Biomedical subjects
J E Tintinalli
Publications and source records attributed to J E Tintinalli.
Domestic violence: issues for health care providers.
Explore the source record for details and available documents.
Serum methanol in the absence of methanol ingestion.
Explore the source record for details and available documents.
Importance of emergency physicians as referral sources for academic medical centers. The Gallup Organization Healthcare Group.
STUDY OBJECTIVE: To identify physician referral patterns and factors involved in the patient referral process. DESIGN: A telephone survey conducted on a systematic sample of physicians who referred at least one patient a month to a tertiary care center. SETTING: A major southeastern tertiary care academic medical center. TYPE OF PARTICIPANTS: Self-identified emergency physicians, family physicians, general surgeons, internists, obstetrician-gynecologists, and pediatricians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Emergency physicians comprised 6% of the surveyed sample. Emergency physicians referred the largest number of patients each month to a tertiary care center (40 patients per month) compared with the other target specialists, who referred an average of 16 patients per month (P < .05). Specialty services most often requested by emergency physicians were internal medicine, trauma, and cardiology. CONCLUSION: Emergency physicians refer more patients to academic medical centers than any other specialty. Academic medical centers should target emergency physicians if they wish to increase their patient referral base.
Emergency department surveillance: an examination of issues and a proposal for a national strategy.
Explore the source record for details and available documents.
Emergency medical evaluation of psychiatric patients.
STUDY OBJECTIVES: To determine the completeness of documentation and accuracy of medical evaluation for a sample of emergency psychiatric patients. DESIGN: Descriptive, retrospective chart review. SETTING: Nine hundred-bed community teaching hospital with a voluntary psychiatric inpatient unit. TYPE OF PARTICIPANTS: Two hundred ninety-eight emergency department patients with psychiatric chief complaints, all of whom were admitted to the voluntary psychiatric unit of the same community teaching hospital. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: There was failure to document mental status at triage in 56% of patients. The most frequent process deficiencies in the medical evaluation were in the neurological examination. Twelve patients (4%) required acute medical treatment within 24 hours of psychiatric admission, and the ED history and physical examination should have identified an acute condition in 83%. The chart was documented "medically clear" in 80% of patients in whom medical disease should have been identified. Patients less than 55 years old had a four times greater chance of a missed medical diagnosis. CONCLUSION: Process deficiencies in the medical history and physical examination accounted for the vast majority of missed acute medical conditions. The statement "medically clear" is inaccurate and should be replaced by a thorough discharge note.
Violent patients and the prehospital provider.
STUDY OBJECTIVES: To estimate the frequency of violence directed toward prehospital providers; to identify the methods used to manage violent patients in the prehospital setting; and to identify the educational, medical, and legal issues in the prehospital management of violent patients. DESIGN: A convenient sample survey and a descriptive review of ambulance call reports from June to December 1991. SETTING: The survey was distributed to registrants at the National Association of EMS Physicians in Pittsburgh, Pennsylvania, in June 1992. Ambulance call reports were reviewed for a metropolitan county with a service population of 60,000. INTERVENTIONS: None. RESULTS: Only about 50% of survey respondents reported having protocols for the management of violent patients. Law enforcement officers provided assistant in managing violent patients for 97% of respondents, and 81% reported that a violent patient who refused transport could be arrested. Injury to prehospital providers in the past year was reported by 67% of respondents. Although 67% reported some training in the management of violent patients, only 9% had training by law enforcement officers and only 25% thought that they were trained in assessing the scene for potential violence. Ambulance call report review identified an 0.8% incidence of violent episodes. Weapons were evident in 12% of violent encounters. Transport was refused by 18% of violent patients. In 9% of violent encounters, patients were hypoglycemic. No emergency medical technician injuries were reported for the study period. CONCLUSION: The potential for injury to prehospital providers from violent patients is probably widespread, and no mechanism for identifying injuries or exposure to violent patients currently exists. All systems should have protocols for managing violent patients and for restraint application. Educational sessions for self-defense and assessment of the scene for violence may be indicated.
Aspiration of radiolucent foreign body.
Explore the source record for details and available documents.
Evaluation and treatment of the gravida and fetus following trauma during pregnancy.
The management of trauma during pregnancy requires an interdisciplinary team approach involving surgeons, emergency medicine physicians, and obstetricians. Management principles are similar to those utilized in nonpregnant patients, but a number of unique circumstances must be considered, including physiologic changes of pregnancy, diagnosis and management of abruptio placentae and fetomaternal hemorrhage, and the management of traumatic cardiac arrest during pregnancy. The routine use of cardiotocography, Kleihauer-Betke assay, and perimortem cesarean section are discussed as new principles in the management of trauma during pregnancy.
The strengths & weaknesses of undergraduate education.
Explore the source record for details and available documents.
The need for coding systems to evaluate emergency medicine residency programs.
Explore the source record for details and available documents.
Associated reactions during and immediately after rtPA infusion.
The complications of IV recombinant tissue-type plasminogen activator (rtPA) have not been previously reported specifically for the first hours after initiation of the therapy when patients are often in emergency departments or in transport. The charts of 124 patients who received rtPA between April 1986 and December 1987 were retrospectively reviewed for reactions associated with rtPA infusion occurring in the first ten hours after the onset of rtPA administration. Minor bleeding developed in 19% of the patients, and life-threatening bleeding in 3%. Half of the life-threatening bleeding episodes were not predictable by history or physical examination. Arrhythmias were frequent despite the fact that all patients were maintained on IV lidocaine. New premature ventricular contractions occurred in 67%, accelerated idioventricular rhythm in 34%, ventricular tachycardia in 30%, and ventricular fibrillation in 2%. Many of the arrhythmias other than ventricular fibrillation had little hemodynamic consequence and did not require treatment. Neurologic episodes occurred in 3%, including two patients with intracerebral bleeding (1.5%); hypotension requiring treatment developed in 3%; and minor symptoms of allergy in 2%. Administration of rtPA in the ED requires careful patient selection to avoid bleeding complications and close monitoring to detect arrhythmias and changes in vital signs.
Evaluation of emergency medicine residents by nurses.
Emergency medicine residents at William Beaumont Hospital are evaluated quarterly by the nursing staff. The nurse discuss each resident and reach consensus on each evaluation item. Copies of the evaluations are given to each resident, and a copy is used at the resident's biannual evaluation meeting with the program director. Between September 1985 and December 1987, 45 residents in all three years of training were evaluated by the nursing staff on four aspects of performance: managerial skills, communication, teamwork, and clinical organization. The nurses were able to evaluate behavior not usually seen by supervising physicians. Although the residents' attitudes toward these evaluations have not been entirely favorable, overall their behavioral interactions have improved markedly.
Myocardial salvage: thrombolytic therapy.
Thrombolytic therapy for acute myocardial infarction is an important advance in patient care. The intravenous administration of tissue plasminogen activator appears to be the most promising combination of route and agent but may need to be coupled with more definitive measures. Although the prehospital use of thrombolysis is largely unexplored, the interhospital use appears to be safe and effective. The administration of thrombolytic therapy must be a coordinated effort between the emergency physician and the cardiologist. Indications for thrombolytic therapy are still evolving and adverse effects will no doubt increase in incidence once the availability and use of effective thrombolytic agents is widespread. The emergency physician, especially, needs to tread the fine line between "minutes are myocardium" and "haste makes waste."