Extracorporeal membrane oxygenation can provide cardiopulmonary support during bronchoscopic clearance of airways after sand aspiration.

BACKGROUND: Sand aspiration occurs in situations of cave-in burial and near-drowning. Sand in the tracheobronchial airways adheres to the mucosa and can cause tracheal and bronchial obstruction, which can be life-threatening even with intensive management. In previous case reports of airway obstruction caused by sand aspiration, fiber optic or rigid bronchoscopy has been effective in removing loose sand, but removal of sand particles lodged in smaller airways has proven challenging and time-consuming. CASE REPORT: In this case report of sand aspiration with acute pulmonary failure, the use of extracorporeal membrane oxygenation for respiratory support allowed more effective removal of sand particles by rigid bronchoscopy and lavage with less patient compromise. CONCLUSION: Our case of sand aspiration is unique in that the patient presents with complex medical problems (mixed respiratory and metabolic acidosis), hypothermia, hypoxemia, and neoplastic conditions. The fact that she survived the sand aspiration and a long inter-hospital transport time (90 min) with inadequate ventilation and oxygenation without apparent ill effects suggests that the measures we took to resuscitate her and extract the sand from her airways were reasonable and appropriate.

Successful resuscitation after multiple injuries in the wilderness.

BACKGROUND: Survival of blunt trauma associated with hypothermic and hemorrhagic cardiac arrest in wilderness areas is extremely rare. CASE REPORT: We describe a case of a 19-year-old female college sophomore who, while glissading down Mt. Adams, had a 400-pound boulder strike her back and left pelvis, propelling her 40 feet down the mountain to land face down in the snow at 7000 feet. It took 4 h from the time of injury until the arrival of the helicopter at our Emergency Department and Trauma Center. The patient lost vital signs en route and had no CO(2) production. A cardiothoracic surgeon was the trauma surgeon on call. The patient was taken directly from the helipad to the operating room, where cutdowns enabled initial intravenous access, median sternotomy and pericardiotomy open heart massage, massive transfusion, chest and abdominal cavity irrigations with warm saline, correction of acid base imbalances and coagulopathies, and epicardial pacing that led to a successful reanimation of the patient. The patient was rewarmed without extracorporeal membrane oxygenation or heat exchangers. The ensuing multiple organ failures (heart, lungs, kidneys, intestines, brain, and immune system) and rhabdomyolysis led to a 2-month intensive care unit stay. She received over 120 units of blood and blood products. The patient regained cognitive function, mobility, and overcame multiple organ failure. CONCLUSION: This report is presented to increase awareness of the potential survivability in hypothermia, and to recognize the heroic efforts of the emergency services personnel whose efforts saved the patient's life.

Revolutionary advances in enhancing patient comfort on patients transported on a backboard.

BACKGROUND: Patients with suspected spinal cord injuries are immobilized to a backboard during ambulance and helicopter air transport. It has been well documented that patients who are immobilized to a backboard experience discomfort and eventually become susceptible to pressure ulcer formation. Because the patient lying on a backboard is subjected to high skin interface pressures, it is imperative to improve patient comfort and prevent pressure ulcer formation. OBJECTIVE: Realizing the dangers of the potentially preventable pressure ulcers, our team of scientists, surgeons, and trauma nurses performed a comprehensive study of the Back Raft system that was designed to reduce patient discomfort and skin interface pressure. METHODS: Pressure under the occipital, scapula, and sacral regions of the back was measured using the Tactilus pressure analyzer of 10 healthy volunteers immobilized on a backboard and a backboard with a Back Raft air mattress system. Discomfort levels of each volunteer were measured using a Visual Analog Scale. RESULTS: Data from this study indicated that the Back Raft significantly reduces discomfort as well as tissue interface pressure in the occipital, scapula, and sacral regions of the back. CONCLUSIONS: The implementation of an air mattress system analogous to the Back Raft would facilitate the prevention of pressure ulcer formation during prehospital care and transportation. In 2008, The Centers for Medicare and Medicaid Services enacted a policy in which the Centers for Medicare and Medicaid Services can refuse payment for hospital-acquired conditions. Pressure ulcers were among the hospital-acquired conditions within the final rule.

Advances in the treatment of peanut allergy: a case report.

BACKGROUND: Peanut allergies affect 1.5% of children. The majority of reactions to peanuts are mild, but peanut allergy is also the most common cause of fatal anaphylactic reactions to food. CASE REPORT: The purpose of this case report was to describe a 1-year old boy who developed difficulty breathing after eating a peanut food product. The boy was taken immediately by his mother to an Emergency Department, exhibiting severe respiratory distress. After speaking to the child's mother, the emergency physician (EP) realized that the wheezing was due to a peanut food allergy. The child's respiratory symptoms responded within 10 min to bronchodilatator inhalation. The EP gave the mother educational information regarding the management of asthma and the proper use of metered dose inhalers with spacer devices. The EP referred the child to a clinical allergist who specializes in the management of food allergies. The diagnosis was made by skin prick testing as well as in vitro measurement of peanut-specific immunoglobulin E. CONCLUSION: The allergist explained that the mainstay of management of peanut allergy is avoidance of the allergenic food. Patient education involved teaching the mother to avoid high-risk situations such as dinner with family members who are not informed about the child's allergy to peanuts, encouraging the child to wear a Medic Alert Bracelet, and teaching the family and child to recognize early symptoms of allergic reactions and to manage an anaphylactic reaction, including the use of self-injectable epinephrine, as well as activating emergency services.

Dreams, teachers, and legislation.

When I accepted the James D. Mills Award from The American College of Emergency Physicians, I had three goals in mind, which I wanted to share with those attending the commemorative dinner meeting. My first goal was to remind those in attendance that each of us must make our academic dreams come true. My next goal was to acknowledge two of my empowering teachers at the dinner, Dr. Peter Rosen and Dr. William Sacco, who have made revolutionary advances in health care; and finally, I wished to remind the membership of the need to work with Congressional leaders to pass the Access to Emergency Medical Services Act of 2009. I warned the leaders in emergency medicine of the necessity to pass the Access to Emergency Medical Services Act of 2009 to ensure that our emergency medical patients receive prompt and responsible care. This has been our quest.

Modern concepts of the diagnosis and treatment of necrotizing fasciitis.

BACKGROUND: Necrotizing fasciitis is a potentially fatal infection involving rapidly progressive, widespread necrosis of the superficial fascia. OBJECTIVES: The purpose of this collective review is to review modern concepts of the treatment and diagnosis of necrotizing fasciitis. DISCUSSION: Necrotizing fasciitis is characterized by widespread necrosis of the subcutaneous tissue and the fascia. Although the pathogenesis of necrotizing fasciitis is still open to speculation, the rapid and destructive clinical course of necrotizing fasciitis is thought to be due to multibacterial symbiosis. During the last two decades, scientists have found that the pathogenesis of necrotizing fasciitis is usually polymicrobial, rather than monomicrobial. Although there has been no published well-controlled, clinical trial comparing the efficacies of various diagnostic imaging modalities in the diagnosis of necrotizing infections, magnetic resonance imaging (MRI) is the preferred technique to detect soft tissue infection. MRI provides unsurpassed soft tissue contrast and spatial resolution, has high sensitivity in detecting soft tissue fluid, and has multiplanar capabilities. Percutaneous needle aspiration followed by prompt Gram's staining and culture for a rapid bacteriologic diagnosis in soft tissue infections is recommended. Surgery complemented by antibiotics is the primary treatment of necrotizing fasciitis. CONCLUSION: Wide, extensive debridement of all tissues that can be easily elevated off the fascia with gentle pressure should be undertaken. Successful use of intravenous immunoglobulin has been reported in the treatment of streptococcal toxic shock syndrome. The use of adjunctive therapies, such as hyperbaric oxygen therapy, for necrotizing fasciitis infection continues to receive much attention.

A case report of a severe musculoskeletal injury in a wheelchair user caused by an incorrect wheelchair ramp design.

The Americans with Disabilities Act (ADA) gives all Americans with disabilities a chance to achieve the same quality of life that individuals without disabilities enjoy. In this case report, we will be discussing the consequences of having inaccessible ramps to persons with disabilities that can result in severe musculoskeletal injuries in a wheelchair user. While going down an inaccessible ramp in the garage of a hospital, a wheelchair tipped over, causing a fracture to the user's right femur. The injured patient was taken to the Emergency Department, where the diagnosis of a fracture of the right femur was made. The fracture then had to be repaired with an intramedullary rod under general anesthesia in the hospital. It was discovered that the ramps in the hospital garage did not comply with the guidelines of the ADA. The wheelchair ramps had a ramp run with a rise > 6 inches (150 mm) and a horizontal projection > 72 inches (1830 mm). This led to the redesign and construction of safe ramps for individuals using wheelchairs as well as for pedestrians using canes, within 1 month after the patient's injury, making it safe for wheelchair users as well as pedestrians using the parking facilities. The ADA specifies guidelines for safe ramps for patients with disabilities. It is important to ensure that hospital ramps comply with these guidelines.

Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part I.

BACKGROUND AND OBJECTIVES: This report provides an overview of advances in wound repair devised by our research team during the last four decades. This collective review is presented in two parts. DISCUSSION: The following components are included in Part I: 1) search and treat life-threatening trauma; 2) conduct a thorough history; 3) examine the wound using aseptic technique; 4) anesthetize the wound before cleansing; 5) hair removal, skin disinfection, hemostasis, surgical debridement, and mechanical cleansing; 6) antibiotics, drains, and open wound management. CONCLUSION: On the basis of these comprehensive research studies, we have noted a marked reduction in the incidence of wound infection in traumatic wounds.

Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part II.

BACKGROUND AND OBJECTIVES: During the last four decades, our research team has devised advances in wound repair that are highlighted in Part II of this collective review. DISCUSSION: There are several different methods to provide an accurate and secure approximation of the skin edges-sutures, tapes, staples, and tissue adhesives. Ideally, the selection of the wound closure technique will be based on the biologic interaction of the materials employed, tissue configuration, and biomechanical properties of the trauma wound. Selection of the appropriate wound dressing is another important consideration in the management of the trauma wound. CONCLUSION: On the basis of the comprehensive research and clinical studies, we have individualized the wound closure techniques for traumatic wounds so that healing can be achieved with more aesthetically pleasing scars.

Delusions of parasitosis.

BACKGROUND: Delusions of parasitosis (DP) is a rare psychiatric disorder in which the patient has a firm belief that she or he is infected by parasites. Although it is a psychiatric disorder, these patients often present to an emergency physician because they are convinced that they have a severe skin problem. TREATMENT: Patients with DP often reject psychiatric referral. The diagnosis of DP can usually be made based on history alone. However, it is important that the patient does not have an organic skin disorder and that the delusion is not secondary to another mental or physical illness. The current treatments of choice are the antipsychotic medications risperidone and olanzapine. CONCLUSIONS: In our experience, patients with DP seen in the emergency department who are suspected of having this condition can be a challenging diagnostic and treatment problem because they usually do not have health insurance. Consequently, we find it difficult to get dermatologic and psychiatric consultation to treat their illness.

Citizen's Petition to Food and Drug Administration to ban cornstarch powder on medical gloves: Maltese cross birefringence.

BACKGROUND: During the last 25 years, scientific experimental and clinical studies have documented the dangers of cornstarch powder on examination and surgical gloves because the cornstarch promotes wound infection, causes serious peritoneal adhesions and granulomatous peritonitis, and is a well-documented vector of the latex allergy epidemic in the world. Realizing the dangers of cornstarch on examination and surgical gloves, Germany's regulations of personal protective equipment banned the use of surgical glove powder cornstarch in 1997. In 2000, the Purchasing and Supply agency for the United Kingdom ceased to purchase any gloves lubricated with cornstarch. DISCUSSION: Realizing the dangers of cornstarch-powdered gloves, many hospitals and clinics in the United States have banned the use of cornstarch-powdered examination and surgical gloves. Hospitals that have banned cornstarch in their examination and surgical gloves have noted a marked reduction in the latex allergy epidemic in their facilities. Realizing the dangers of cornstarch-powdered examination and surgical gloves, Dr Sheila A. Murphey, branch chief, Infection Control Devices Branch, Division of Anesthesiology, General Hospital, Infection Control, and Dental Devices Office of Device Evaluation, Center for Devices and Radiological Health of the Food and Drug Administration (FDA), recommended that a Citizen's Petition be filed to the FDA to ban cornstarch on surgical and examination gloves. CONCLUSION: The 12 authors of this report have attached the enclosed petition to the FDA to ban the use of cornstarch on all synthetic and latex examination and surgical gloves used in the United States.

Dangers of cornstarch powder on medical gloves: seeking a solution.

This article reviews information on the hazards of cornstarch powder on medical gloves. Dusting powders were first applied to latex gloves to facilitate donning. After 1980, manufacturers devised innovative techniques without dusting powder. It has been well documented that these powders on gloves present a health hazard to patients and health care workers by 5 different mechanisms. First, the glove cornstarch has documented detrimental effects on wound closure techniques. Second, this powder potentiates wound infection. Third, cornstarch induces peritoneal adhesion formation and granulomatous peritonitis. Finally, these powders serve as carriers as latex allergen and they precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powder have caused the United Kingdom and Germany to ban cornstarch powder on medical gloves over 10 years ago.

Modern concepts of the diagnosis and treatment of purpura fulminans.

Purpura fulminans is a rare syndrome of intravascular thrombosis and hemorrhagic infarction of the skin that is rapidly progressive and accompanied by vascular collapse and disseminated intravascular coagulation. It usually occurs in children, but this syndrome has also been noted in adults. The purpose of this collective review is to provide modern concepts on the diagnosis and treatment of neonatal purpura fulminans, idiopathic purpura fulminans, and acute infectious purpura fulminans. There are three forms of this disease that are classified by the triggering mechanisms. First, neonatal purpura fulminans is associated with a hereditary deficiency of the natural anticoagulants Protein C and Protein S as well as Antithrombin III. Idiopathic purpura fulminans usually follows an initiating febrile illness that manifests with rapidly progressive purpura. Deficiency of Protein S is considered to be central to the pathogenesis of this form of the disease. The third and most common type of purpura fulminans is acute infectious purpura fulminans. The mortality rate has decreased with better treatment of secondary infections, supportive care, and new treatments, but it remains a disabling condition often requiring major amputations.

Implementation of revolutionary legislation for informed consent for dental patients receiving amalgam restorations.

Mercury is one of the most dangerous environmental toxins. Realizing the environmental dangers of mercury, the Norwegian Minister of the Environment and International Development, Erik Solheim, has therefore prohibited the use of mercury in products in Norway. This ban will include dental filling materials (amalgam) and measuring instruments, as well as other products. This ban is valid from January 1, 2008. Sweden announced a similar ban, and dentists in Denmark will no longer be able to use mercury in fillings after April 1, 2008. It is indeed unfortunate that the United States has not taken a leadership role in enacting Informed Consent Legislations for patients receiving dental amalgam restorations. Informed Consent Legislations have been enacted by Maine, California, Connecticut, and Vermont.

Breast cancer and ovarian cancer genetics: an update.

The purpose of this report on breast cancer and ovarian cancer genetics is to review the evidence for the efficacy of surveillance for early detection, bilateral prophylactic mastectomy, prophylactic oophorectomy, and chemoprevention in preventing breast cancer and improving survival of BRCA1 and BRCA2 carriers. This collective review highlights radiologic screening of patients with this genetic predisposition for cancer as well as discusses cancer risk reduction strategies and reproductive concerns in female BRCA1/2 mutation carriers. It has now been well documented that magnetic resonance imaging (MRI) of the breast has a higher sensitivity than mammography for the diagnosis of breast cancer in patients predisposed to breast cancer. We also emphasize that a new diagnostic device, molecular breast imaging (MBI), is now available and may be as sensitive as MRI. To date, this exciting technology, MBI, has not been used in studies of patients with BRCA1/2 genes. We also discuss in more detail the unique psychological ramifications of female BRCA1/2 mutation carriers. These women face unique choices regarding management of their high risk for breast and ovarian cancer that impact their reproductive options. Despite their high levels of concern, few female BRCA1/2 mutation carriers consider assisted reproduction technologies such as pregnancy surrogate, cryopreservation of oocytes or embryos, or implantation genetic diagnosis to select embryos without BCRA1/2 mutation. Further research must be undertaken to explore the risk management of patients with inherited cancer predisposition and to incorporate these preferences into clinical care.

The food and drug administration agrees to classify mercury fillings.

In the United States Court of Appeals of the District of Columbia Circuit, the Appellants Mom's Against Mercury, Connecticut Coalition for Environmental Justice, Oregonians for Life, California Citizens for Health Freedom, Kevin J. Biggers, Karen Johnson, Linda Brocato, R. Andrew Landerman, and Antia Vazquez Tibaul filed a petition for review of Regulatory Inaction by the Food and Drug Administration (FDA). On Monday June 2, 2008, the lawsuit was settled with the FDA after it agreed to classify mercury fillings. During its negotiation session with the Appellants, the FDA indicated that it would change its website on mercury fillings. The FDA no longer claims that no science exists about the safety of mercury amalgam or that other countries have acted for environmental reasons only. On its website, the FDA now states the following: "Dental amalgams contain mercury, which may have neurotoxic effects on the nervous systems of developing children and fetus." The FDA also states that "Pregnant women and persons who may have a health condition that makes them more sensitive to mercury exposure, including individuals with existing high levels of mercury bioburden, should not avoid seeking dental care, but should discuss options with their health practitioner." The FDA decision to classify mercury fillings is a reflection of the legislations enacted in Europe and Canada that highlight the neurotoxic effects of mercury fillings.

Management of femoral fracture in a patient with essential thrombocythemia treated with plateletpheresis and intramedullary rod fixation, followed by hydroxyurea: a case report.

We describe the management of a patient with a femoral fracture who had asymptomatic essential thrombocythemia. When the diagnosis of essential thrombocythemia was made, the patient was treated with plateletpheresis to reduce the platelet count before intramedullary rod fixation of his fracture. His postoperative management included the examination of his peripheral blood as well as bone marrow, which confirmed that the cause of his elevated platelet count was due to JAK2 V617F mutation that is treated by hydroxyurea and aspirin after being discharged from the hospital.

Legislation and informed consent brochures for dental patients receiving amalgam restorations.

In 2008, Norway banned the use of mercury for amalgam restorations. Four states in the United States have developed Informed Consent Brochures for amalgam restorations that must be given to their dental patients. The authors describe a patient who had a large cavity in his left lower molar tooth no.18 that had to be removed by an oral surgeon. When the patient went to the oral surgeon, the surgeon told the patient that he would replace the carious tooth with a gold implant. He was not given an Informed Consent Brochure regarding dental restorative materials. The oral surgeon extracted the carious tooth, replacing the tooth with a supposed gold crown implant. On his yearly dental examination, his dentist took an x-ray of his dental implant and explained that the x-ray could not distinguish whether the implant contained either gold or mercury. Consequently, the dentist referred him to a dental clinic in which the dental implant could be removed without mercury contamination of the patient's neurologic system during the extraction of the implant from the root canal. During the removal of the dental restoration, the dentist found build up expanding into the root canal that had a black color. The crown and underlying tooth were sent to ALT BioScience for analysis. Elemental analysis of the crown and underlying tooth confirmed the presence of mercury in the restoration. The patient should have been given an Informed Consent Brochure by the dentist that described the dental restoration that was used in the dental implant.