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Biomedical subjects

R L Norton

Publications and source records attributed to R L Norton.

At least 19 recordsLinked to original sources
PubMed2001

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.

Alcoholic Intoxication↗
PubMed1999

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.

California↗
PubMed1998

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.

Adrenergic beta-Antagonists↗
PubMed1996

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.

Administration, Oral↗
PubMed1996

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.

Adolescent↗
PubMed1994

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.

Adolescent↗
PubMed1994

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)

Administration, Oral↗
PubMed1992

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.

Autopsy↗
PubMed1990

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.

Acute Disease↗
PubMedDate not supplied

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.

Humans↗
PubMedDate not supplied

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.

Clinical Protocols↗