Increasing compliance with the Residency Review Committee requirements for follow-up in academic emergency departments. Emergency Medicine Follow-up Study Group.

STUDY OBJECTIVES: The purpose of this study was to assess patient follow-up activities and changes in compliance with the Residency Review Committee follow-up requirements among emergency medicine residency training programs over a 12-year period. METHODS: A cross-sectional survey of residency directors of all accredited programs in emergency medicine listed in the Graduate Medical Education Directory was performed in 1996. Program director responses were matched with the results of our study group's previous surveys performed in 1984, 1988, and 1992. The survey requested information regarding the mechanism for follow-up on patients admitted to the hospital, as well as those treated and released from the emergency department. RESULTS: All residency programs responded to the survey. Seventy-four percent of the residency programs surveyed reported a formal system of follow-up for admitted patients, and 51% had a formal system in place for discharged patients. Inpatient follow-up mechanisms included follow-up case conferences (56%), discharge summaries (55%), follow-up book/cards (47%), or follow-up rounds (11%). Outpatient follow-up mechanisms included routine telephone follow-up (86%), follow-up document (37%), ED follow-up clinic (24%), or home visits (<1%). During the past 12 years, compliance with the Residency Review Committee requirements for follow-up activity has improved from 38% to 78% for inpatients and from 33% to 52% for outpatients. CONCLUSION: Emergency medicine residency training programs report an increasing compliance with residency requirements for ED patient follow-up. However, a significant number of programs still lack a formal mechanism. Compliance continues to be much better for patients admitted to the hospital than those treated and released. Specific suggestions and model follow-up mechanisms are described.

New-onset bronchospasm or recrudescence of asthma associated with cocaine abuse.

OBJECTIVE: To determine whether the occurrence of new-onset bronchospasm or the recrudescence of asthma is associated with the use of cocaine. METHODS: A consecutive sample of patients presenting to an inner-city adult ED with new-onset bronchospasm or recrudescence of bronchospasm after > 5 years were prospectively enrolled in a case-control prevalence study. The bronchospasm patients were queried as to their exposure to illicit drugs, and urine was obtained to screen for cocaine and its metabolite, benzoylecgonine. An age- and sex-matched control group was composed of randomly chosen subjects without respiratory complaints or a history of asthma. The control group was also screened by urine toxicology for cocaine and its metabolite, benzoylecgonine. RESULTS: In the asthma group, 21/59 (36%) had a urine toxicologic screen positive for cocaine metabolite (benzoylecgonine). Of the 21 with a positive screen for cocaine, 8 denied illicit drug abuse. Among the 13 patients reporting drug use, 10 said that they smoked crack and 3 snorted cocaine. In the control group, 8/53 (15%) were positive. Multivariate logistic regression analysis, with adjustment for age and sex, indicated that the use of cocaine was associated with a 3-fold higher prevalence of new-onset bronchospasm or recrudescence of asthma (OR = 3.28, 95% CI: 1.26 to 8.50). CONCLUSIONS: There appears to be an association between cocaine use and new-onset bronchospasm or recrudescence of asthma in this inner-city ED population. Further study is necessary to determine the basis for this association.

College research associates: a program to increase emergency medicine clinical research productivity.

STUDY OBJECTIVE: To evaluate a program using health care preprofessional college students as research associates (RAs) to facilitate research in emergency medicine. METHODS: We developed a program using health care preprofessional college students as RAs in an urban ED with an emergency medicine residency program. RAs were recruited from four local colleges. Potential RAs were instructed during four 2-hour sessions on clinical research in emergency medicine, the ethical issues of confidentiality and informed consent, personal safety, and specifics on data collection for the individual studies. For the 13 weeks of the 1995 spring semester, each RA served one 4-hour shift in the ED each week. They identified patients who were eligible for the studies, began the informed-consent process, obtained nonclinical and historical information, and assisted the physicians in the study protocols. The RAs were evaluated on every shift by two faculty members from New York Medical College. The RAs were surveyed at the completion of the semester about their experiences with the program. RESULTS: Forty-one students completed the orientation course and served at least one shift in the ED. Thirty-three completed more than 7 of 13 possible shifts and received credit for the semester. The average number of shifts served for all RAs was 9 (average numbers of shifts served by RAs receiving credit for the semester and RAs not receiving credit were 10.3 and 4, respectively). Two studies were completed during the semester, each with a significant increase in patient enrollment after the RAs' arrival. Three studies were ongoing at the end of the semester and had patient entries well above projected expectations. The principal investigators for the studies expressed their satisfaction with the RAs' productivity. The faculty evaluations were overwhelmingly positive, as were the results of the RA survey at the end of the semester. The cost of the program was minimal. CONCLUSION: College students serving as research associates can be an economical and successful tool for clinical studies in the emergency department.

Theophylline toxicity in a premature neonate--elimination kinetics of exchange transfusion.

Exchange transfusion was utilized in the treatment of a 1871 gram female, 32 weeks gestational age, who received an IV bolus of aminophylline at 11 h for the treatment of apnea, with subsequent tachycardia and hypotension. At 22 h, plasma theophylline was 369.29 mumol/L (67 mg/L). During a single volume exchange transfusion at 33 h, the plasma theophylline decreased 19% and the estimated removal of theophylline was 13.5% of the whole body theophylline. The theophylline apparent half-times before, during, and after the exchange were 52.5, 6.6, and 53.3 h respectively.

Intrapelvic calculi demonstrated in a patient after laparoscopic laser cholecystectomy: a case report.

Laparoscopic laser cholecystectomy is becoming increasingly popular in the surgical community for the treatment of gallbladder disease. Physicians will need to familiarize themselves with the imaging consequences of this new therapy. Described below is a case report of a woman in whom calculi were incidentally found within the pelvis on a plain radiograph of the abdomen after she presented to the hospital with pancreatitis. Initial confusion regarding the etiology of these calculi was solved after it was discovered that the patient had proven gallstones and a recent laparoscopic procedure. In the appropriate clinical setting, gallstones should be added to the differential consideration of intrapelvic calcifications.

The value of postoperative ultrasound examination after laparoscopic laser cholecystectomy surgery.

Laparoscopic cholecystectomy surgery is rapidly becoming the procedure of choice for patients undergoing gallbladder removal. For the patient, this new minimally invasive surgery allows shorter hospitalization and faster recuperation than traditional open cholecystectomy surgery. Examinations were performed to determine the value of ultrasound in predicting morbidity of patients undergoing the laparoscopic cholecystectomy procedure. Examinations were performed immediately and 6-8 weeks postlaparoscopic surgery on 24 patients with acute or chronic gallbladder disease. All patients had ultrasound examinations prior to surgery. Of the 24 patients studied, 6 patients (25%) developed small fluid accumulations immediately postsurgery. All patients were asymptomatic clinically and remained asymptomatic 6-8 weeks after surgery. The fluid accumulation was thought to be insignificant on the immediate postsurgical studies. This percentage equals that found in open cholecystectomy surgeries. On the delayed ultrasound studies, no fluid deposits or other abnormalities were seen. Ultrasound examination of the asymptomatic patient postlaparoscopic cholecystectomy surgery is not of value for predicting complications in patients undergoing this procedure. Furthermore, immediately postlaparoscopic cholecystectomy surgery, 25% of patients will have small fluid collections, but will not develop complications.

Lead poisoning in adults from renovation of an older home.

Presented is the case of a group exposure to lead occurring during the removal of lead-based paint from an older home. One patient had symptoms from the time of exposure to the time of presentation, when he was acutely ill and encephalopathic. The patient was treated successfully with an initial course of British Anti-Lewisite agent and calcium disodium versenate (CaEDTA) chelation, and two subsequent chelations with CaE-DTA alone. The other two patients had elevated lead levels but were asymptomatic. They were followed closely, and their lead levels steadily declined over several months. The evaluation and treatment of lead poisoning and excessive lead levels in adults is discussed, as is the need for physicians and the lay public to become aware of the hazards of renovating older homes.

Single-dose oral phenytoin loading.

A single 18 mg/kg dose of oral phenytoin capsules or suspension (mean dose, 1.3 g) was given to 44 patients with recent seizures and no detectable serum phenytoin level. Mean serum phenytoin levels after loading for patients receiving capsules were 6.8 micrograms/mL at two hours, 9.7 micrograms/mL at three to five hours, 12.3 micrograms/mL at six to ten hours, and 15.1 micrograms/mL at 16 to 24 hours. Mean levels for patients receiving suspension were slightly, but not significantly, lower than for patients receiving capsules. No seizures occurred during an eight-hour observation period after loading. Drug toxicity was minimal. Single-dose, 18 mg/kg oral phenytoin loading provides rapid therapeutic levels and is well tolerated.

Oral analgesia for treatment of painful crisis in sickle cell anemia.

A therapeutic plan that emphasized oral narcotic analgesia was instituted for the treatment of painful crisis of sickle cell anemia. Of the 100 adult sickle cell syndrome patients registered at North Central Bronx Hospital, 15 were identified as using the emergency department facilities three or more times per year. This "frequent user" patient population was tracked in their hospital and drug usage patterns during the first full year of the oral protocol and compared to their own patterns during the year prior to the protocol. The patients used the ED at the same rate but their frequency of admissions to the hospital dropped by 75%. The oral program produced a significant fall in the amount of narcotics dispensed in the ED (P less than .01).

Excess ventilation with oxygen-powered resuscitators.

Massive subcutaneous emphysema developed in three patients following ventilation with an oxygen-powered, positive pressure resuscitator used by an urban emergency medical service. A faulty valve regulator was identified as the source of the problem. Following this discovery, an extensive field test of all oxygen-powered resuscitators used by the emergency service was carried out. Sixty resuscitators were tested, 15 of which (25%) were found to be deficient on at least one of the test criteria. It is strongly recommended that all personnel using these devices be trained to recognize equipment malfunction and that periodic performance evaluations be carried out on all such equipment. The results of this field test, and other performance tests done previously, raise questions about the use of positive pressure resuscitators in the emergency setting.