Casey A. Grover

Quantifying Drug-seeking Behavior: A Case Control Study

BACKGROUND Drug-seeking behavior (DSB) is common in the Emergency Department (ED), yet the literature describing DSB in the ED consists predominantly of anecdotal evidence. STUDY OBJECTIVES To perform a case-control study examining the relative frequency of DSB in suspected drug-seeking patients as compared to all ED patients. METHODS We performed a retrospective chart review of 152 drug-seeking patients and of age- and gender-matched controls, noting which of the following behaviors were exhibited during a 1-year period: reporting a non-narcotic allergy, requesting addictive medications by name, requesting a medication refill, reporting lost or stolen medication, three or more ED visits complaining of pain in different body parts, reporting 10 out of 10 pain, reporting > 10 out of 10 pain, three or more ED visits within 7 days, reporting being out of medication, requesting medications parenterally, and presenting with a chief complaint of headache, back pain, or dental pain. RESULTS The odds ratios for each studied behavior being used by drug seeking patients as compared to controls were: non-narcotic allergy: 3.4, medication by name: 26.3, medication refill: 19.2, lost or stolen medication: 14.1, three or more pain related visits in different parts of the body: 29.3, 10 out of 10 pain: 13.9, three visits in 7 days: 30.8, out of medication: 26.9, headache: 10.9, back pain: 13.6, and dental pain: 6.3. Zero patients in the control group complained of greater than 10-out-of-10 pain or requested medication parenterally, resulting in a calculated odds ratio of infinity for these two behaviors. CONCLUSIONS Requesting parenteral medication and reporting greater than ten out of ten pain were most predictive of drug-seeking, while reporting a non-narcotic allergy was less predictive of drug-seeking than other behaviors.

How frequently are "classic" drug-seeking behaviors used by drug-seeking patients in the Emergency Department?

Introduction: Drug-seeking behavior (DSB) in the emergency department (ED) is a very common problem, yet there has been little quantitative study to date of such behavior. The goal of this study was to assess the frequency with which drug seeking patients in the ED use classic drug seeking behaviors to obtain prescription medication. Methods: We performed a retrospective chart review on patients in an ED case management program for DSB. We reviewed all visits by patients in the program that occurred during a 1-year period, and recorded the frequency of the following behaviors: complaining of headache, complaining of back pain, complaining of dental pain, requesting medication by name, requesting a refill of medication, reporting medications as having been lost or stolen, reporting 10/10 pain, reporting greater than 10/10 pain, reporting being out of medication, and requesting medication parenterally. These behaviors were chosen because they are described as “classic” for DSB in the existing literature. Results: We studied 178 patients from the case management program, who made 2,486 visits in 1 year. The frequency of each behavior was: headache 21.7%, back pain 20.8%, dental pain 1.8%, medication by name 15.2%, requesting refill 7.0%, lost or stolen medication 0.6%, pain 10/10 29.1%, pain greater than 10/10 1.8%, out of medication 9.5%, and requesting parenteral medication 4.3%. Patients averaged 1.1 behaviors per visit. Conclusion: Drug-seeking patients appear to exhibit “classically” described drug-seeking behaviors with only low to moderate frequency. Reliance on historical features may be inadequate when trying to assess whether or not a patient is drug-seeking.

“Thumb Sign” of Epiglottitis

A 58-year-old man presented to the ER after having had severe throat pain, hoarseness, and fever for 2 days. There was no stridor, respiratory distress, or drooling, and oropharyngeal examination was unremarkable. A lateral soft-tissue radiograph of the neck showed a “thumb sign.”

Significant toxicity in a young female after low-dose tricyclic antidepressant ingestion.

Background Tricyclic antidepressant (TCA) ingestions are a relatively common pediatric ingestion, with significant potential for both cardiac and neurological toxicity. Previous studies on pediatric TCA ingestions have found the threshold of toxicity to be 5 mg/kg. Case We report a case of an 8-year-old girl who presented to the emergency department with depressed mental status and seizure-like movements. An extensive workup was pursued to evaluate the cause of her mental status, which only revealed a positive urine toxicology screen for TCA. Quantified serum levels of amitriptyline were 121 ng/mL (therapeutic range, 50–300 ng/mL) and nortriptyline were 79 ng/mL (therapeutic range 70–170 ng/mL), 18 hours after onset of symptoms. Subsequent history obtained after her mental status returned to normal revealed that she had ingested amitriptyline at a dose of 0.8 mg/kg. Conclusions Tricyclic antidepressant ingestion has a high potential for toxicity in pediatric patients. This case suggests, contrary to previous literature, that toxicity may occur even with small doses.

Anorexia nervosa: a case report of a teenager presenting with bradycardia, general fatigue, and weakness.

Background Anorexia nervosa is a disease with high prevalence in adolescents and carries the highest mortality of any psychiatric disorder. Case We present a case of a 17-year-old female presenting to the emergency department with bradycardia that was subsequently diagnosed with anorexia nervosa. We also review the clinical features, diagnosis, complications, and emergency department management of this disease. Conclusions Patients with anorexia may present with multiple medical complaints, and it is imperative that the emergency physician be familiar with the syndrome so as to correctly identify and treat patients with this disease.

Albert Behnke: Nitrogen Narcosis

As early as 1826, divers diving to great depths noted that descent often resulted in a phenomenon of intoxication and euphoria. In 1935, Albert Behnke discovered nitrogen as the cause of this clinical syndrome, a condition now known as nitrogen narcosis. Nitrogen narcosis consists of the development of euphoria, a false sense of security, and impaired judgment upon underwater descent using compressed air below 3-4 atmospheres (99 to 132 feet). At greater depths, symptoms can progress to loss of consciousness. The syndrome remains relatively unchanged in modern diving when compressed air is used. Behnkes use of non-nitrogen-containing gas mixtures subsequent to his discovery during the 1939 rescue of the wrecked submarine USS Squalus pioneered the use of non-nitrogen-containing gas mixtures, which are used by modern divers when working at great depth to avoid the effects of nitrogen narcosis.

Narcotic Bowel Syndrome

BACKGROUND Narcotic bowel syndrome is characterized by chronic or recurrent abdominal pain associated with escalating doses of narcotic pain medications. It may occur in as many as 4% of all patients taking opiates, and yet few physicians are aware that the syndrome exists. OBJECTIVES The objectives of this case report are to raise awareness of narcotic bowel syndrome among emergency physicians, as well as review the clinical features, diagnosis, pathophysiology, and emergency department (ED) management of the syndrome. CASE REPORT We report a case of narcotic bowel syndrome diagnosed in a 24-year-old woman after > 1 year of ED visits for recurrent abdominal pain of unknown origin. CONCLUSIONS It is particularly important for emergency physicians to be familiar with this syndrome, as many patients with narcotic bowel syndrome seek evaluation and treatment in the ED. Although the diagnosis is unlikely to be made in the ED, timely referral for evaluation of this syndrome may help patients to receive definitive treatment for their recurrent and chronic pain.

The Efficacy of Case Management on Emergency Department Frequent Users: An Eight-Year Observational Study.

BACKGROUND Case management is an effective short-term means to reduce Emergency Department (ED) visits in frequent users of the ED. OBJECTIVES Our study aimed to assess the long-term efficacy of intensive case management in frequent users of the ED. METHODS This was an observational study of ED usage conducted at a community hospital that has an ED case management program in which frequent users of the ED are enrolled and provided with intensive care management to reduce ED use. RESULTS We identified 199 patients that were enrolled for 6 or more years. Patients averaged 16 visits per person per year in the year prior to enrollment. Patients averaged the following number of visits per person per year after enrollment: year 1 (7.1), year 2 (4.1), year 3 (3.1), year 4 (3.3), year 5 (3.1), year 6 (2.0), year 7 (2.1), and year 8 (1.9), all statistically significant compared to the year prior to enrollment. Twenty-nine patients, despite case management, continued their frequent use, and required a revision to their plan of care. Five patients required a second revision to their plan of care secondary to recurrent ED usage. Persistent use despite case management was primarily due to prescription medication misuse and chronic pain. CONCLUSION Case management of ED frequent users seems to be an effective means to reduce ED usage in both the short and long term. Patients with prescription drug misuse or chronic pain may continue to demonstrate frequent use despite case management, and may require revisions to their plan of care.

Unilateral Facial Swelling With Fever

A 3-year-old fully vaccinated girl presented to the emergency department with a 2-day history of low-grade fevers, runny nose, and a “swelling” on the left side of her face. Physical examination demonstrated a well-appearing child with a firm, mobile, 2-cm swelling over the angle of the left mandible. Ultrasonography of the swelling was performed with a 5to 10-MHz linear array transducer probe (Figure 1). For comparison, ultrasonography of the same area on the right side was performed (Figure 2). Figure 1. Ultrasonography of the swelling over the patient’s left mandible, demonstrating an enlarged tissue mass with prominent hypoechoic areas. Figure 2. Ultrasonography of the corresponding area on the patient’s right side, for comparison, demonstrating decreased tissue mass and less prominent hypoechoic areas as compared to the left side. Used with permission of Casey A. Grover, MD, Stanford/Kaiser Emergency Medicine Residency, Stanford, CA.

Case Management Reduces Length of Stay, Charges, and Testing in Emergency Department Frequent Users

Introduction Case management is an effective, short-term means to reduce emergency department (ED) visits in frequent users of the ED. This study sought to determine the effectiveness of case management on frequent ED users, in terms of reducing ED and hospital length of stay (LOS), accrued costs, and utilization of diagnostic tests. Methods The study consisted of a retrospective chart review of ED and inpatient visits in our hospital’s ED case management program, comparing patient visits made in the one year prior to enrollment in the program, to the visits made in the one year after enrollment in the program. We examined the LOS, use of diagnostic testing, and monetary charges incurred by these patients one year prior and one year after enrollment into case management. Results The study consisted of 158 patients in case management. Comparing the one year prior to enrollment to the one year after enrollment, ED visits decreased by 49%, inpatient admissions decreased by 39%, the use of computed tomography imaging decreased 41%, the use of ultrasound imaging decreased 52%, and the use of radiographs decreased 38%. LOS in the ED and for inpatient admissions decreased by 39%, reducing total LOS for these patients by 178 days. ED and hospital charges incurred by these patients decreased by 5.8 million dollars, a 41% reduction. All differences were statistically significant. Conclusion Case management for frequent users of the ED is an effective method to reduce patient visits, the use of diagnostic testing, length of stay, and cost within our institution.