Online medical control and initial refusal of care: does it help to talk with the patient?

UNLABELLED: The use of online medical control (OLMC) for initial refusal of care is time-consuming and has medical-legal risks. OBJECTIVES: This study attempted to answer the following: Does physician-patient communication (PPC) increase the rate of transport and at what cost in terms of increased physician time? Do altered mental status (AMS) patients agree to transport more frequently and do they require more physician time? Can senior emergency medicine resident (RES) and emergency medicine faculty (FAC) physicians be equally efficient in handling refusal calls? METHODS: The study evaluated a retrospective cohort for six months at a single base station, university hospital. Online medical control audiotapes and written records of radio and telephone communications were reviewed. RESULTS: One hundred forty-seven refusal cases were analyzed, PPC was used 70 times, and 37 patients were transported. Twenty-four of 70 (34%) patients with PPC agreed to be transported, while ten of 77 (13%) patients without PPC agreed to be transported (p = 0.002). Sixteen of 30 (53%) patients with AMS were transported compared with 21 of 117 (18%) patients with normal mental status (p = 0.00007). Call times were longer with PPC utilization [406.3 sec PPC vs 230.1 sec no PPC (p < 0.001)] and with AMS patients [411.2 sec AMS vs 289.1 sec no AMS (p = 0.028)]. The RES and FAC physicians did not differ in transport rates [21% RES vs 26% FAC (p = 0.612)] and call times [329.4 sec RES vs 310.4 sec FAC (p = 0.659)]. CONCLUSIONS: Although time-consuming, the use of PPC is associated with more patients' agreeing to be transported. Patients with AMS are transported more frequently and they use more physician time. Emergency medicine RES and FAC physicians have equal efficiency and efficacy in handling these calls.

The strength of specific EMS dispatcher questions for identifying patients with important clinical field findings.

INTRODUCTION: There is growing interest in more efficiently matching emergency medical services (EMS) resources to patient need. Emergency medical services dispatchers may be asked to distinguish between callers with an immediate need for EMS and those who may safely use alternative services. New dispatcher protocols are required or existing protocols must be shown to be reliable for this new task. OBJECTIVE: To examine whether answers to currently asked dispatcher questions in one urban center can identify callers with important clinical field findings (ICFFs). METHODS: Audio recordings of EMS dispatcher-caller conversations within three nature codes (falls, sick, trauma) were retrospectively reviewed. Specifically scripted "cardinal" questions, asked of all callers, identify what happened, whether the patient is breathing okay, and whether the patient is conscious. "Key" questions are specific to each nature code and further specify patient circumstances. Compliance with protocol and caller answers were documented. Researchers developed a list of ICFFs that, if present on the corresponding EMS record, were judged to justify an immediate EMS response. Logistic regression was used to analyze the relationship between caller answers and the presence of ICFFs. A p-value of 0.10 was used. RESULTS: Of 430 recordings, 383 (89%) were usable. Falls: 103 (26%); trauma: 136 (37%); sick: 144 (37%). The caller was the patient 41 (11%) times. There were 198 (52%) females in the sample. There was no matching EMS record for 96 (25%) cases. An ICFF was determined to be present in 191 (67%) of the 287 recordings with matching EMS data. Compliance across the cardinal and key questions ranged from 62% to 88%. Age alone was suggestive of a patient who may be identified at dispatch as having an ICFF [adjusted OR 1.01 (90% CI: 0.999-1.025), p < 0.10]. No other key or cardinal questions were related to ICFFs. CONCLUSION: Cardinal questions are most often asked. Implied or volunteered information is often relied upon to answer key questions. Key questions for certain nature codes are not answered about one third of the time. Increasing age may suggest a stronger likelihood for an ICFF to be identified at dispatch. Otherwise, in this sample, caller answers to currently asked questions do not appear useful if the goal is to identify at dispatch those without an ICFF.

Survey of health maintenance organization instructions to members concerning emergency department and 911 use.

STUDY OBJECTIVE: Anecdotal concerns suggest that health management organization (HMO) membership instructions may deter members from calling 911 or going to an emergency department for a perceived emergency. This study examines such instructions, specifically in regard to their definition of an emergency condition and associated instructions. METHODS: Member instructions were requested from 28 HMOs in 3 large West Coast cities with HMO penetration exceeding 30%. Fifteen (54%) provided membership materials. Features examined included the definition of an emergency, instructions for calling 911, specific instructions regarding chest pain and stroke, and mention of costs associated with emergency care. RESULTS: Instructions and definitions varied widely. Six HMOs (40%) included chest pain in their definition of an emergency; 2 (13%) included symptoms of stroke. Ten (67%) made mention of calling 911 or going to the ED somewhere within their instructions; 4 (27%) provided no options for calling 911 or seeking ED care. Three (20%) cited higher costs associated with ED care. Eleven (73%) indicated that claims would be denied for visits determined on retrospective review to be nonemergencies. CONCLUSION: Instructions varied considerably. Most did not include chest pain or symptoms of stroke in their definition of an emergency. Most did include directions to call 911 or go to an ED. Other instructions may lead members to call the HMO first during an emergency.

State insurance commissioner actions against health maintenance organizations for denial of emergency care.

OBJECTIVE: Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims. METHODS: Telephone survey of all state insurance commissioners (SICs). The specific question asked was: "What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?" Each office was contacted at least three times. RESULTS: Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action. CONCLUSIONS: Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.

Life-threatening interaction of mibefradil and beta-blockers with dihydropyridine calcium channel blockers.

Mibefradil is a T-type and L-type calcium channel blocker (CCB) released in the United States in 1997 for management of hypertension and chronic stable angina. Postmarketing surveillance revealed a potential serious interaction between mibefradil and beta-blockers, digoxin, verapamil, and diltiazem, especially in elderly patients. The manufacturer voluntarily withdrew mibefradil on June 8, 1998. We describe 4 cases of cardiogenic shock in patients taking mibefradil and beta-blockers who began taking dihydropyridine CCBs. One case resulted in death; the other 3 survived episodes of cardiogenic shock with intensive support of heart rate and blood pressure. Physicians who are preparing to switch patients' medications from mibefradil to other antihypertensive agents should be aware of these potentially life-threatening drug-drug interactions.

Urinary chromium concentrations in humans following ingestion of safe doses of hexavalent and trivalent chromium: implications for biomonitoring.

In this study, we evaluate the significance of increased urinary chromium concentrations as a marker of chromium exposure and potential health risk. Six human volunteers ingested trivalent chromium [Cr(III)] and hexavalent chromium [Cr(VI)] at doses that are known to be safe but are much higher than typical dietary levels. The following dosing regimen was used: d 1-7, 200 micrograms/d chromium picolinate (a dietary supplement); d 8-10, Cr(VI) ingestion at the U.S. Environmental Protection Agency (EPA) reference dose (RfD) of 0.005 mg/kg/d; d 11-13, no dose; d 14-16, Cr(III) ingestion at the U.S. EPA RfD of 1.0 mg/ kg/d; and d 17-18, postdose. Urine voids were collected throughout the dosing periods and analyzed for chromium. Our findings are as follows: (1) ingestion of 200 micrograms/d of chromium picolinate yielded significantly elevated urine concentrations such that each participant routinely exceeded background, (2) ingestion of the Cr(VI) RfD (0.005 mg/kg/d) yielded individual mean urinary chromium levels (1.2-23 micrograms/L) and a pooled mean urinary chromium level (2.4 micrograms/L) that significantly exceeded background, and (3) ingestion of the Cr(III) RfD yielded no significant increase in urinary chromium concentrations, indicating that little, if any, absorption occurred. Our work identified three critical issues that need to be accounted for in any future studies that will use urinary chromium as a marker of exposure. First, a minimum urinary chromium concentration of approximately 2 micrograms/L should be used as a screening level to critically identify individuals who may have experienced elevated exposures to chromium. Second, if Cr(III) levels in soils are known to be less than 80,000 ppm and the Cr(III) is insoluble, urinary chromium concentrations are not an appropriate marker of exposure. Third, newer forms of chromium supplements that contain organic forms of Cr(III) must be considered potential confounders and their contribution to residential chromium uptake must be carefully evaluated.

Blood lead of intravenous drug users.

OBJECTIVE: A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors may result in methamphetamine grossly contaminated with lead. Three reports have documented outbreaks of acute lead poisoning in intravenous methamphetamine users. METHODS: This study measured blood lead concentrations in intravenous drug users of methamphetamine, cocaine or heroin presenting to the emergency department to determine the prevalence of subclinical lead poisoning in intravenous methamphetamine users. RESULTS: Mean blood leads for methamphetamine users (n = 92) were 6.22 micrograms/dL or 0.30 mumol/L (range 0.10-1.15, SD 0.20) and 7.25 micrograms/dL or 0.35 mumol/L (0.10-0.80, SD 0.15) for the nonmethamphetamine users (n = 53) with no significant difference between groups. CONCLUSIONS: The data suggest that previous outbreaks of acute intravenous lead poisoning among methamphetamine users were probably related to episodic contamination of methamphetamine. Subclinical lead poisoning was not found among the methamphetamine users presenting to the emergency department.

Urinary excretion of chromium following ingestion of chromite-ore processing residues in humans: implications for biomonitoring.

Biomonitoring programs for urinary chromium (Cr) typically attempt to evaluate occupational exposure via the inhalation route. This study investigated whether Cr can be detected in the urine of people following the ingestion of soils that contain relatively high concentrations of chromium in chromite ore processing residue (COPR). To evaluate the reasonableness of using urinary monitoring to assess environmental exposure, six volunteers ingested 400 mg of soil/day (low-dose group), two others ingested 2.0 g of soil/day (high-dose group) for 3 consecutive days, and one person ingested a placebo on each of 3 days. The soil and COPR mixture contained concentrations of total chromium (Cr) and hexavalent chromium [Cr(VI)] of 103 +/- 20 and 9.3 +/- 3.8 mg/kg, respectively. Therefore, the low-dose group ingested 41 micrograms Cr/day [including 3.7 micrograms Cr(VI)] and the high-dose group ingested 206 micrograms Cr/day [including 18.6 micrograms Cr(VI)] on each of 3 consecutive days. All urine samples were collected and analyzed individually for total Cr on the day prior to dosing, during the 3 days of dosing, and up to the first void 48 h after the last dose. No significant increases in urinary Cr excretion were found when background excretion data were compared with data following each of the 3 days of dosing or in daily mean urine concentrations of the high- vs the low-dose groups. It appears that Cr present in a soil and COPR mixture at Cr doses up to 200 micrograms/day is not sufficiently bioavailable for biomonitoring of urine to be informative.(ABSTRACT TRUNCATED AT 250 WORDS)

Pediatric carbamazepine overdoses.

Thirty pediatric cases of carbamazepine overdoses were reviewed retrospectively for the frequency of toxic effects. Patients were divided into three groups, depending on the type of overdose: acute, acute-on-chronic, and chronic. Effects included lethargy in 93%, ataxia in 50%, nystagmus in 13%, and minor arrhythmias in 10%. Major effects included seizures in 20%, coma in 27%, and need for intubation in 20%. Higher serum carbamazepine levels were associated with these major effects in the acute and acute-on-chronic groups but not in the chronic group. Serum levels greater than 35 mg/L (147 mumol/L), were significantly associated with major toxicities.

Urinary excretion of chromium by humans following ingestion of chromium picolinate. Implications for biomonitoring.

This study investigated the variability in urinary chromium (Cr) excretion following the ingestion of Cr picolinate by human volunteers. A pharmacokinetic model was used to estimate the bioavailability of Cr from ingested Cr picolinate using known distribution patterns and elimination rates of Cr by humans. The possible advantages of using sequential, individual spot, or 24-hr urine sample collection for biomonitoring of Cr exposure were examined. Background concentrations of urinary Cr determined from the spot samples in this study compared well with values reported by others. The variability in urinary excretion of Cr in untreated volunteers indicated that it is virtually impossible to distinguish exposures to most occupational and virtually all environmental exposures to Cr. Sequential urine sampling was found superior to both 24-hr and spot urine collection for indicating exposure to Cr picolinate. The extent of absorption of Cr from the picolinate matrix in the gastrointestinal tract was 2.80 +/- 1.14% (SD). It was estimated that 10 mg of soil containing between 7,400 and 52,000 mg Cr(III)/kg would have to be ingested by an adult to result in urinary excretion of Cr clearly above the upper bound of Cr in urine from background populations (1.8 microgram Cr/liter), depending on certain assumptions regarding bioavailability. This study supports the results of other recent work that demonstrated urinary excretion of Cr resulting from low-level environmental exposure is unlikely to be distinguished from that resulting from dietary uptake.

The effect of hospital resource unavailability and ambulance diversions on the EMS system.

HYPOTHESES: 1) There is no increase in transport or scene time of diverted patients and no increase in distances traveled; 2) hospital resource shortages bear no relationship to the number of patients diverted; and 3) paramedics are able to match their patient correctly with the resources available at a given hospital. METHODS: This was a five-month, prospective, observational study in an urban area with a population of 600,000 comparing all 9-1-1 ambulance diversions against a randomly selected sample of 5% of all other 9-1-1 originated patients. All patient diversions that originated from the 9-1-1 center are included in the study. RESULTS: Hospitals identify their diversion status on a community-wide computer system monitored at the 9-1-1 center and base station. Accepted categories include: 1) diversion of all patients through the 9-1-1 center from the emergency department (ED); 2) trauma system patients (T); 3) psychiatric secure beds (PSB); 4) general acute ward beds (AW); 5) critical care (CC); 6) computed tomography scan (CT); 7) labor and delivery (LD); and 8) pediatric beds (PEDS). Data were abstracted from 481 patients' records. A total of 111 were diverted from their intended destination. Transport times were longer and diverted patients traveled further (p < .002). Hospitals showing ED and LD diversion categories were more likely to have patients diverted away (r2 = .895, multilinear regression, p < .001). Of the 111 patients, 21 (19%) were diverted because of CC unavailability. Six of these (28%) were inappropriate because they did not fit the CC definition. CONCLUSIONS: In this system, hospital diversions increase transport times and distances traveled. Diversion of patients correlated strongly to unavailability of specific categories. Paramedics make errors in determining appropriate CC diversions. Systems reviewing their diversion problems need to assess the impact of longer out-of-hospital times and of certain diversion categories, and to clarify definitions.

Improved LAboratory Prototype ELectrolarynx (LAPEL): using inverse filtering of the frequency response function of the human throat.

The electrolarynx (EL) provides a valued means of verbal communication for people who have lost their larynx. Existing ELs have some drawbacks such as harsh, raucous, and unpleasant sound and the presence of background noise. This study presents an experimental analysis of two commercial ELs and describes the development and testing of an improved LAboratory Prototype ELectrolarynx (LAPEL) which more accurately simulates the sound of a natural larynx and has lower background noise. This natural sound is obtained by determining the frequency response function (FRF) of the tissue of the human neck and using this information to tailor the input signal to the EL by inverse filtering such that its output spectrum resembles that of the natural larynx. The result was subjectively judged to have a superior and more natural sound than existing electrolarynxes.

Sudden death in the ED: educating residents to compassionately inform families.

We describe a program used in our emergency medicine residency to help teach residents new skills in interacting with survivors following a patient's sudden death in the emergency department. This teaching module requires about two and a half hours to complete. It includes a brief presentation of new skills, videotapes of family notification, resident role play experiences, and a summary. Trained volunteers are used as simulated survivors in the role plays. Although labor intensive and time consuming, the program offers educational advantages. The residents have an opportunity to practice their communication skills in a protected setting. In addition, they receive immediate and specific feedback from the faculty facilitator, fellow residents, and, most importantly, the simulated survivor. Following the role play sessions, residents feel they are more skillful in meeting survivors' needs.

Massive strychnine intoxication: serial blood levels in a fatal case.

A fatal case of strychnine intoxication is reported. The patient expired despite early aggressive management and prevention of metabolic complications. Serial blood levels are reported. In contrast to a previous report describing first order elimination kinetics, our data suggest that strychnine follows Michaelis-Menton elimination kinetics. The case illustrates the rapid, dramatic course of severe strychnine ingestions. A review of the toxicokinetics, mechanism of action and treatment of strychnine intoxication follows.

Computerized hospital on-line resources allocation link (CHORAL): a mechanism to monitor and establish policy for hospital ambulance diversions.

Ongoing monitoring of the availability of hospital critical care resources is necessary to assure patients in the emergency medical services (EMS) system reach appropriate care. In this densely populated area Multnomah County, Oregon, ambulances have been diverted by radio from several hospitals before finding one that would accept the patient. Dispatch centers and base-stations had no reliable method to monitor the availability of hospital resources. Data were not available for use in establishing policy. In response, this community developed an on-line, computerized system known as Computerized Hospital On-Line Resources Allocation Link (CHORAL) that visually displays the resource status of all hospitals to the 911 center, base station, and participating hospitals. A change of status requires simple keystrokes for entry into the computer which in turn transmitted automatically to all other CHORAL computers. Six patient care resources are monitored: Adult Ward (AW); Computerized Axial Tomography Scan (CT); Critical Care (CC); Labor and Delivery (LD); Pediatric (PEDS); and Psychiatric Secure Beds (PSB). Paramedics use protocol to determine if a particular patient fits one of these categories. Availability is relayed to paramedics by the 911 center and the base-station. During the first three months of system operation, there were 337 diversions representing 4,527 hours among 10 of the 12 participating hospitals. The most common resource resulting in diversion was PSB, which was unavailable for 2,195 hours (48.5%). Unavailability of CT resulted in the lowest number of diversions (1.3%, 60.3 hours).(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of hospital ability to provide trauma services: a comparison between teaching and community hospitals.

HYPOTHESIS: Teaching hospitals (TH) can maintain the American College of Surgeons Committee on Trauma (ACSCOT) criteria for Level II trauma care more consistently than can community hospitals (CH). METHODS: A retrospective analysis of 2,091 trauma system patients was done to determine if TH in an urban area are better able to meet the criteria for Level II trauma care than are CH. During the study period, a voluntary trauma plan existed among five hospitals; two TH and three CH. A hospital could accept patients that met trauma system entry criteria as long as, at that moment, it could provide the resources specified by ACSCOT. Hospitals were required to report their current resources accurately. A centralized communications center maintained a computerized, inter-hospital link which continuously monitored the availability of all participating hospitals. Trauma system protocols required paramedics to transport system patients to the closest available trauma hospital that had all the required resources available. Nine of the required ACSCOT Level II trauma center criteria were monitored for each institution emergency department (ED); trauma surgeon (TS); operating room (OR); angiography (ANG); anesthesiologist (ANE); intensive care unit (ICU); on-call surgeon (OCS); neurosurgeon (NS); and CT scanner (CT) available at the time of each trauma system entry. RESULTS: With the exception of OR, TH generally maintained the required staff and services more successfully than did CH. Further, less day to night variation in the available resources occurred at the TH. Specifically, ANE, ICU, TS, NS, and CT were available more often both day and night, at TH than CH. However, OR was less available at TH than CH during both day and night (p less than .01). CONCLUSIONS: In this community, TH provided a greater availability of trauma services than did CH. This study supports the designation of TH as trauma centers. A similar availability can be performed in other communities to help guide trauma center designation.

Liver transplantation for severe Amanita phalloides mushroom poisoning.

Amanita phalloides mushroom poisoning is an increasingly common and potentially lethal problem for which liver transplantation offers definitive therapy in selected patients. When significant liver dysfunction appears, early transfer to a liver transplant center is important to identify appropriate candidates and to begin the search for a donor organ. The clinical course of five severely poisoned patients, four of whom underwent liver transplantation, is reviewed. Indications for transplantation included primarily a markedly prolonged prothrombin time that was only partially correctable and a constellation of findings including metabolic acidosis, hypoglycemia, hypofibrinogenemia, and increased serum ammonia, following a marked elevation in serum aminotransferase levels. Unlike viral fulminant hepatic failure, grade III or IV hepatic encephalopathy, marked elevation of the serum bilirubin level, and azotemia were not indications for transplantation. Resected livers demonstrated hepatocyte viability of 0% to 30%. Manifestations of Amanita poisoning complicating preoperative and/or postoperative care included severe diarrhea, gastrointestinal hemorrhage, hypophosphatemia, bowel edema, and marrow suppression with lymphopenia, thrombocytopenia, and neutropenia. All five patients are well 1 year later. This largest experience with liver transplantation for Amanita poisoning further defines the early clinical and laboratory indications for, and the unique complicating features of, transplantation in this setting.