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Introduction: Emergency department (ED) crowding and hospital diversion times are increasing nationwide, with negative effects on patient safety and an association with increased mortality. Crowding in referral centers makes transfer of complex or critical patients by rural emergency physicians (EP) more complicated and difficult. We present a case requiring an unorthodox transfer method to navigate extensive hospital diversion and obtain life-saving neurosurgical care. Case Report: We present the case of a previously healthy 21-year-old male with two hours of headache and rapid neurologic decompensation en route to and at the ED. Computed tomography revealed obstructive hydrocephalus recognized by the EP, who medically managed the increased intracranial pressure (ICP) and began the transfer process for neurosurgical evaluation and management. After refusal by six referral centers in multiple states, all of which were on diversion, the EP initiated an unorthodox transfer procedure to the institution at which he trained, ultimately transferring the patient by air. Bilateral external ventricular drains were placed in the receiving ED, and the patient ultimately underwent neurosurgical resection of an obstructive colloid cyst. Conclusion: First, our case illustrates the difficulties faced by rural EPs when attempting to transfer critical patients when large referral centers are refusing transfers and the need for improvements in facilitating timely transfers of critically ill, time-sensitive patients. Second, EPs should be aware of colloid cysts as a rare but potentially catastrophic cause of rapid neurologic decline due to increased ICP, and the ED management thereof, which we review. [ABSTRACT FROM AUTHOR]

A greater number of patients aged 90 and over will become candidates for total hip arthroplasty (THA) as the nonagenarian population continues to grow. This study evaluated the patient characteristics and incidence of postoperative morbidity and mortality of 183 nonagenarian THA patients among 43,543 primary THA patients followed by a total joint replacement registry. Nonagenarians had a greater number of comorbidities preoperatively, experienced a higher one year mortality and had a longer hospital length of stay. However, nonagenarians did not have an increased risk of infection, deep vein thrombosis or pulmonary embolism and postoperative mortality was within expected rates for individuals 90 years and older. Higher readmission rates, however, highlight the benefits of close follow up during a prolonged postoperative period. [ABSTRACT FROM AUTHOR]

As the nonagenarian patient population continues to grow, more patients aged 90 and over will become candidates for total knee arthroplasty (TKA). This study evaluated the patient characteristics and incidence of postoperative morbidity and mortality of 216 nonagenarian TKA patients among 81,835 primary TKA patients followed by a total joint replacement registry. Nonagenarians had a greater number of comorbidities preoperatively, experienced a higher rate of deep vein thrombosis and 30 day mortality, and had a longer hospital length of stay. However, nonagenarians did not have an increased risk of infection nor pulmonary embolism and postoperative mortality was within expected rates for individuals 90 years and older. Higher readmission rates, however, highlight the benefits of close follow up during a prolonged postoperative period. [ABSTRACT FROM AUTHOR]