Biomedical subjects
Publications and source records attributed to W K Mallon.
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OBJECTIVES: Los Angeles County-University of Southern California Medical Center, like many large urban hospitals, has a large immigrant population from regions of the world where leprosy is endemic. Emergency physicians (EPs) in these settings can expect to encounter leprosy patients. This study reviewed the emergency department (ED) course of patients with confirmed leprosy in an attempt to describe the most common presenting patterns so that future cases can be more easily recognized. METHODS: This was a retrospective chart review of all patients followed in the Hansen's disease clinic. Demographics, leprosy type, clinical presentations to the ED, and medications were recorded. RESULTS: Of the total number of patients (415), most were of Mexican (52%), Filipino (15%), Vietnamese (14%), and Chinese (5%) origin. Leprosy was classified as lepromatous (56%), borderline (40%), and tuberculoid (4%). There were a total of 118 ED visits by 74 patients. The mean age was 46 years, with 51% male and 49% female. Dermatologic (68%), neurologic (23%), and ophthalmologic (9%) complaints were the most common reasons for ED presentation related to leprosy. The EP did not elicit a history of leprosy in 34% of those patients followed in the leprosy clinic. The ED diagnosis of leprosy was made in 3 of 15 (20%) undiagnosed cases. Of the 63 patients prescribed medications in the leprosy clinic at the time of their ED visits, 22 (35%) ED charts did not report leprosy drugs. CONCLUSION: Patients with leprosy present to U.S. EDs, and new cases can be identified. Early recognition is important given leprosy's devastating consequences, major drug side effects of medications used for treatment, and improved prognosis with multidrug therapy. A history of leprosy and associated medications are often not documented in the ED chart, which may reflect a continued fear of stigmatization among these patients.
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OBJECTIVE: To report two epidemic outbreaks of scombroid food poisoning and their emergency medical services (EMS) response and emergency department (ED) treatment, analyzing the impact of early physician involvement and on-line medical control. METHODS: Retrospective case series of two multiple-casualty incidents (MCIs) involving scombroid food poisoning. RESULTS: A total 57 patients were treated from two separate incidents, with 30 patients transported to area hospitals. One patient required treatment with a cardiac medication in the field and another patient eventually required hospital admission. On-scene medical control (incident 1) and early identification of the index case (incident 2) were instrumental to out-of-hospital care interventions and conservation of resources. Patient triage, field treatment, and hospital transport were expedited, with some patients treated and released from the scene. CONCLUSIONS: Immediate diagnosis of a food-borne illness in the out-of-hospital setting allows rapid treatment at the scene and allows for the efficient transport of multiple patients to a single receiving facility. EMS medical directors should be able to immediately respond to such incidents to make presumptive diagnoses and accurately direct patient care. When this is not possible, early identification of the index case facilitates early diagnosis and treatment.
STUDY OBJECTIVE: To determine whether an intensive educational campaign of emergency department personnel on the organ donor and procurement process would result in both increased organ donor referrals and organs procured. METHODS: A retrospective review of the performance of an urban teaching ED in identifying and referring potential organ donor candidates was performed. Subsequently an intensive educational campaign of all ED staff, in conjunction with the Regional Organ Procurement Agency of Southern California (ROPA), was initiated. Physicians and nurses were educated about the procurement process, and a ROPA representative was on call 24 hours a day to assist in this process. The need for aggressive resuscitation and vital sign maintenance in potential donors as a strategy to promote organ recovery was emphasized. Reeducation by ROPA occurred every 2 to 3 months. The identification and referral rates were then retrospectively reviewed to evaluate any improvement. RESULTS: In 1994 the initial referral rate of potential organ donors from the ED was 30% (3 of 10) resulting in no organs procured. After the intervention the referral rate increased to 100% (25 of 25) in 1995 (P < .0001). The number of actual donors procured was 0 in 1994, 5 in 1995, and 9 in 1996. The increased ED referrals resulted in 14 and 32 organs procured in 1995 and 1996, respectively. CONCLUSION: Emergency physicians are in a unique position as first caregivers to interact with both potential donors and their families. With intensive education of ED staff, proper identification and referral, as well as timely intervention by organ procurement representatives, the consent and donation rate of organs for transplantation can be increased and maintained.
Over the past 60 years, trauma has become the leading cause of morbidity and mortality in the pregnant patient. The emotional and physiological challenges of treating two patients simultaneously adds to an already stressful situation. Resuscitation of the pregnant trauma patient is discussed from the prehospital setting to disposition. Also discussed are non-invasive monitoring tools, such as tocodynanomometry and ultrasonography.
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OBJECTIVE: To measure the degree of burnout among emergency physicians (EPs) and to identify and rank predictive factors. METHODS: Using the Maslach Burnout Inventory as well as a 79-item questionnaire, a cross-sectional survey was conducted for physician registrants at the Annual Scientific Assemblies of the American College of Emergency Physicians from 1992 to 1995. Degrees of burnout were stratified into low, moderate, and high ranges. Univariate and stepwise multiple regression analyses were conducted to identify and rank correlates to burnout scores. RESULTS: Of 1,272 registrants taking the inventory, 60% registered in the moderate to high burnout ranges. Twenty-one correlates were identified. These were classified broadly in terms of negative perceptions of self, negative practice habits and attitudes, and unhealthy lifestyles. The most highly ranked correlates were: self-recognition of burnout, lack of job involvement, negative self-assessment of productivity, dissatisfaction with career, sleep disturbances, increased number of shifts per month, dissatisfaction with specialty services, intent to leave the practice within 10 years, higher levels of alcohol consumption, and lower levels of exercise. Age and years of practice were not significant predictors of burnout. Projected attrition rates were 7.5% over 5 years and 25% over 10 years. CONCLUSIONS: Elevated levels of burnout exist among a substantial percentage of surveyed EPs. However, there is evidence for a "survivor" category of practitioners for whom burnout either does not develop or is a reversible process. The projected attrition rate over 5 and 10 years appears to be no greater than that of the average medical specialty.
Parotid swelling as the presenting symptom of acute tuberculosis is uncommon and often missed. Inappropriate treatment or referral can lead to serious sequelae. Because the incidence of extrapulmonary tuberculosis at all sites has been increasing steadily since 1985, this diagnosis now must enter into the differential of any individual at risk. Awareness on the part of the emergency physician will allow prompt recognition and appropriate treatment of this disease.
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STUDY PURPOSE: To evaluate the efficacy of adenosine in the treatment of emergency department patients with unstable paroxysmal supraventricular tachycardia (PSVT). DESIGN: A retrospective chart review conducted over two years. SETTING: A university-affiliated hospital ED. PARTICIPANTS: Patients with unstable PSVT (systolic blood pressure of less than 90 mm Hg, chest pain, pulmonary edema, and/or altered mental status) who were treated with adenosine. INTERVENTIONS: Patients' preadenosine and postadenosine heart rates, symptoms, and blood pressure were recorded, as were complications and recurrence of PSVT. PSVT was diagnosed by surface ECG. RESULTS: Twelve patients were identified (three men and nine women with a mean age of 47.6 years). Nine patients presented with hypotension (mean systolic blood pressure, 79 mm Hg), ten with chest pain, and six with both chest pain and hypotension. There were no patients with altered mental status or pulmonary edema. Eight patients converted to sinus rhythm with a single 6-mg bolus of adenosine; the remaining four required an additional 12-mg bolus. In all cases, chest pain and hypotension resolved within minutes of conversion to sinus rhythm. There were no clinically significant adverse effects or recurrence of PSVT during ED observation (mean, 1.8 hours). All patients responded to adenosine; none required electrical cardioversion. CONCLUSION: In the unstable patient with PSVT, adenosine appears to be a safe and effective alternative to current advanced cardiac life support-recommended immediate electrical cardioversion.
The case presented offers a demonstration of a rare yet devastating condition that may go unrecognized and incompletely worked up by the emergency physician. Internal carotid artery dissection is seen most often in previously healthy, young patients and thus all efforts toward diagnosing this condition and providing proper stabilization must be made. Unfortunately, little advancement in the therapeutic progress of this frequently fatal condition has been made over the past decades. To date, both medical management and surgical techniques have been utilized with variable success. This case should serve to remind physicians evaluating young patients with stroke symptoms or other neurological findings that a negative head CT scan may not be the last test necessary for the definitive diagnosis.