David A. Jerrard

The erythrocyte sedimentation rate

The erythrocyte sedimentation rate has been used for over 50 years for everything from predicting disease severity to assessing general sickness index. Its perceived utility has been based on medical myths and its use too often based only on a consultants demand or a shotgun approach to diagnosis. This article focuses on examining the specific utility of the erythrocyte sedimentation rate in the emergency department as a tool for predicting both disease likelihood and severity.

Prescription noncompliance: contribution to emergency department visits and cost.

We randomly surveyed 100 patients in the acute care section of a large urban university hospital Emergency Department (ED) on 6 days with regard to the existence of and reasons for prescription noncompliance. Noncompliance was considered a major factor contributing to the ED visit if: (1) no medications had been taken for at least 48 h before the ED visit; (2) the medications, when previously taken, had routinely controlled the condition for which the patient was presenting to the ED; and (3) no other significant cause or illness was believed to have precipitated the ED visit. ED, admissions, and yearly medication costs were calculated for all patients. Noncompliance was found to be a contributing factor in the cases of 22 patients (22%). The most common medications involved were phenytoin and albuterol. Cost was the most common reason for noncompliance (11 [50%]). The average ED charge per noncompliant patient discharged was

Unsuspected heterotopic pregnancy in a woman without risk factors

576.61. Six noncompliant patients were admitted at an average cost of

Patients leaving against medical advice (AMA) from the emergency department--disease prevalence and willingness to return.

4,834.62. The average cost of a years medication was

The efficacy and safety of a continuous albuterol protocol for the treatment of acute adult asthma attacks

520.72. Noncompliance with drug prescriptions is a significant contributor to ED visits and health care costs.

How Long Are Patients Willing to Wait in the Emergency Department Before Leaving Without Being Seen

A 27-year-old woman presented to the emergency department with abdominal pain. One week prior to this she had had an ultrasound which revealed an intrauterine pregnancy (IUP). A second ultrasound performed at our institution revealed an intrauterine pregnancy along with a concomitant ectopic pregnancy which had ruptured. This case emphasizes that coincident pregnancies may occur in women who are without risk of ectopic pregnancy or multiple gestations. In addition, ultrasound must be evaluated fully for heterotopic pregnancy in all women.

Malaria: a rising incidence in the United States.

BACKGROUND How patients fare once they leave the emergency department (ED) against medical advice (AMA), and the extent of illness burden that accompanies them, remains unstudied. OBJECTIVE To determine the fate of patients leaving the ED AMA for a defined period of time post-discharge. METHODS This was a prospective follow-up study of a convenience sample of patients leaving the ED AMA during two 6-month periods in consecutive calendar years at an urban academic ED with 32,000 annual patient visits. RESULTS A total of 199 patients were identified, with 194 enrolled. Categories of discharge diagnoses included cardiovascular, undifferentiated abdominal pain, respiratory, and cellulitis. Of the 194 patients studied, 126 patients (64.9%, 95% confidence interval [CI] 57.6-71.5%) stated that their symptoms had improved or resolved. Of these 126 patients, 109 (86.5%, 95% CI 78.9-91.7%) had their original AMA discharge diagnoses referable to cardiovascular pathology. Ninety-five patients (75.4%, 95% CI 66.7-82.4%) with improved or abated symptoms did not plan to return. Of those with improved or abated symptoms, 31 patients (24.6%, 95% CI 17.6-33.2%) did return, and with further evaluation, 15 of them were found to have significant clinical findings. Of the 68 patients with continuing symptoms, 36 (52.9%, 95% CI 40.5-64.9%) returned for further evaluation. A total of 127 patients did not return. Twenty-five patients (19.7%, 95% CI 15.9-25.4%) expressed a reluctance to return to the same ED for fear of embarrassment. Seven patients (5.5%, 95% CI 4.8-8.7%) who did not seek alternative care but were still having symptoms did not return due to job or family commitments or because they would follow-up with a personal physician. CONCLUSION Patients who leave the ED AMA have significant pathology.

ED management of insect stings

We performed a prospective study over a 6-month period to test the efficacy and safety of a continuous nebulized albuterol protocol for the treatment of acute adult asthma attacks. All patients 18 years or older presenting to the emergency department with acute asthma attacks were begun by the triage nurse on the protocol of three continuous albuterol (2.5 mg) nebulizer treatments. Pretreatment and posttreatment peak flow, respiratory rate, pulse, and blood pressure were documented and patients gave a pretreatment and posttreatment rating of the clinical severity of their attack using a (1 to 10) visual analog scale. In addition, all adverse effects were noted. Seventy-six patients were entered in the study. The average age was 44 years (range, 20 to 82 years). Pretreatment and posttreatment peak flow, respiratory rate, pulse, blood pressure, and clinical severity were compared using the paired t test. Patients showed statistically significant increases in peak flow (128 to 292; P < .0001) and statistically significant decreases in respiratory rate (27 to 20; P < .0001); pulse, 103 to 94 (P < .0001); clinical severity, 7.8/10 to 1.8/10 (P < .0001); and blood pressure, 141/82 to 132/77 (P < .001). Adverse effects were minimal. Two patients (2.6%) felt flushed, three patients (4%) felt jittery, and one patient (1.3%) had a sensation of palpitations. We conclude that a continuous nebulized albuterol protocol is both extremely efficacious and safe for the treatment of acute adult asthma attacks.

Simultaneous uvulitis and epiglottitis without fever or leukocytosis.

Introduction: Our goal was to evaluate patients’ threshold for waiting in an emergency department (ED) waiting room before leaving without being seen (LWBS). We analyzed whether willingness to wait was influenced by perceived illness severity, age, race, triage acuity level, or insurance status. Methods: We conducted this survey-based study from March to July 2010 at an urban academic medical center. After triage, patients were given a multiple-choice questionnaire, designed to ascertain how long they would wait for medical care. We collected data including age, gender, race, insurance status, and triage acuity level. We looked at the association between willingness to wait and these variables, using stratified analysis and logistic regression. Results: Of the 375 patients who were approached, 340 (91%) participated. One hundred seventy-one (51%) were willing to wait up to 2 hours before leaving, 58 (17%) would wait 2 to 8 hours, and 110 (32%) would wait indefinitely. No association was found between willingness to wait and race, gender, insurance status, or perceived symptom severity. Patients willing to wait >2 hours tended to be older than 25, have higher acuity, and prefer the study site ED. Conclusion: Many patients have a defined, limited period that they are willing to wait for emergency care. In our study, 50% of patients were willing to wait up to 2 hours before leaving the ED without being seen. This result suggests that efforts to reduce the percentage of patients who LWBS must factor in time limits.

Serum determinations in toxic isopropanol ingestion.

Malaria is frequently a deadly disease, particularly in tropical countries of the world where this protozoan infection is endemic. While physicians in tropical countries are familiar with the presentation, those who do not practice in endemic regions of the world may neglect to add tropical diseases to their differential diagnosis of fever. Epidemiologic data from the CDC show the number of cases of malaria being diagnosed in the United States in the last decade has risen sharply. With international travel continuing to rise, there is strong reason to consider malaria as a source of fever.