The emergency department care of hemodialysis patients.

AIMS: To describe the emergency department (ED) presentation, evaluation and disposition of maintenance hemodialysis (HD) patients. MATERIALS AND METHODS: A retrospective review of adult HD patients seen 1/1-12/31/97. The following was collected: demographics, mode of arrival, chief complaint, etiology of renal failure, evaluation, treatment, disposition, length of stay and facility charges. During the study period, this tertiary care ED had an annual adult census of 45,000. No clinical pathways were in place. RESULTS: 143 patients made 355 visits: 351 charts were available. Mean patient age was 51 (range 20-86), 62% were male, 51% were white. 70% presented from home, 26% from dialysis. EMS transported 32%. Medicare insured 78%. Etiologies of renal failure included hypertension (33%), diabetes (27%), HIV (7%) and glomerulonephritis (8%). Complaints were related to infection (18%), dyspnea (17%), vascular access (16%). chest pain or dysrhythmia (15%) and gastrointestinal complaints (12%). ED evaluation included CBC (79%), electrolytes (75%), CXR (57%) and EKG (48%). Antibiotics were administered to 21%. HD was performed earlier than scheduled in 14%. Two hundred and eighteen patients (62%) were admitted (ICU 11%, telemetry 22%), 19 (5%) refused admission and 2 expired in the ED. The average hospital length of stay was 7.8 days (range 1-59), with 29% hospitalized more than 1 week, compared to 6.54 days for non-HD patients. The mean facility charge for admitted subjects was $14,758, while the average cost for non-HD admissions was $7,152. Of the 133 patients (38%) who were discharged directly from the ED, the mean length stay was 223 minutes (range 30 to 750) and the mean charge was $658. The mean length of stay for non-HD patients was 124 minutes. CONCLUSION: The ED evaluation of adult HD patients involves multiple diagnostic modalities, and patients are usually admitted. The admit rate, ED length of stay for discharged patients and hospital charges for care were substantially higher in the HD patients than in the general population. Further research in the ED care of these complex patients should be undertaken.

Comparison of capillary and venous glucose measurements in healthy volunteers.

BACKGROUND: Out-of-hospital (OOH) emergency personnel measure serum glucose in order to determine the need for dextrose therapy. Most devices that measure serum glucose are designed to use capillary blood obtained from a finger puncture. However, OOH emergency personnel often use venous blood obtained during intravenous line (IV) placement to determine serum glucose. OBJECTIVE: To compare capillary and venous glucose measurements. METHODS: This prospective study used healthy, non-fasting volunteers. Simultaneous venous and capillary blood samples were obtained from each subject. Glucose levels were measured using a glucometer designed for capillary samples. The capillary and venous measurements were compared using a Pearson correlation coefficient. Power analysis revealed that the study had the ability to detect a difference of 15 mg/dL. RESULTS: Ninety-seven volunteers (56 males, 41 females) with a mean age of 37 +/- 11.9 years were enrolled. The mean capillary and venous glucose values were 104.5 +/- 20.7 mg/dL and 109.7 +/- 22.4 mg/dL, respectively. The Pearson correlation coefficient was 0.24. CONCLUSIONS: The correlation between venous and capillary blood glucose measurements is relatively poor in this group of healthy volunteers. Further research must be conducted on patients at risk for abnormal blood glucose.

Education of paramedics regarding aspirin use.

OBJECTIVE: Paramedics (EMT-Ps) often care for patients having an acute myocardial infarction (AMI). The benefit of early administration of aspirin in AMI is well established. This study was undertaken to determine whether EMT-Ps are able to retain information regarding the use of aspirin in AMI after a standard didactic session. METHODS: The EMT-Ps from a suburban EMS system with an annual call volume of 4,000 were given a 12-question test regarding the out-of-hospital use of aspirin in AMI. They then received a 30-minute lecture about the use of aspirin in the out-of-hospital venue. Aspirin was then put into the treatment protocols for AMI. Three months after the educational session, a follow-up test was administered. A paired, two-tailed t-test was used to compare pretest and posttest scores with a p < or = 0.05 for statistical significance. RESULTS: The study was completed by 22 of 25 EMT-Ps. The scores on the pretest ranged from 50% to 100% correct, with an average score of 83%. The posttest scores ranged from 83% to 100%, with an average score of 94% (p = 0.002). The questions missed on the posttest were regarding: 1) the length of the effects of aspirin, 2) the bronchospastic effects of aspirin, and 3) the recently instituted indications for its out-of-hospital use. All paramedics correctly identified the contraindications to aspirin use. CONCLUSION: These results suggest that EMT-Ps can retain information regarding the out-of-hospital use of aspirin for AMI after a standard didactic session. Further study is needed to determine how this information is clinically applicable.

Managed care enrollee utilization of 911 medical services.

OBJECTIVE: To determine the mechanism by which managed care organization (MCO) enrollees enter the emergency medical services (EMS) system. METHODS: All enrollees belonging to the region's largest MCO and transported to emergency departments by a paramedic-level municipal EMS system were identified from billing records. Dispatch logs were examined to determine the time and origin of the call to the 911 communication center. Patient care records were used to obtain age, the level of care delivered (advanced or basic life support), and whether the patient received any medications while out of hospital. Hospital admission was also determined. RESULTS: Over a six-month period, 195 enrollees were transported. Three modes of 911 EMS system entry were identified: group I-enrollees who called 911 directly; group II-enrollees who called the MCO triage center, who then called 911 on behalf of the patient; and group III--enrollees who were sent to the MCO health center for evaluation, and subsequently the MCO called 911 to transfer the patient to the hospital. Of the 195 patients transported to the emergency department, the dispositions of 108 (55%) patients were obtained. Group I (n = 109) patients were more likely to be transported in the evening (3 PM to 11 PM), less likely to require advanced life support therapies, and less likely to be admitted to the hospital when compared with groups II (n = 32) and III (n = 54) patients. Group III patients were the most likely to receive advanced life support care and require admission to the hospital. CONCLUSION: The majority of MCO enrollees called 911 directly, and were most likely to do so during evening hours. Enrollees who called 911 directly (group I) had a trend toward lower acuity, based on the lowest ALS utilization of any group. Those enrollees who most frequently required advanced life support were those who received initial treatment at the MCO center prior to EMS transport. Though EMS system-specific, this type of descriptive analysis is helpful in assisting both EMS systems and MCOs to better assess utilization of 911 EMS resources by MCO enrollees. This study also challenges the prudent layperson paradigm.

EMS systems: foundations for the future.

Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as out-of-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.

Do patients receive adequate pain control after discharge from the ED?

Studies on the effectiveness of pain management have uniformly concluded that health care providers underestimate or undertreat pain. In the emergency department (ED) in which this study was conducted, physicians receive formal didactic and bedside teaching on pain recognition and management in order to heighten the awareness of patients' need for pain control. The purpose of this study was to determine if this outpatient pain management of patients with acute, painful conditions is better than that reported in the medical literature. In this prospective study, 110 adult patients who had an acute, painful diagnosis were telephoned 48 hours after discharge from the ED and asked if they felt their pain at home was well controlled. Patient satisfaction with pain control was higher (91%) than that reported in the medical literature. Also, pain medication was provided more frequently by this study's ED (95%). Education on pain awareness and treatment is a way to improve pain management.

Effectiveness of mechanical versus manual chest compressions in out-of-hospital cardiac arrest resuscitation: a pilot study.

A prospective, randomized effectiveness trial was undertaken to compare mechanical versus manual chest compressions as measured by end-tidal CO2 (ETCO2) in out-of-hospital cardiac arrest patients receiving advanced cardiac life support (ACLS) resuscitation from a municipal third-service, emergency medical services (EMS) agency. The EMS agency responds to approximately 6,700 emergencies annually, 79 of which were cardiac arrests in 1994, the study year. Following endotracheal intubation, all cardiac arrest patients were placed on 100% oxygen via the ventilator circuit of the mechanical cardiopulmonary resuscitation (CPR) device. Patients were randomized to receive mechanical CPR (TCPR) or human/manual CPR (HCPR) based on an odd/even day basis, with TCPR being performed on odd days. ETCO2 readings were obtained 5 minutes after the initiation of either TCPR or HCPR and again at the initiation of patient transport to the hospital. All patients received standard ACLS pharmacotherapy during the monitoring interval with the exception of sodium bicarbonate. CPR was continued until the patient was delivered to the hospital emergency department. Age, call response interval, initial electrocardiogram (ECG) rhythm, scene time, ETCO2 measurements, and arrest outcome were identified for all patients. Twenty patients were entered into the study, with 10 in each treatment group. Three patients in the TCPR group were excluded. Measurements in the HCPR group revealed a decreasing ETCO2 during the resuscitation in 8 of 10 patients (80%) and an increasing ETCO2 in the remaining 2 patients. No decrease in ETCO2 was noted in the TCPR group, with 4 of 7 patients (57%) actually showing an increased reading and 3 of 7 patients (43%) showing a constant ETCO2 reading. The differences in the ETCO2 measurements between TCPR and HCPR groups were statistically significant. Both groups were similar with regards to call response intervals, patient ages, scene times, and initial ECG rhythms. One patient in the TCPR group was admitted to the hospital but later died, leaving no survivors in the study. TCPR appears to be superior to standard HCPR as measured by ETCO2 in maintaining cardiac output during ACLS resuscitation of out-of-hospital cardiac arrest patients.

Injuries distracting from intraabdominal injuries after blunt trauma.

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Incidence of aspiration after urgent intubation.

This study sought to determine the incidence of aspiration after urgent endotracheal intubation (ET) performed in the emergency department (ED), and to offer a descriptive evaluation of these intubations. In a retrospective review of 133 charts, 87 patients met inclusion criteria. Aspiration occurred in 3 (3.5%) patients (95% confidence interval, 0%, 7.4%). One had witnessed aspiration, and 2 had positive sputum cultures. None of the 87 patients had a positive chest radiograph or unexplained hypoxemia up to 48 hours after ET. Rapid-sequence induction and oral ET was performed in 79 (91%) patients, whereas 4 spontaneously breathing patients were nasally intubated. Seventy percent of patients underwent ET by PGY I or II residents, 29% by PGY III or IV residents, and 1% by ED attending physicians. Seventy-seven patients were intubated on the first attempt, and airway blood or vomitus during ET was noted in 11 patients. This study offers significant descriptive information regarding urgent ET performed in the ED, and shows that aspiration after urgent ET occurs infrequently in ED patients.

The impact of prehospital physicians on out-of-hospital nonasystolic cardiac arrest.

OBJECTIVE: To determine whether the presence of an on-scene medical control physician (OSMCP) alters the management and outcome of out-of-hospital nontraumatic, nonasystolic cardiac arrest (CA) patients. METHODS: This was a retrospective case series of CA patients who were cared for in an all advanced life support, third-service, municipal emergency medical services (EMS) system over a one-year period. Excluded from the study were all traumatic CA patients and solely asystolic patients. The remaining CA patients were divided into the two study groups according to the presence of an OSMCP or whether they were cared for by paramedics only (PO). For each group patient age, EMS response time, the number of personnel on the scene, the presence of bystander CPR, the initial cardiac rhythm, and scene time were determined. In addition, time to first defibrillation for patients in ventricular fibrillation, the rate of drug administrations per minute, the return of spontaneous circulation (ROSC) on emergency department (ED) arrival, and survival to hospital discharge were collected for each group. RESULTS: Eighty CA runs were reviewed, with 49 meeting entry criteria; nine in the OSMCP group and 40 in the PO group. There was no difference between the groups with regard to patient age, response time, scene time, or number of personnel on the scene. The two groups were similarly matched with regard to initial cardiac rhythm, the presence of bystander or first-responder CPR, and time to first defibrillation. The number of drug dosages administered per minute was higher in the OSMCP group (0.62 doses per minute) as compared with the PO group (0.34 doses per minute)[p < 0.03]. ROSC and survival to hospital discharge revealed a nonsignificant tendency toward more frequent ROSC in the OSMCP group [p < 0.07], and a significantly higher incidence of survival to discharge in the OSMCP group [p < 0.009]. CONCLUSIONS: Out-of-hospital CA patients treated in the OSMCP group had a trend toward more frequent ROSC upon ED arrival and a higher rate of survival to hospital discharge. The OSMCP group patients received medications at nearly twice the rate of the PO group patients. Although a larger trial is needed, more frequent dosing of drugs during CA may have contributed to increased survival in the OSMCP group.

Anabolic steroid use as the possible precipitant of dilated cardiomyopathy.

Anabolic-androgenic steroid (AAS) use is common among young males, including adolescents. There have been several anecdotal reports of severe cardiovascular events in self-reported young users of AAS, including acute myocardial infarction, sudden cardiac death, and cardiomyopathy. We present an additional case of a young male weight lifter who presented with dyspnea and chest pain attributable to dilated cardiomyopathy (DC), his only known risk factor being the recent use of AAS. The possible role of AAS in the development of DC is discussed.

Managed care organizations: a link in the chain of survival?

Managed care organizations (MCOs) have proliferated throughout the United States. Interaction by patients, physicians, and emergency medical services systems with MCOs is evolving. Although MCOs have had some notable successes in reducing health care expenditures, the way in which MCO enrollees gain access to emergency medical care remains a contested issue. We present the cases of two patients who died after they delayed calling 911 in keeping with the rules of their MCO.

Patient refusal of care in the out-of-hospital setting.

A case vignette of out-of-hospital refusal of emergency care is reported with accompanying discussion. This case illustrates the challenges faced by out-of-hospital emergency care personnel in these scenarios and provides guidance to the emergency physician and emergency medical technician. Recommendations are provided for preparing the emergency medical services system to handle these cases.

Agreement between rectal and tympanic membrane temperatures in marathon runners.

STUDY OBJECTIVE: To determine the agreement between rectal temperature and infrared tympanic membrane temperatures in marathon runners presenting to a field hospital at the finish line. METHODS: The subjects of this prospective, blinded, controlled study were runners 18 years or older who were triaged to the acute care medical area at the finish line for suspected hypothermia, hyperthermia, dehydration, or altered mental status. Rectal and tympanic temperatures were measured simultaneously in all subjects for whom rectal temperature measurement had been deemed necessary and recorded on separate data cards. RESULTS: Of the 239 runners treated in the acute care medical area, 37 required rectal temperature measurement and were enrolled in the study. The mean rectal temperature was 38.45 degrees +/- 1.20 degrees C (range, 35.9 degrees to 41.5 degrees C). The mean tympanic membrane temperature was 37.81 degrees +/- 95 degrees C (range, 36.3 degrees to 40.4 degrees C). Pearson's correlation coefficient revealed a moderate correlation (r = .6902, P = .00023). The mean temperature difference between the two thermometers, mean rectal minus mean tympanic membrane, was .64 degrees C (95% confidence interval, .35 degrees to .93 degrees C). Sixty-Two percent of the tympanic membrane readings were within 1 degree C of their rectal counterparts. Agreement ranged from 1.16 degrees (+2 SD) to -2.95 degrees (-2 SD). The 95% confidence interval was 1.67 degrees to -2.95 degrees C. CONCLUSION: We were able to demonstrate only a moderate correlation between the two thermometer readings, with a wide spread between the limits of agreement. This spread could be clinically significant and therefore limits the usefulness of tympanic temperature in the marathon race setting. Because of the potentially large and clinically significant differences in rectal and tympanic temperatures and the limitations inherent in our study, we cannot endorse the use of tympanic temperature in the setting of a marathon event.

A retrospective review of positive chlamydial cultures in emergency department patients.

This study evaluated the accuracy of diagnosis and treatment of chlamydial infection based solely on clinical presentation in the emergency department (ED). The signs and symptoms of women with chlamydial infection confirmed by cervical culture were identified and compared between appropriately treated and nontreated groups to determine which clinical features tended to lead to the correct or incorrect diagnosis. The study also determined which signs and symptoms were consistently present in the entire study group. Two hundred thirty-three charts of female ED patients with positive cervical chlamydial cultures were obtained via computerized records from the microbiology lab and reviewed retrospectively. Only 20% of the patients were correctly diagnosed as having a sexually transmitted disease and only 24% were properly treated during their initial ED visit. Although abdominal pain and vaginal discharge were the most frequent symptom and sign, only 70% and 54% of all patients had these clinical manifestations, respectively. Patients with vaginal discharge and cervical motion tenderness were significantly (P < .01) more likely to be treated in the ED. Patients with urinary tract symptoms and pregnancy were significantly (P < .01) less likely to be treated in the ED. Cervical cultures should be performed during all pelvic examinations because of the variability in the clinical presentation of chlamydial infection. A follow-up system must be in place to identify positive cultures and locate patients to ensure appropriate treatment.

Model curriculum in emergency medical services for emergency medicine residency programs. SAEM Emergency Medical Services Committee.

An emergency medical services (EMS) curriculum, as developed by the SAEM Emergency Medical Services Committee, is provided for the training of emergency medicine residents in EMS.

Geriatric use of emergency medical services.

STUDY OBJECTIVE: To quantify use by geriatric patients of emergency medical services (EMS) compared with that by young adult patients. METHODS: We conducted a retrospective, consecutive case series over a 6-month period in a suburban, all-paramedic municipal EMS system serving 76,500 residents, of whom approximately 15% are 65 years of age or older and 33% are between 25 and 45 years old. Patient age, the sole entry criterion, was used to distinguish two groups: the young adult group, defined as patients 25 to 45 years old; and the geriatric group, defined as patients 65 years or older. RESULTS: Of the 2,712 patients whose cases were reviewed during the study period, 1,734 (65%) met the entry criterion. The geriatric group (n=1,043) accounted for 39% of the total call volume, compared with the young adult group (n=690), which accounted for 25% of total call volume. Patients in the young adult group were 7.3 times more likely to have been in a motor vehicle accident, whereas the GP group was 2.6 times more likely to have cardiorespiratory complaints, 1.8 times more likely to have fallen, and 1.7 times more likely to have minor medical problems requiring transportation and more frequently required advanced life support (ALS) care (54% versus 33%) (P<.001 for all comparisons). Scene times for geriatric patients were found to be longer than those for young adults (ALS, P<.001; basic life support [BLS], P<.05). However, costs billed to the patient were greater for young adults for all care rendered (BLS, P<.001; ALS, P<.05). CONCLUSION: Use by geriatric patients of EMS differed significantly from that by young adults. Geriatric patients used EMS more frequently and required more ALS care than did young adults. Although geriatric patients required longer scene times for EMS care, young adults incurred greater charges for service. These findings, although perhaps system specific, speak to the need for ongoing analysis of EMS health care delivery to better serve a population increasing in age.

Incorporating drugs and devices into emergency medical services systems.

The proliferation of new medical technology and pharmacology forces the medical community to ensure the efficacy and safety of new drugs and devices before their use in patient care. Although traditional medical practices have a fairly consistent means to achieve this end, prehospital medical practice often does not. In addition, it often appears that the emergency medical services marketplace does not always follow conventional supply/demand and cost/quality paradigms. This article describes a process implemented in Pennsylvania to standardize the mechanism by which new drugs and devices are introduced into prehospital medical practice.