Erin L. Simon

Caffeine overdose resulting in severe rhabdomyolysis and acute renal failure.

Despite the fact that caffeine is the most commonly used stimulant in modern society, cases of caffeine overdose are relatively rare, with fatalities reported from doses of 10 g and higher (Nord J Psychiatry. 2006;60:97-106). Large doses produce symptoms associated with stimulation of the cardiovascular, central nervous, and gastrointestinal symptoms (Associates of the California Poison Control Center, Poisoning and Drug Overdose, pp. 142-143. 5th Ed). We present the first reported case of a man with delayed presentation to the emergency department after ingesting 24 g of caffeine in a suicide attempt who suffered complications of severe rhabdomyolysis and acute renal failure requiring subsequent hemodialysis.

Regionalization of Emergency Care Future Directions and Research: Workforce Issues

The provision of emergency care in the United States, regionalized or not, depends on an adequate workforce. Adequate must be defined both qualitatively and quantitatively. There is currently a shortage of emergency care providers, one that will exist for the foreseeable future. This article discusses what is known about the current emergency medicine (EM) and non-EM workforce, future trends, and research opportunities.

Variation in hospital admission rates between a tertiary care and two freestanding emergency departments

Background Recently, freestanding emergency departments (FSEDs) have grown significantly in number. Critics have expressed concern that FSEDs may increase healthcare costs. Objective We determined whether admission rates for identical diagnoses varied among the same group of physicians according to clinical setting. Methods This was a retrospective comparison of adult admission rates (n = 3230) for chest pain, chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure (CHF) between a hospital‐based ED (HBED) and two FSEDs throughout 2015. Frequency distribution and proportions were reported for categorical variables stratified by facility type. For categories with cell frequency less or equal to 5, Fishers Exact test was used to calculate a P value. Chi square tests were used to assess difference in proportions of potential predictor variables between the HBED and FSEDs. For continuous variables, the mean was reported and Students t‐test assessed the difference in means between HBED and FSED patients. Multivariate logistic regression analyses were performed to estimate the unadjusted and adjusted prevalence odds ratio with 95% confidence interval (CI) for patient disposition outcomes associated with type of ED facility visited. Results Of 3230 patients, 53% used the HBED and 47% used the FSED. Patients visiting the HBED and FSED varied significantly in gender, acuity levels, diagnosis, and number of visits. Age was not significantly different between facilities. Multivariable adjusted estimated prevalence odds ratio for patients admitted were 1.2 [95%CI: 1.0–1.4] in the HBED facility compared to patients using FSEDs. Conclusion In our healthcare system, FSEDs showed a trend towards a 20% lower admission rate for chest pain, COPD, asthma and CHF.

Patient-reported reasons for seeking emergency care at a freestanding emergency department compared to a hospital-based emergency department

The popularity and number of freestanding emergency departments (FEDs) has substantially increased in the past few years. FEDs are typically open 24/7 and are staffed by qualified emergency care providers. FEDs generally offer faster throughput and more efficient hospital admission when necessary [1]. Becausemany communities have at least one FED and oneHBED, patients are more frequently faced with the choice of seeking emergency care at one of these facilities. It is unclear what drives some patients to FEDs and others to HBEDs. There is literature on why patients come to an ED. The most common reasons cited are seriousness of condition,

Traumatic Pulmonary Herniation at the Diaphragmatic Junction in a Pediatric Patient: A Rare Complication of Blunt Chest Trauma.

We present a case of traumatic intercostal pulmonary herniation in an 11-year-old boy after blunt trauma to the chest, without associated chest wall disruption or pneumothorax. This condition is especially uncommon in children, with only 5 previously reported cases and most occurring after penetrating chest trauma. To date, there are no reports in literature describing traumatic intercostal lung herniation at the diaphragmatic junction with a closed chest cavity in a child. The number of traumatic lung herniation diagnoses may be expanded by a more liberal use of computed tomography when serious injury is suspected. Computed tomography and advanced imaging should be considered in pediatric trauma patients presenting with concern for intrathoracic injury that may not be seen on plain film. Traumatic blunt intrathoracic and intra-abdominal injuries in the pediatric population that are within proximity of diaphragmatic insertion should be thoroughly evaluated to rule out diaphragmatic injury. As in our case, invasive surgical intervention such as thoracoscopy may be necessary.

Uveitis and acute glaucoma as first presenting symptoms of sarcoidosis in a healthy male

Sarcoidosis is a disease that causes noncaseating granulomas in tissues such as the lungs, heart, skin, and eyes. Sarcoidosis is often found through chest x-ray or lesions in the skin and eyes. In over half of patients the disease is detected incidentally by radiographic abnormalities on a routing chest x-ray prior to development of any symptoms. The disease varies in incidence among geographic regions and can also aggregate in families. It is more common in African-Americans who have a lifetime-estimated risk of 2.4 percent compared to a lifetime risk of 0.85 percent in whites. Multiple cases have been reported on sarcoidosis with eye involvement, especially uveitis. We present a healthy 36-year-old male with no past medical who initial presentation of sarcoidosis was uveitis with acute angle closure glaucoma. To our knowledge this is the first reported case of sarcoidosis with this presentation.

Comparison of critically ill patients from three freestanding ED's compared to a tertiary care hospital based ED

BACKGROUND Freestanding emergency departments (FEDs) care for all patients, including critically ill, 24/7/365. We characterized patients from three FEDs transferred to intensive care units (ICU) at a tertiary care hospital, and compared hospital length of stay(LOS) between patients admitted to ICUs from FEDs versus a hospital-based ED (HBED). METHODS We performed a retrospective, observational cohort study from January 2014 to December 2016. Demographic and clinical information was compared between FED and HBED patients with chi-square and fishers exact tests for categorical variables and Students t-test for continuous variables. The main outcome of interest was hospital LOS. Multi-variable linear regression was performed to estimate association between LOS and emergency facility type, while adjusting for potential confounders. RESULTS We included 500 critically ill patients (FED = 250 and HBED = 250). Patients did not differ by age, gender, or BMI. FED patients were more likely to be white (89.6% vs. 70.8%, p < 0.001) and have higher Charlson Co-morbidity Index scores (3.5 vs. 2.4, p < 0.001). Average LOS for FED patients was 5 days, compared to 7 days for HBED patients (p < 0.001). After adjusting for demographic and clinical confounders, there was significant correlation between ED facility type and LOS in hospital (p < 0.001). CONCLUSION Patients transferred from FEDs to an ICU were similar in age and gender, but more likely to be white with a higher Charlson Comorbidity Index score. FED patients experienced shorter hospital length of stay compared to patients admitted from a HBED.