Is the Puerto Rican racer, Alsophis portoricensis, really harmless? A case report series.

Puerto Rico (PR) is home to 10 indigenous species of snake. Alsophis portorricensis has traditionally been considered harmless. In 1961, Hageman classified A portorricensis as somewhere between "venomous" and "nonvenomous." In 1966, Heatwole and Banuchi reported the only case found in the literature of a "venomous" bite from Alsophis portorricensis. Only 6 cases of snakebite were reported to the PR Department of Health from 1998 to 2007; ecchymosis, swelling, and abnormal vital signs were noted in all of the cases. In 5 of these 6 cases, the captured snake was, in fact, identified as Alsophis portorricensis of the Colubridae family; in the remaining case, the description strongly suggests that it was the same species as the others. All bites were inflicted on fingers, which were presented for evaluation from 2 to 24 hours after the event. All documented cases report that the bite lasted from 1 to 4 minutes. All of the victims presented with localized pain and ecchymosis. Localized edema extended from the hand to the elbow in 4 cases, and up to the shoulder in 2 cases. All patients were treated symptomatically, observed at the Emergency Department (ED), and discharged home within 24 hours after the ED evaluation. All patients reported the resolution of symptoms within 1 week. Traditionally, PR has not been associated with any dangerous species of snake. These cases show that the second most abundant snake on the island can inflict a venomous bite, with local and systemic symptoms that warrant adequate preparation by the medical community.

Essential concepts of wound management.

The practice of wound care has greatly improved and evolved over the years. The emergency provider (EP) can choose from a wide variety of sutures, adhesives, strips, and surgical staples, and uses proven wound closure techniques to address this common Emergency Department (ED) patient complaint. All EPs should be comfortable and proficient in the management and care of wounds in the ED. Because wound care is responsible for a large number of malpractice claims, EPs need to be aware of practices that can limit bad outcomes and thus decrease their liability risk. EPs should follow a standard examination and ensure that there is no damage to underlying structures (ie, nerves, tendons, and vasculature), and that foreign bodies are meticulously looked for and removed if found. Discharge instructions that alert the patient on warning signs of infection, and having all patients return within 48hours for a wound check are 2 ways to optimize patients' outcomes.

Spinal cord toxoplasmosis as an unusual presentation of AIDS: case report and review of the literature.

Approximately 10% of patients with AIDS present with some neurological deficit as their initial complaint, and up to 80% will have CNS involvement during the course of their disease. Toxoplasmosis is the most common cause of cerebral mass lesions in patients with AIDS, but appears to be an uncommon cause of spinal cord disease. The incidence of myelopathy may be as high as 20%, with 50% of the cases reported post-mortem. We present a unique case of spinal cord disease as the initial presentation of AIDS. We also present a comprehensive literature review of this topic, its diagnosis and treatment. This is a retrospective chart review case report. After a detailed case presentation, several diagnostic and therapeutic aspects of this unique case are thoroughly discussed. Although spinal cord toxoplasmosis is uncommon, it has been suggested that most patients with AIDS that present with evolving myelopathy, characterized by extremity weakness, sensory involvement, spinal cord enlargement, enhancing lesions in brain or spinal cord CT or MRI, have toxoplasmic myelitis.

Workforce projections for emergency medicine in Puerto Rico: a five-year follow-up of an evident demand.

In this study, two mathematical equations were used to calculate and establish the actual Emergency Medicine workforce needed in Puerto Rico (PR) and project the time frame to meet the actual demand. 1) Supply equals the number of existing Emergency Physicians (EPs) plus residency-trained graduates in EM per year minus the annual attrition rate (3%); and 2) Demand equals six (6) full time equivalent positions per Emergency Department (ED) times the total number of EDs in PR. Under both scenarios tested, the significant EP shortage in PR will continue until 2044. The actual calculated shortage is 287 EPs. There is an actual significant shortage in the Puerto Rico EP workforce. It will take a long time to make leaders understand the positive impact of having residency-trained EPs in every ED, on quality patient care and the whole health care system.