AEM Education and Training 13: Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient‐centered Empathy in Emergency Care

Welcome to the thirteenth episode of AEM Education and Training, a podcast collaboration between the Academic Emergency Medicine E&T Journal and Brown Emergency Medicine. Each quarter, we'll give you digital open access to AEM E&T Articles or Articles in Press, with an author interview podcast and links to curated supportive educational materials for EM learners and medical educators.

Find this podcast series on iTunes here.


Coming in Warm: Qualitative Study and Concept Map to Cultivate Patient‐centered Empathy in Emergency Care. Katie E. Pettit MD Nicholas A. Rattray PhD Hao Wang MD, PhD Shanna Stuckey MS D. Mark Courtney MD, MSCI Anne M. Messman MD Jeffrey A. Kline MD



Katie Pettit, MD

Assistant Professor of Clinical Emergency Medicine

Associate Program Director, Emergency Medicine Residency Program

Indiana University School of Medicine



Increased empathy may improve patient perceptions and outcomes. No training tool has been derived to teach empathy to emergency care providers. Accordingly, we engaged patients to assist in creating a concept map to teach empathy to emergency care providers.


We recruited patients, patient caretakers and patient advocates with emergency department experience to participate in three separate focus groups (n = 18 participants). Facilitators guided discussion about behaviors that physicians should demonstrate to rapidly create trust; enhance patient perception that the physician understood the patient's point of view, needs, concerns, and fears; and optimize patient/caregiver understanding of their experience. Verbatim transcripts from the three focus groups were read by the authors, and by consensus, five major themes with 10 minor themes were identified. After creating a codebook with thematic definitions, one author reviewed all transcripts to a library of verbatim excerpts coded by theme. To test for inter‐rater reliability, two other authors similarly coded a random sample of 40% of the transcripts. Authors independently chose excerpts that represented consensus and strong emotional responses from participants.


Approximately 90% of opinions and preferences fell within 15 themes, with five central themes: provider transparency, acknowledgment of patient's emotions, provider disposition, trust in physician, and listening. Participants also highlighted the need for authenticity, context, and individuality to enhance empathic communication. For empathy map content, patients offered example behaviors that promote perceptions of physician warmth, respect, physical touch, knowledge of medical history, explanation of tests, transparency, and treating patients as partners. The resulting concept map was named the “Empathy Circle.”


Focus group participants emphasized themes and tangible behaviors to improve empathy in emergency care. These were incorporated into the Empathy Circle, a novel concept map that can serve as the framework to teach empathy to emergency care providers.

AEM Early Access 26: The Yield of Computed Tomography of the Head Among Patients Presenting With Syncope: A Systematic Review

Welcome to the twenty-sixth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

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The Yield of Computed Tomography of the Head Among Patients Presenting With Syncope: A Systematic Review. J. Alexander Viau, MA, BMBS, Hina Chaudry, MBBS, EMBA, Ailish Hannigan, PhD, Mish Boutet, MIS, Muhammad Mukarram, MBBS, MPH, and Venkatesh Thiruganasambandamoorthy, MBBS, MSc

LISTEN NOW: AUTHOR INTERVIEW WITH J. Alexander Viau, MA, BMBS and Venkatesh Thiruganasambandamoorthy CCFP-EM, M.Sc

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Venkatesh Thiruganasambandamoorthy CCFP-EM, M.Sc

Associate Professor, Dept. of Emergency Medicine, and School of Epidemiology and Public Health

Scientist, Ottawa Hospital Research Institute

New Investigator, Heart and Stroke Foundation Canada

Staff Attending Physician, The Ottawa Hospital

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J. Alexander Viau, MA, BMBS

Emergency Medicine Resident

University of Ottawa


Background: Overuse of head computed tomography (CT) for syncope has been reported. However, there is no literature synthesis on this overuse. We undertook a systematic review to determine the use and yield of head CT and risk factors for serious intracranial conditions among syncope patients.

Methods: We searched Embase, Medline, and Cochrane databases from inception until June 2017. Studies including adult syncope patients with part or all of patients undergoing CT head were included. We excluded case reports, reviews, letters, and pediatric studies. Two independent reviewers screened the articles and collected data on CT head use, diagnostic yield (proportion with acute hemorrhage, tumors or infarct), and risk of bias. We report pooled percentages, I2, and Cochran’s Q-test.

Results: Seventeen articles with 3,361 syncope patients were included. In eight ED studies (n = 1,669), 54.4% (95% confidence interval [CI] = 34.9%–73.2%) received head CT with a 3.8% (95% CI = 2.6%–5.1%) diagnostic yield and considerable heterogeneity. In six in-hospital studies (n = 1,289), 44.8% (95% CI = 26.4%–64.1%) received head CT with a 1.2% (95% CI = 0.5%–2.2%) yield and no heterogeneity. In two articles, all patients had CT (yield 2.3%) and the third enrolled patients ≥ 65 years old (yield 7.7%). Abnormal neurologic findings, age ≥ 65 years, trauma, warfarin use, and seizure/stroke history were identified as risk factors. The quality of all articles referenced was strong.

Conclusion: More than half of patients with syncope underwent CT head with a diagnostic yield of 1.1% to 3.8%. A future large prospective study is needed to develop a robust risk tool.

An Open-and-Shut Case? Diagnosis and Management of Open Fractures in the Emergency Department


A 53 year-old woman with no past medical history stepped out of the house to walk her dog when she slipped on the icy front stairs. She noted immediate pain and an obvious deformity of her right ankle, but denied head strike, loss of consciousness, or other symptoms.

On physical exam, the there was appreciable skin tenting over the ankle deformity, as well as a nearby abrasion across her lateral malleolus. She was neurovascularly intact, but the ankle was immediately reduced, due to skin tenting. She thinks she remembered scraping the ankle while on the ground but was not positive about that fact. With the reduction performed, the next step was to determine if the fracture was open or not...


An open fracture occurs when a fracture site communicates with the outside environment. Open fractures have much higher rates of infection, up to 25%, depending on a number of factors. The most important way to reduce infection rate is early administration of antibiotics, so prompt identification of an open fracture is crucial.[1]

Another consideration with open fractures is to remember that compartment syndrome is still possible, despite the soft tissue disruption. One study found that, among patients with open tibial fractures, the rate of compartment syndrome was 9.1%.[2], although tibial fractures tend to develop compartment syndrome more often than other locations, so the rates associated with other sites is likely lower.

Interestingly, the majority of open fractures occur with low energy mechanisms.[3] The most common mechanism is crush injury, followed by ground-level falls and motor vehicle crashes. There is also a bi-modal distribution with most high-energy open fractures occurring in young males and most low-energy injuries occurring in elderly females. Finger phalanges are the most common sites, followed by the tibia and distal radius.

Generally, the worse the open fracture, the higher the rate of infection.[4] Fractures are graded on a number of scales, but the most commonly used is the Gustilo Classification, which correlates with infection rate:

Gustilo Classification

Fracture type Definition Infection rate (%)

Wound <1 cm; minimal contamination,
comminution and soft-tissue damage


II Wound >1 cm; moderate soft-tissue
damage, minimal periosteal stripping


III A Severe soft-tissue damage and substantial
contamination; coverage adequate


III B Severe soft-tissue damage and substantial
contamination; coverage inadequate


III C Arterial injury requiring repair


Other factors that increase the rate of infection include the bacterial contamination[5], diabetes[6], age > 80, tobacco use, location of the fracture, malignancy, and immunocompromised state[7].



Some open fractures are easy to diagnose, but many will be more subtle. For injuries unrelated to the joint, copious irrigation and cleaning of the site, followed by sterile probing is the standard of care.

A potential traumatic arthrotomy, or open joint, has historically been diagnosed with a saline load test (SLT). The amount of fluid necessary to achieve 95% sensitivity varies by joint, but the most common are:

  • 155 mL for knees[8]

  • 55 mL for ankles[9]

  • 40 mL for elbows[10]

  • 7 mL for wrists[11]

Emerging evidence, though, is supporting heavier reliance on advanced imaging to diagnose traumatic arthrotomy. One study found 100% sensitivity and specificity for finding air in potentially open knees using computed tomography[12], compared to 92% when SLT was performed on this same group of patients. Meta-analyses show that more research is needed into both SLT as well as using CT imaging for the diagnosis of traumatic arthrotomy[13].


In addition to standard treatment for a fracture (analgesia, immobilization, neurovascular exam etc.), open fractures warrant:

  • Immediate antibiotics (first generation cephalosporin)

  • Orthopedic surgery consult

  • Irrigation and debridement

  • Tetanus prophylaxis

Antibiotics within 3 hours of injury have been associated with a six-fold decrease in infection, so early administration is critical. For irrigation and debridement, one study recommended very low pressure sterile saline irrigation, as re-operation rates were no higher when comparing the low pressure and high pressure groups.[1]

Case Conclusion

After reducing the patient’s ankle, the emergency department provider probed the patient’s soft tissue injury but was unable to track to bone. Was this simply an abrasion from the ice? Could it be skin breakdown secondary to the swelling? Was it an injury from a fracture fragment?

The orthopedic surgery team evaluated the patient and were also unsure whether or not the wound communicated with the fracture site. In fact, this is a relatively common situation, as the injury has time to clot, the bones have shifted, and full wound exploration in the emergency department is difficult.

In this case, the injury was treated as an open fracture and the patient was immediately given antibiotics. She was admitted to the hospital to undergo a thorough washout and debridement in the operating room.

Take Away Points

  • When in doubt, treat a fracture with associated soft tissue injury as open

  • Use antibiotics as soon as possible

  • Do not discount the mechanism, as most open fractures occur from low energy injuries

  • Compartment syndrome is still possible

  • If you see air in the joint on imaging, it is an open fracture

Faculty Reviewer: Dr. Jeffrey Feden


  1. FLOW Investigators. A trial of wound irrigation in the initial Management of Open Fracture Wounds. N Engl J Med. 2015;373:2629–41.

  2. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA: Compartment syndrome in open tibial fractures. J Bone Joint Surg Am 1986;68: 1348-1353.

  3. Court-Brown CM, Bugler KE, Clement ND, Duckworth AD, McQueen MM. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012; 43(6):891–7.

  4. Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006;88:2739–48.

  5. Merritt K. Factors increasing the risk of infection in patients with open fractures. J Trauma 1988; 28: 823–7. doi:

  6. Lavery LA, Walker SC, Harkless LB, et al. Infected puncture wounds in diabetic and nondiabetic adults. Diabetes Care 1995;18(12):1588–91.

  7. Bowen TR, Widmaier JC: Host classification predicts infection after open fracture. Clin Orthop Relat Res 2005;433:205-211.

  8. Nord R.M., Quach T., Walsh M., Pereira D., Tejwani N.C. Detection of traumatic arthrotomy of the knee using the saline solution load test. J Bone Jt Surg Am Vol. 2009;91(1):66–70.

  9. Bohl DA, Frank RA, Lee SI, Hamid KA, Holmes GE, Lin JO. Sensitivity of the Saline Load Test for Traumatic Arthrotomy of the Ankle With Ankle Arthroscopy Simulation. Foot & Ankle International Vol. 39; 39(6):736-740.

  10. Feathers T., Stinner D., Kirk K. Effectiveness of the saline load test in diagnosis of traumatic elbow arthrotomies. J Trauma. 2011;71(5):E110–E113.

  11. Gittings DJ, Fryhofer GW, Hast MW, Steinberg DR, Levin LS, Gray BL. The Saline Load Test is Effective at Diagnosing Traumatic Arthrotomies of the Wrist. Tech Hand Up Extrem Surg. doi: 10.1097/BTH.0000000000000233.

  12. Konda S.R., Davidovitch R.I., Egol K.A. Computed tomography scan to detect traumatic arthrotomies and identify periarticular wounds not requiring surgical intervention: an improvement over the saline load test. J Orthop Trauma. 2013;27(9):498–504.

  13. Browning BB, Ventimiglia AV, Dixit A, et al. Does the saline load test still have a role in the orthopaedic world? A systematic review of the literature. Acta Orthop Traumatol Turc 2016;50:597–600.doi:10.1016/j.aott.2016.01.004.