft. The western journal of emergency medicine Liang, E. C., Rossi, J., Gharahbaghian, L. 2011; 12 (1): 116-117

  View details for PubMedID 21691484

  View details for PubMedCentralID PMC3088387

• Out-Of-Hospital Evaluation of Effusion, Pneumothorax, and Standstill: EMS and Point-Of-Care Ultrasonography Conference on American-College-of-Emergency-Physicians-Research-Forum PIEROG, J. E., Zaia, B. E., Bhat, S. R., Johnson, D. A., Gharahbaghian, L., Gilbert, G. H., Williams, S. R. MOSBY-ELSEVIER. 2010: S115–S115

  View details for Web of Science ID 000281438000356

• Use of Cadaver Models In Point-Of-Care Emergency Ultrasonography Education for Diagnostic and Procedural Applications Conference on American-College-of-Emergency-Physicians-Research-Forum Zaia, B. E., BRIESE, B., Gharahbaghian, L., Williams, S. R. MOSBY-ELSEVIER. 2010: S98–S98

  View details for Web of Science ID 000281438000298

• Methemoglobinemia and sulfhemoglobinemia in two pediatric patients after ingestion of hydroxylamine sulfate. The western journal of emergency medicine Gharahbaghian, L., Massoudian, B., DiMassa, G. 2009; 10 (3): 197-201

  Abstract

  This case report describes two pediatric cases of immediate oxygen desaturation from methemoglobinemia and sulfhemoglobinemia after one sip from a plastic water bottle containing hydroxylamine sulfate used by a relative to clean shoes. Supplemental oxygen and two separate doses of methylene blue given to one of the patients had no effect on clinical symptoms or pulse oximetry. The patients were admitted to the pediatric Intensive Care Unit (ICU) with subsequent improvement after exchange transfusion. Endoscopy showed ulcer formation in one case and sucralafate was initiated; both patients were discharged after a one-week hospital stay.

  View details for PubMedID 19718385

• Clitoral priapism with no known risk factors. The western journal of emergency medicine Gharahbaghian, L. 2008; 9 (4): 235-237

  Abstract

  Clitoral priapism is a rare condition that is associated with an extended duration of clitoral erection due to local engorgement of clitoral tissue resulting in pain. Although the pathophysiology is not completely understood, it has been associated with specific classes of medications, diseases that alter clitoral blood flow or others associated with small to large vessel disease. We present a case report of a 26-year-old patient who developed clitoral priapism without a clear medication or disease related etiology. The patient was treated with opiates, imipramine, non-steroidal anti-inflammatory medication, and local ice packs. She recovered uneventfully.

  View details for PubMedID 19561754

• Welcome to the Resident/Student/Fellow Section of WestJEM! The western journal of emergency medicine Gharahbaghian, L. 2008; 9 (1): 46-?

  View details for PubMedID 19561703

• Biliary Ultrasound CLINICAL EMERGENCY RADIOLOGY Scruggs, W., Gharahbaghian, L., Fox, J. C. 2008: 218–35

  View details for DOI 10.1017/CBO9780511551734.014

  View details for Web of Science ID 000312297500014

• Biliary Ultrasound Clinical Emergency Radiology Scruggs, W., Gharahbaghian, L., Fox, J. C. Cambridge University Press. 2008; 1
• Welcome to the Resident/Fellow/Student Section. Western Journal of Emergency Medicine Gharahbaghian, L. 2008; 9 (4)
• . Central Diabetes Insipidus Misdiagnosed as Acute Gastroenteritis in a Pediatric Patient: a Case Report. Canadian Journal of Emergency Medicine Gharahbaghian, L., McCoy, C., Lotfipour, S., Langdorf, M. 2008; April
• New Onset Thyrotoxicosis Presenting as Vomiting, Abdominal Pain and Transaminitis in the Emergency Department: a Case Report. Western Journal of Emergency Medicine Gharahbaghian, L., Brosnan, D., Fox JC., Stratton, S., Langdorf, M. 2007; 8 (3)
• Sarin and Other Nerve Agents of the Organophosphate Class: Properties, Medical Effects and Management. International Journal of Disaster Medicine Gharahbaghian, L., Bey, T. 2003; 2: 103-108
• Survival After Ethylene Glycol Poisoning in a Patient With an Arterial pH of 6.58 Veterinary and Human Toxicology Bey, T., Walter, F., Gilby, R., James, S.T., Gharahbaghian, L. 2002