Kenneth V. Iserson

Hypnosis for pediatric fracture reduction

Hypnosis can diminish pain and anxiety for many emergency patients during examinations and procedures. While hypnosis has been used for millennia and was demonstrated to be of use in clinical medicine more than a century ago, modern physicians have been reluctant to adopt this technique in clinical practice. This article describes four children with angulated forearm fractures who had no possible access to other forms of analgesia during reduction, and in whom hypnosis was used successfully. A simple method for hypnotic induction is described.

Ethics in Emergency Medicine

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Parenteral chlorpromazine treatment of migraine.

A prospective, uncontrolled clinical trial was conducted to test the safety and efficacy of intramuscular chlorpromazine (1 mg/kg) in the acute, outpatient treatment of migraine. One hundred adult patients were included in the study. There was complete relief of both pain and nausea/emesis symptoms in 96 patients within 55 minutes of the injection. Eighteen patients experienced orthostatic hypotension following injection. All but one responded to noninvasive therapy. The results suggest that chlorpromazine is a safe, effective alternative medication in the outpatient treatment of acute migraine.

Use of the emergency department for hypertension screening: a prospective study

There is controversy as to whether the emergency department is an inappropriate site for screening for hypertensive patients. The pain and apprehension associated with many ED visits have been thought to elevate blood pressure readings falsely in this setting. To resolve this question, all patients admitted to the ED of a university hospital during a one-year period were screened prospectively for hypertension. Follow-up was attempted for patients who, on admission and discharge, had systolic pressures higher than 159 mm Hg or diastolic pressures higher than 94 mm Hg. A total of 239 patients met these criteria, and follow-up was obtained in 45% of the cases. Significant hypertension (systolic greater than 159 mm Hg or diastolic greater than 94 mm Hg) was found in 35% of these patients on follow-up. Borderline hypertension (systolic, 140 to 159 mm Hg; or diastolic, 90 to 94 mm Hg) was documented in 33% of the patients. Thirty-two percent were found to be normotensive when evaluated in a follow-up visit. The number of patients experiencing pain at the time of their initial ED visit was similar among the three groups. Almost half the patients with hypertension on follow-up needed further workup or therapy. The ED can be a useful screening site for hypertension; elevated blood pressure on discharge should ensure referral for follow-up evaluation and therapy.

Intraosseous infusions in adults

Intraosseous (IO) access in adults via the distal tibia has never been a widely accepted technique. Yet there have been occasional reports of the successful use of this procedure. This study was done to demonstrate the utility of IO infusions in the adult patient, including those patients in cardiac arrest. Twenty-two patients, aged 36 through 84 (mean 65.1 years), who arrived in the emergency department (ED) in cardiac arrest from nonhypovolemic causes and in whom an intravenous line was not established prior to arrival or was found to be inadequate (nonfunctioning or poorly functioning) upon arrival in the ED, had an IO needle (13-gauge Kormed/Jamshidi, Pharmaseal Division, Baxter Healthcare Corp., Valencia, CA) placed above the medial malleolus. The IO needle was then connected to a standard IV tubing, with a pressure bag or pressure device delivering 300 mm Hg to the solution bag. The resultant flow rate through the IV line ranged from 5 to 12 mL/min. The IO needle was placed and flow established in under one minute in all patients. Temporally related pharmacologic effects were observed after the IO administration of sodium bicarbonate, lidocaine, atropine, and vasopressors. This study shows that I.O. access can be quickly and easily obtained in adults in the medial supramalleolar position during cardiac arrest. This method of drug administration appears to hold promise as another useful modality for adults and older children during nontraumatic resuscitations.

Fight or flight: the ethics of emergency physician disaster response

Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system’s front line during crises that involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers’ decisions in these situations. After reviewing physicians’ response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians’ duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals’ risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to “stay and fight.”

Intraosseous infusions: A usable technique

Intraosseous infusions were widely used in pediatric patients during the 1930s and 1940s. Recent reports have re-introduced this concept and confirmed its safety and ready accessability for fluid and drug administration. However, these reports have not addressed the difficulties encountered during insertion of the intraosseous needle. Spinal needles, standard metal intravenous (IV) needles, and bone marrow biopsy needles have been suggested for intraosseous infusion. These needles were tested for ease of insertion on a pediatric cadaver leg. The site for needle placement was also evaluated during the study. It was found that the 13-gauge Kormed/Jamshidi disposable bone marrow/aspiration needle was the easiest to insert and did not plug with bone or tissue during insertion. An area proximal to the medial malleolus was found to provide a stable, relatively flat, and easily penetrable location for needle placement. This method was successfully utilized in ten pediatric and five adult patients. Intraosseous needle placement is a safe, rapid method to gain access to the venous circulation. By utilizing these techniques, a stable, usable fluid line can be established in even the most dehydrated pediatric patients.

Topical anesthesia for laceration repair: Tetracaine versus TAC (tetracaine, adrenaline, and cocaine)

Abstract Topical anesthetics have always had a place in anesthetizing mucous membranes. The earliest writing in Greek medical literature makes reference to the use of these topical anesthetizing agents. Previous studies utilized a mixture of tetracaine, Adrenalin, and cocaine in the pediatric population with increased patient compliance. In contrast, another study cites the increased risk of infection in cases where topical anesthetics in combination with potent vasoconstrictors are used. To examine the efficacy and safety of a tetracaine and a tetracaine, Adrenalin, and cocaine mixture (TAC), a randomized, double-blind study was undertaken. A total of 68 patients participated in the study, with 36 receiving TAC and 32 receiving tetracaine. The results indicate that the most efficacious use of TAC is on facial lacerations, regardless of length or depth. Of the 46 participants available for follow-up, one patient in the tetracaine group reported a wound infection. A recommendation of increased use of TAC on facial lacerations, in both the adult and pediatric populations, is made based on the results of this study.

Efficacy of the posttraumatic cross table lateral view of the cervical spine

This is a retrospective study of 128 patients with a discharge diagnosis of cervical spine fracture, dislocation, or subluxation. The study was undertaken to establish the accuracy of the posttraumatic cross table lateral view radiograph of the cervical spine (CTLV). The radiographs were read by the faculty emergency physician author. If his diagnosis differed from the patients final radiologic diagnosis, the radiograph was reevaluated by the radiologist author. The accuracy in diagnosing posttraumatic cervical spine abnormalities on CTLV alone was 74.2% and 79.7% for the emergency physician and radiologist, respectively. Thirty percent of cases undiagnosed by the emergency physician were subsequently treated as unstable injuries. Thirty-five percent of C1, 14.8% of C2, and 42.4% of C6 abnormalities were missed on CTLV by both the emergency physician and the radiologist. The results indicate that the CTLV, alone, is unreliable and potentially dangerous as a screening exam in diagnosing posttraumatic abnormalities of the cervical spine.

Postmortem procedures in the emergency department: using the recently dead to practise and teach.

In generations past, it was common practice for doctors to learn lifesaving technical skills on patients who had recently died. But this practice has lately been criticised on religious, legal, and ethical grounds, and has fallen into disuse in many hospitals and emergency departments. This paper uses four questions to resolve whether doctors in emergency departments should practise and teach non-invasive and minimally invasive procedures on the newly dead: Is it ethically and legally permissible to practise and teach non-invasive and minimally invasive procedures on the newly dead emergency-department patient? What are the alternatives or possible consequences of not practising non-invasive and minimally invasive procedures on newly dead patients? Is consent from relatives required? Should doctors in emergency departments allow or even encourage this use of newly dead patients?