James Lantry

Emergency department medication history taking: current inefficiency and potential for a self-administered form.

BACKGROUND Emergency Departments (EDs) struggle with obtaining accurate medication information from patients. OBJECTIVE Our aim was to estimate the proportion of urban ED patients who are able to complete a self-administered medication form and record patient observations of the medication information process. METHODS In this cross-sectional study, we consecutively sampled ED patients during various shifts between 8 AM and 10 PM. We created a one-page medication questionnaire that included a list of 49 common medications, categorized by general indications. We asked patients to circle any medications they took and write the names of those not on the form in a dedicated area on the bottom of the page. After their visit, we asked patients to recall which providers had asked them about their medications. RESULTS Research staff approached 354 patients; median age was 45 years (interquartile range 29-53 years). Two hundred and forty-nine (70%) completed a form, 61 (17%) were too ill, 19 (5%) could not read it, and 25 (7%) refused to participate. Excluding refusals, 249 of 329 (76%; 95% confidence interval 70-80%) were able to complete the form. Of 209 patients recalling their visit, 180 (86%) indicated that multiple providers took a history, including 103 in which every provider did so, and 9 (4%) indicated that no provider took a medication history. CONCLUSIONS The process of ED medication information transfer often involves redundant efforts by the health care team. More than 70% of patients presenting for Emergency care were able to complete a self-administered medication information form.

Emergency department septic shock patient mortality with refractory hypotension vs hyperlactatemia: A retrospective cohort study

Background: Our objective was to compare in‐hospital mortality among emergency department (ED) patients meeting trial‐based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L). Methods: We conducted a retrospective cohort analysis by chart review of ED patients admitted to an intensive care unit with suspected infection during 1 August 2012–28 February 2015. We included all patients with body fluid cultures sampled either during their ED stay without antibiotic administration or within 24 h of antibiotic administration in the ED. We excluded patients not meeting criteria for either refractory hypotension or hyperlactatemia. Trained chart abstractors blinded to the study hypothesis double entered data from each patients record including demographics, clinical data, treatments, and in‐hospital mortality. We compared in‐hospital mortality among patients with isolated refractory hypotension, isolated hyperlactatemia, or both. We also calculated odds ratios (ORs) via logistic regression for in‐hospital mortality based on presence of refractory hypotension or hyperlactatemia. Results: Of 202 patients included in the analysis, 38 (18.8%) died during hospitalization. Mortality was 10.9% among 101 patients with isolated refractory hypotension, 24.4% among 41 patients with isolated hyperlactatemia, and 28.3% among 60 patients with both (p = 0.01). Logistic regression analyses yielded in‐hospital mortality OR for refractory hypotension of 1.3 (95% CI 0.5–3.8) versus OR for hyperlactatemia of 2.9 (95% CI 1.2–7.4). Conclusions: Hyperlactatemia appears associated with higher in‐hospital mortality compared to refractory hypotension among ED patients with septic shock.

Remote tele-mentored ultrasound for non-physician learners using FaceTime: A feasibility study in a low-income country

Purpose Ultrasound (US) is a burgeoning diagnostic tool and is often the only available imaging modality in low‐ and middle‐income countries (LMICs). However, bedside providers often lack training to acquire or interpret US images. We conducted a study to determine if a remote tele‐intensivist could mentor geographically removed LMIC providers to obtain quality and clinically useful US images. Materials and methods Nine Haitian non‐physician health care workers received a 20‐minute training on basic US techniques. A volunteer was connected to an intensivist located in the USA via FaceTime. The intensivist remotely instructed the non‐physicians to ultrasound five anatomic sites. The tele‐intensivist evaluated the image quality and clinical utility of performing tele‐ultrasound in a LMIC. Results The intensivist agreed (defined as “agree” or “strongly agree” on a five‐point Likert scale) that 90% (57/63) of the FaceTime images were high quality. The intensivist felt comfortable making clinical decisions using FaceTime images 89% (56/63) of the time. Conclusions Non‐physicians can feasibly obtain high‐quality and clinically relevant US images using video chat software in LMICs. Commercially available software can connect providers in institutions in LMICs to geographically removed intensivists at a relatively low cost and without the need for extensive training of local providers. HighlightsUltrasound is a valuable diagnostic tool, although education in interpretation can be limited.Our prior work proves that live FaceTime images are high quality.High quality, clinically useful images can be transmitted from an LMIC to the United States.Commercially available technology can be used to increase diagnostic yield in LMICs.Telementored ultrasound partnerships between a LMIC and the United States are feasible.

1880: AEROMEDICAL EVACUATION FROM A COMBAT ZONE

Crit Care Med 2016 • Volume 44 • Number 12 (Suppl.) received a 2 units/kg regular insulin IV bolus and an infusion of 2 units/kg/hr. A norepinephrine infusion was started and titrated to 0.3 mcg/kg/min. He was intubated due to altered mental status, a dopamine infusion was started, and he received two 20% lipid boluses. He was hypotensive while on max rates of norepinephrine and dopamine, so epinephrine and vasopressin were started. He then received 2 grams of calcium chloride and 250 mL of 20% lipids, but MAP remained in the 50s. Phenylephrine was added and titrated to 5 mcg/kg/min. Persistent hypotension prompted administration of two 100 mg doses of methylene blue, and MAPs improved to the 60s. After methylene blue, MAP decreased to the 50s. Calcium chloride 2 grams and calcium gluconate 4 grams were given. MAP dropped again leading to administration of 200 mg of methylene blue. Plasma exchange was ordered to reduce the amlodipine levels, which decreased from 120 to 63 ng/mL after 2 hours. Over the next 2 hours, he received an additional 250mL of lipids and 2 grams of calcium chloride. Due to persistent hypotension, extracorporeal membrane oxygenation (ECMO) was started. Prior to the procedure, the patient coded and ACLS protocols were used. Following ECMO placement, he was unresponsive due to anoxic brain injury, leading to the decision to withdraw care. Results: There is limited evidence in the literature describing the refractory treatment modalities utilized in this patient. This report is unique as it describes the clinical course of a patient when a multitude of unique treatments were combined.