Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city.

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.

Effect of nitric oxide on mitogenesis and proliferation of cerebellar glial cells.

In the brain, nitric oxide (NO) has been identified as a messenger molecule and a mediator of excitatory amino acid-induced neurotoxicity. In this study, the effects of NO on serum-induced mitogenesis and cell proliferation of the cerebellar glial cells were assessed. NO-generating agent, S-nitroso-N-acetylpenicillamine (SNAP) increased intracellular cyclic guanosine monophosphate (cGMP) levels. Furthermore, 2 chemically dissimilar NO-generating agents, SNAP and sodium nitroprusside (SNP) inhibited serum-induced thymidine incorporation and cell proliferation. The antimitogenic effect of NO was mimicked by 8-bromo-cGMP and blocked by hemoglobin, a known inhibitor of NO. The effect of NO was not cytotoxic, since the cells were not stained with Trypan blue and did not show increased release of lactate dehydrogenase in the culture supernatants. However, NO-treated cells showed decreased conversion of tetrazolium to blue formazan suggesting that NO inhibited mitochondrial activity in the glial cells. These results demonstrate that NO inhibits serum-induced mitogenesis and cell proliferation of cultured rat cerebellar glial cells.

Antagonism of acute cocaine toxicity by buprenorphine.

The effect of buprenorphine pretreatment on the acute cocaine toxicity was assessed in male Swiss Webster mice. Buprenorphine pretreatment (0.15 or 0.30 mg/kg ip, 30 mins before) significantly attenuated the lethal effects of cocaine (60-140 mg/kg ip). The dose of cocaine which resulted in 50% mortality (LD50) in saline pretreated group was 100.61 mg/kg while the LD50 of cocaine in buprenorphine (0.15 and 0.3 mg/kg) pretreated groups were 113.57 and 118.16 mg/kg respectively. There was no significant change in the ratio of brain/plasma levels of cocaine in buprenorphine pretreated group when compared to the ratio from saline treated controls. Furthermore, neither naloxone (10 mg/kg ip, 15 mins before) nor naltrexone (3 mg/kg ip, 15 mins before) pretreatment affected the LD50 of cocaine. When tested 0.5, 1, 2, 4, 8 and 24 hrs after cocaine administration, sublethal dose of cocaine (80 mg/kg ip) injection resulted in significant increase in the plasma lactate dehydrogenase (LDH) levels. Buprenorphine pretreatment significantly attenuated cocaine-induced release of LDH. These results suggest that buprenorphine could be of potential advantage over naloxone in the management of cocaine and heroin ("speed ball") toxicity and in studies on the pharmacotherapy of cocaine-induced toxicity, LDH levels may be used as a biochemical marker to assess the protective effects of drugs.

Assessment of visual acuity in the supine position.

OBJECTIVE: To determine whether a modified Snellen eye chart could be used to accurately assess visual acuity (VA) in the supine position. METHOD: This was a prospective study involving ED staff volunteers comparing VA on a standard Snellen eye chart with VA on a size-reduced ceiling-mounted modified Snellen eye chart. RESULTS: Fifty-six volunteers participated. VA ranged from 20/10 to 20/200 on both of the charts, but 87% of the volunteers had VA of 20/50 or better. The VA results for the 2 charts were highly correlated; right eye r = 0.931 and left eye r = 0.953. Weighted ks showed substantial agreement for both eyes; kappa = 0.63 and 0.79 for the right and left eyes, respectively. In only 4 of 112 paired measurements did the VA recorded with the ceiling chart differ by > 1 line from that recorded on the Snellen chart. CONCLUSION: There is an excellent correlation between VAs determined in the erect and the supine positions using the standard Snellen eye chart and the modified ceiling-mounted version. Substantial agreement exists between readings using the 2 charts. Although additional testing is warranted in an ophthalmologically diverse patient population, use of this chart for the assessment of VA in the supine ED patient may allow for earlier VA evaluation.

The effects of lidocaine pretreatment on cocaine neurotoxicity and lethality in mice.

OBJECTIVE: To evaluate the effects of an antiarrhythmic dose of lidocaine on cocaine-induced ataxia, seizures, and death in mice. METHODS: A randomized, controlled, blinded investigation was conducted using 220 female Swiss albino mice. Groups of 20 animals received intraperitoneal (IP) administration of either 31.6 mg/kg of lidocaine hydrochloride in 0.9% NaCl (ten animals) or an equal volume of 0.9% NaCl solution (ten animals). After 5 minutes, all the animals received IP cocaine in incremental doses ranging from 40 to 110 mg/kg. The animals were observed for ataxia, seizures, and death. The animals pretreated with lidocaine were compared with the control animals for the number of adverse effects from cocaine at each dose tested. RESULTS: Lidocaine significantly increased the overall incidences of cocaine-induced ataxia (p = 0.02) and seizures (p < 0.001). However, pretreatment with lidocaine offered protection against cocaine lethality (p < 0.0001). CONCLUSION: In this preexposure model, lidocaine protects mice against cocaine-induced lethality. These effects seem to be independent of convulsive activity. Further study is required to determine the safety and efficacy of lidocaine for the management of cocaine-induced arrhythmias.

Alcoholism in the emergency department: an epidemiologic study.

OBJECTIVE: To describe the epidemiology of alcoholism in ED patients. METHODS: Over a two-month period, every adult patient brought by ambulance to the ED of a large municipal hospital was prospectively enrolled by questionnaire. Data collected included demographics, previous ED use, triage complaint-related diagnoses, hospital admission rates, and ethanol levels (if determined). The CAGE alcoholism questions were administered to all patients by trained assistants. The only exclusion criterion was the inability to communicate while in the ED. A chi-square analysis was used to compare categorical variables. RESULTS: A total of 2,658 patients were enrolled in the study; 226 were unable to respond to the CAGE questions. Five hundred eighty-eight of the remaining 2,432 patients (24%) were defined as being alcoholic by an affirmative response to at least two of the CAGE questions. All four questions were answered affirmatively by 17% of the total patients. Alcoholic patients were more likely to be male (88% vs 60%), unemployed (87% vs 71%), undomiciled (46% vs 20%), polysubstance users (52% vs 25%), and tobacco users (77% vs 41%), and to have had an ED visit in the previous six months (51% vs 35%) (p < 0.001 for all tests). Ethanol levels ranged from zero to 573 mg/dL. Whereas no positive response to a single CAGE question was predictive of a final diagnosis of alcoholism, a blood ethanol level more than 300 mg/dL predicted an affirmative response to at least two CAGE questions in 97% of cases. CONCLUSIONS: Alcoholism should be presumed to be present in a substantial number of patients who present to urban EDs by ambulance.

A prospective evaluation of the electrocardiographic manifestations of hypothermia.

OBJECTIVE: To determine the effects of body temperature, ethanol use, electrolyte status, and acid-base status on the electrocardiograms (ECGs) of hypothermic patients. METHODS: Prospective, two-year, observational study of patients presenting to an urban ED with temperature < or =95 degrees F (< or =35 degrees C). All patients had at least one ECG obtained. Electrocardiograms were interpreted by a cardiologist blinded to the patient's temperature. J-point elevations known as Osborn waves were defined as present if they were at least 1 mm in height in two consecutive complexes. RESULTS: 100 ECGs were obtained in 43 patients. Presenting temperatures ranged between 74 degrees F and 95 degrees F (23.3 degrees C-35 degrees C). Initial rhythms included normal sinus (n = 34), atrial fibrillation (n = 8), and junctional (n = 1). Osborn waves were present in 37 of 43 initial ECGs. Of the six initial ECGs that did not have Osborn waves present, all were obtained in patients whose temperatures were > or =90 degrees F > or =32.2 degrees C). For the entire group, the Osborn wave was significantly larger as temperature decreased (p = 0.0001, r = -0.441). The correlation between temperature and size of the Osborn wave was strongest in six patients with four or more ECGs (range r = -0.644 to r = -0.956, p = 0.001). No correlation could be demonstrated between the height of the Osborn waves and the serum electrolytes, including sodium, chloride, potassium, bicarbonate, BUN, creatinine, glucose, anion gap, and blood ethanol levels. CONCLUSIONS: The presence and size of the Osborn waves in hypothermic patients appear to be a function of temperature. The magnitude of the Osborn waves is inversely correlated with the temperature.

Domestic abuse in the emergency department: can a risk profile be defined?

OBJECTIVES: The main purpose of this study was to determine whether any clinical or demographic characteristics could identify adult female patients presenting to the emergency department (ED) with a history of domestic abuse. A second objective was to describe the frequency, types, and severity of this abuse. METHODS: This study was a crosssectional survey of 611 women conducted in an academically-affiliated, urban ED. Domestic abuse was described as "recent" (within the preceding 12 months) or "lifetime" (recent or past). This included emotional, physical, and sexual abuse. RESULTS: Recent (7.9%, n = 48) and lifetime (38%, n = 232) domestic abuse was reported. For recently abused women, violence had been severe (87.5%, n = 42) and was associated with 1) trauma (OR 5.4, 95% CI = 2.6 to 11.6), 2) obstetrical and gynecological syndromes (OR 5.6, 95% CI = 2.4 to 13.2), and 3) psychiatric symptoms and substance use (OR 7.3, 95% CI = 2.4 to 22.0). The sensitivities and positive predictive values of these risk factors individually (<27.1% and <25.0%, respectively) and in aggregate (56.3% and 20.9%, respectively) were low. These indicators predicted only 27 (56.3%) of recently abused women. Lifetime domestic violence was more likely in homeless women (OR 5.8, 95% CI = 2.2 to 15.0), although less likely in immigrants (OR 0.4, 95% CI = 0.3 to 0.7). CONCLUSIONS: Clinical presentations and demographic characteristics of women presenting to the ED may not be sensitive or predictive indicators of domestic abuse. In the absence of typical clinical or demographic findings, asking all women in the ED about domestic abuse remains a necessary priority.

Current status of academic emergency medicine within academic medicine in the United States.

OBJECTIVE: To characterize the status of emergency medicine within U.S. academic medical centers. METHODS: All accredited emergency medicine residency programs and all four-year allopathic medical schools in the United States were identified. Institutions were defined as academic medical centers based upon NIH research grant funding. These institutions were ranked using five measures of academic stature: a survey of medical school deans, a survey of internal medicine residency directors, level of research funding, characteristics of the student body, and an unweighted composite variable reflecting overall academic stature. The relationship between institutional academic stature and an empiric scale of institutional affiliation with emergency medicine was assessed. RESULTS: Sixty-two institutions were designated academic medical centers. These medical schools captured 90% of all NIH grant monies awarded in fiscal year 1990. Twenty-six of 87 emergency medicine residency programs (30%) were closely affiliated with one of these medical schools. Within academic medical centers, the presence of a residency or an academic department of emergency medicine was inversely associated with the medical school deans' ranking (p < 0.005), research rank (p < 0.001), and composite academic rank (p < 0.001). CONCLUSION: The majority of emergency medicine residency programs (70%) are not closely affiliated with institutions receiving the bulk (90%) of NIH resources for research. Within the institutions receiving the majority of NIH funding, there is a quantitatively and statistically significant inverse association of institutional emergency medicine affiliation and institutional academic rank.

Herbal preparation use among urban emergency department patients.

OBJECTIVE: To determine the prevalence of herbal preparation use among patients presenting to an urban teaching hospital ED. METHODS: A prospective anonymous survey on herbal preparation use was performed. Consecutive, acutely ill or injured adult (> or = 18 years old) ED patients were offered the survey over a 1-month period. The survey also asked for information related to patient age, ethnicity, gender, employment, education, cigarette smoking history, ethanol consumption, use of illicit drugs, chief complaint, and HIV status. RESULTS: Of 2,473 eligible subjects, 623 (25%) participated. The overall reported prevalence of herbal preparation use among the participants was 21.7%. Women were more likely to use herbal preparations than men (28.5% vs 17.2%, p = 0.013). Prevalence rates in different ethnic populations were: whites, 18.2%; Hispanics, 13.9%; blacks, 26.4%; and Asians, 36.8%. Asians had a significantly higher use rate than the other ethnic groups (p = 0.039). Neither HIV positivity, educational level, employment status, nor age was significantly associated with herbal preparation use. The most commonly reported herbal preparations were goldenseal tea, garlic, and ginger. Several of the herbal preparations reported as used by patients in this study have been associated with severe systemic toxicity in the medical literature. CONCLUSION: Although the survey response rate was low, the prevalence of herbal preparation use among acutely ill or injured patients presenting to this urban ED remains significant. A directed history toward specific herbal preparation use may provide relevant pharmacologic information and uncover cases of herbal-preparation-induced toxicity.

Occupational exposures to blood among emergency medicine residents.

OBJECTIVES: To investigate the epidemiologic characteristics of potentially infectious occupational exposures to blood among emergency medicine (EM) residents. METHODS: A SAEM-sponsored multiple-choice survey was administered anonymously to all EM residents participating in the 1998 American Board of Emergency Medicine in-service examination. Survey questions included resident demographics, use of universal precautions, frequency and types of exposures to blood, and exposure reporting. Residents who experienced at least one exposure were then asked to complete an additional set of questions referring only to their latest exposure. Mean values were calculated for each variable and differences between groups were compared by chi-square analysis. RESULTS: Three thousand one hundred sixty-two surveys were distributed to the resident participants, and 2,985 surveys (94.4%) were returned. Of the participants, 56.1% reported at least one exposure to blood during their EM training. The frequency of this self-reported exposure increased with advancing EM level of training (43% EM-1, 58% EM-2, 64% EM-3, 76% EM-4, p<0.001). Of these residents, 36.6% always followed universal precautions, 54% frequently, and 9.4% sometimes, rarely, or never. Those individuals who "always" followed universal precautions reported significantly fewer exposures than those who did not (p<0.005). The latest exposures were most commonly caused by a solid needle or sharp object (39.4%), by a hollow-bore needle (30.6%), or by eye splashes (17.2%). Of these exposures, 71.7% occurred in the ED setting, and only 46.7% of these exposures were reported to health care providers. CONCLUSION: Emergency medicine residents are frequently exposed to blood, most commonly due to puncture injuries by sharp objects. The rate of exposure reporting is low, which may compromise appropriate postexposure counseling and prophylaxis.

Evaluation of the physician's ability to recognize the presence or absence of anemia, fever, and jaundice.

OBJECTIVE: The evaluation of the patient through a comprehensive history and physical examination is considered the cornerstone of medical diagnosis, but many studies suggest that physicians have inadequate physical examination skills. It is unknown whether these skills are reliable and whether they can be adequately acquired through training. The objective of this study was to evaluate the ability of the clinician to detect the presence and discriminate the extent of clinical anemia, fever, and jaundice in an ED or hospitalized patient. METHODS: This was a prospective observational study of a convenience sample of patients presenting to the ED or admitted to the hospital who had a rectal temperature measurement within 30 minutes prior to the observation, serum hematocrit measurement on the day of observation, or serum bilirubin measurement one day prior to the day of observation. Observers' (emergency medicine attending physicians', resident physicians', and rotating medical students') estimated serum hematocrit, rectal temperature, and serum bilirubin values were obtained after each observation. Sensitivity, specificity, positive predictive value, negative predictive value, and mean absolute difference between actual and estimated values were calculated for each observer. RESULTS: The physicians detected the presence or absence of anemia, fever, and jaundice in patients with sensitivities and specificities of approximately 70%. Their predictions varied from the measured value on average by 6.0 +/- 4.6% for serum hematocrit, 1.3 + 1.1 degrees F for rectal temperature, and 3.4 +/- 5.3 mg/dL for serum bilirubin. Observer accuracy decreased when evaluating patients with high and low measured values. CONCLUSIONS: The ability to correctly perform and interpret the physical examination appears to be independent of the observer level of training, patient ethnicity, or patient gender. The examination for pallor, warmth, and jaundice is unreliable in predicting the corresponding laboratory or electronic measurement. Certain anemic, febrile, or jaundiced patients may not be reliably detected solely by a focused physical examination.

A public health approach to emergency medicine: preparing for the twenty-first century.

This paper focuses on the implications of an inadequate public health/preventive health care system for emergency medicine (EM), the role that EM providers can play in remedying critical health problems, and the benefits gained from a public health approach to EM. A broad definition of public health is adopted, suggesting shared goals of public health and EM. Critical problems posed for EM include alcohol, tobacco, and other drug abuse; injury; violence; sexually transmitted diseases and human immunodeficiency virus (HIV) infection occupational and environmental exposures; and the unmet health needs of minorities and women. A blueprint for future merging of public health issues with EM is presented that includes the application of public health principles to 1) clinical practice; 2) public education, community involvement, and public policy advocacy; 3) development of medical school and residency public health/prevention curricula and teaching methods; and 4) research opportunities and surveillance. Finally, recommendations are proposed that require restructuring the present health care system to provide resources, incentives, and organizational changes that promote an integration of public health and preventive services in the practice of EM.

Update in medical toxicology.

This article examines some current issues in toxicologic care. First there is a review of the scope of pediatric poisonings and some aspects of initial management. Then there is a discussion of the decision-making process required to properly use gastric decontamination in the management of poisonings. Each of the common methods available--emesis, gastric lavage, activated charcoal, catharsis, and whole bowel irrigation--is discussed. Finally, several new and old antidotes are reviewed, namely naloxone, glucagon, bicarbonate, dimercaptosuccinic acid, digoxin-specific fab fragments, and flumazenil.

Feasibility and pharmacokinetics of carbamazepine oral loading doses.

The pharmacokinetics and adverse effects of an oral loading dose of carbamazepine administered in tablet or suspension form were studied. Patients on a hospital epilepsy unit who were to receive carbamazepine as a discharge medication were randomly assigned to receive either an oral 8-mg/kg loading dose of the tablet formulation or the same dose of the suspension on an empty stomach. Blood samples were drawn before and at intervals up to 12 hours after the loading dose. Adverse effects were evaluated subjectively and objectively. Total and free serum carbamazepine and carbamazepine-10, 11-epoxide (CBZE) concentrations were determined by high-performance liquid chromatography. Six adult patients were enrolled in and completed the study. All the patients achieved therapeutic total carbamazepine levels; the suspension group did so within two hours and the tablet group within five hours. Maximum serum carbamazepine concentrations ranged from 7.10 to 9.92 mg/L, area under the concentration-versus-time curve from 54.85 to 82.23 micrograms.hr/L, and terminal elimination half-life from 14.05 to 15.71 hours. Adverse effects were mild, few, and short-lived; none of the patients developed gastrointestinal toxicity. Adverse effects were not associated with total or free carbamazepine and CBZE concentrations or with total or free CBZE:carbamazepine ratios. An oral loading dose of carbamazepine 8 mg/kg achieved therapeutic levels within two hours when given as a suspension and within five hours when given as tablets and was well tolerated in all patients.

Ethanol-associated metabolic disorders.

The ingestion of alcohol, both intermittently and habitually, results in significant patient morbidity and mortality and stresses an already compromised socioeconomic system. Ethanol can interact with normal metabolic pathways to produce a variety of life-threatening abnormalities, particularly in those with underlying poor nutritional status, as is found in many alcohol users. Once identified, the metabolic derangements associated with alcohol use generally respond well to therapeutic interventions. The recurrence rate, however, is extremely high. Any attempt at long-term solutions must involve extensive rehabilitative services. Current research is directed largely toward improving survival from alcohol-related illnesses such as cirrhosis and cardiac disease. We must focus our efforts on the social implications of alcoholism, providing medical support, counseling, and rehabilitation to affected persons. Since alcohol-related problems present most frequently to the Emergency Department, it is appropriate that the emergency physician take the first step in attacking this disease, a step that may be as simple as a referral for detoxification or social services support.

The impact of drug abuse and addiction on society.

Over 28 million Americans have admitted to abusing a substance in the last year alone, at a direct purchase price of over 79 billion dollars. Substance abuse and addiction have grave consequences on our existing social systems, effecting crime rates, hospitalizations, child abuse, and child neglect, and are rapidly consuming limited public funds. The intravenous drug abuser represents the fastest growing vector of HIV virus. This report focuses on the social and economic implications of substance abuse and addiction and discusses the merits and limitations of several popular solutions to the problem.

Substance withdrawal.

As long as drug use and abuse persist in our society, a significant number of patients with various types of drug withdrawal will present to Emergency Departments. It is imperative that we recognize the signs and symptoms of drug withdrawal and render the appropriate treatments. Although it may be easy to recognize "skid row" alcoholics, a drug abuser with track marks on his (or her) arms or with a perforated nasal septum, the executive alcoholic, the elderly patient on chronic diazepam therapy, or the "blue collar" worker using cocaine may be more common and more elusive. Because most drug abusers use and can be dependent on multiple drugs, detoxification may need to proceed with one drug or one class of drugs at a time. Although our discussion has concentrated on the acute presentation and treatment of these symptoms for the emergency physician, we recognize that the acute treatment of withdrawal symptoms is only a small but vital part of withdrawal treatment. These patients will require chronic treatment, including social and psychologic counseling. As emergency physicians, by performing our jobs of recognition, stabilization, and counseling, we will fulfill the first critical link in the treatment of these patients.

Special considerations in gastrointestinal decontamination.

Many considerations factor into selecting the most appropriate method of gastrointestinal decontamination used in the poisoned patient. A thorough knowledge of the indications and efficacy as well as contraindications and complications of each modality is critical to the clinician's assessment. This article examines the current utility of syrup of ipecac-induced emesis, orogastric lavage, activated charcoal, cathartics, and whole bowel irrigation. In addition, the role of multiple dose activated charcoal and the controversial issue of the N-acetylcysteine and activated charcoal interaction are discussed.

The difficult patient.

The term difficult patient refers to a group of patients with whom a physician may have trouble forming a normal therapeutic relationship. The care of these patients can present many ethical dilemmas, ranging from issues of patient autonomy to questions of appropriate use of resources, which the emergency physician must be prepared to handle. Encounters with these patients also challenge physicians to explore and cultivate many of the character traits and virtues necessary to being a humane, caring, and ethical practitioner.