Richard Goldberg

Drug-drug and drug-disease interactions in the ED: Analysis of a high-risk population

A study was undertaken to determine the potential for adverse drug interactions (ADIs) and drug-disease interactions (DDIs) in a high-risk population of emergency department (ED) patients and to characterize drug-drug and drug-disease interactions in terms of percentage of patients at risk from existing drug regimens, percentage of patients at risk from ED treatment, relation between number of drugs and potential for interactions, types of drugs and diseases posing greatest potential for interaction, and the differences in a general versus community hospital population with respect to these parameters. Records of 205 consecutive patients, 111 from a general hospital teaching facility ED (Facility 1) and 94 from a community hospital ED (Facility 2) were retrospectively reviewed. The records of all patients receiving three or more medications and all patients older than 50 years of age receiving two or more medications were analyzed by two computer programs for the presence of potential drug-drug and drug-disease interactions. A total of 226 potential ADIs were found in 89 patients (47%), with 50% of ADIs being related to ED treatment. A total of 94 potential DDIs were found in 44 patients (21%), with 34% of DDIs being related to ED treatment. The risk of an ADI rose from 13% for patients taking 2 medications to 82% for patients taking 7 or more medications. Eleven medications and four disease categories were identified as having particular potential for interactions. No significant differences were found between the general and the community hospital populations in these respects. ED patients taking three or more medications and patients older than 50 years of age taking two or more medications are at substantial risk for adverse drug-drug and drug-disease interactions. The risk is increased in patients taking particular drugs or having particular disease states.

The effect of spinal immobilization on healthy volunteers

STUDY OBJECTIVE To determine the effects of standard spinal immobilization on a group of healthy volunteers with respect to induced pain and discomfort. DESIGN Prospective study. SETTING University teaching hospital. TYPE OF PARTICIPANTS Twenty-one healthy volunteers with no history of back disease. INTERVENTIONS Subjects were placed in standard backboard immobilization for a 30-minute period. Number and severity of immediate and delayed symptoms were determined. MEASUREMENTS AND MAIN RESULTS One hundred percent of subjects developed pain within the immediate observation period. Occipital headache and sacral, lumbar, and mandibular pain were the most frequent symptoms. Fifty-five percent of subjects graded their symptoms as moderate to severe. Twenty-nine percent of subjects developed additional symptoms over the next 48 hours. CONCLUSION Standard spinal immobilization may be a cause of pain in an otherwise healthy subject.

Tolerance for Uncertainty, Burnout, and Satisfaction With the Career of Emergency Medicine

STUDY OBJECTIVE Questions about burnout, career satisfaction, and longevity of emergency physicians have been raised but no studies have examined tolerance for uncertainty as a risk factor for burnout. Primary objectives of this study are to assess the role of uncertainty tolerance in predicting career burnout and to estimate the proportion of emergency physicians who exhibit high levels of career burnout. METHODS A mail survey incorporating validated measures of career satisfaction, tolerance for uncertainty, and burnout was sent to a random sample of members of the American College of Emergency Physicians. Best- and worst-case scenarios of point estimates are provided to assess for the effect of nonresponse bias, and multivariable logistic regression was used to predict evidence of career burnout. RESULTS One hundred ninety-three surveys were returned (response rate 43.1%). A high level of career burnout was exhibited in 62 (32.1%; best-worst case 13.8% to 64.1%) respondents. No demographic variables were associated with burnout status. The final model identified that high anxiety caused by concern for bad outcomes (odds ratio=6.35) was the strongest predictor of career burnout, controlling for all other variables. CONCLUSION A large percentage of emergency physicians in this study, 32.1%, exhibited emotional exhaustion, which is the core symptom of burnout. Emotional exhaustion was not related to age or type of practice and was not mitigated by training in emergency medicine. Physicians studied did not feel anxiety because of general uncertainty, difficulty in disclosing uncertainty to patients, or admitting errors to other physicians. High anxiety caused by concern for bad outcomes was the strongest predictor of burnout. Despite exhibiting emotional exhaustion, the majority of respondents are satisfied with the career of emergency medicine.

Intranasal midazolam in patients with status epilepticus.

The patient in status epilepticus presents many challenges to the emergency physician. IV access is frequently difficult to achieve, and prolonged attempts at access can jeopardize the patient and endanger the caregiver. We present two cases in which the administration of intranasal midazolam appeared to successfully terminate status epilepticus. No adverse effects were noted. Studies are needed to clarify the safety, optimal dosing, and clinical utility of this treatment modality.

Backboard versus mattress splint immobilization: a comparison of symptoms generated.

The study objective was to compare spinal immobilization techniques to a vacuum mattress-splint (VMS) with respect to the incidence of symptoms generated by the immobilization process. We used a prospective, cross-over study in a university hospital setting. Participants consisted of 37 healthy volunteers without history of back pain or spinal disease. Interventions consisted of two phases. In Phase I, subjects were randomly assigned to be immobilized on either a wooden backboard or a mattress-splint for 30 min. The incidence and severity of any symptoms generated by the immobilization process were recorded. In Phase II, the two groups were again tested after a 2-week washout period, with the method of immobilization being reversed. Symptoms and severity were again recorded. Pain symptoms were confined to four anatomic sites: Occipital prominence, lumbosacral spine, scapulae, and cervical spine. After adjusting for the effect of order of exposure, subjects were 3.08 times more likely to have symptoms when immobilized on a backboard than when immobilized on the VMS. They were 7.88 times more likely to complain of occipital pain and 4.27 times more likely to complain of lumbosacral pain. Severity of occipital and lumbosacral pain was also significantly greater during backboard immobilization. We conclude that, when compared to a VMS, standard backboard immobilization appears to be associated with an increased incidence of symptoms in general and an increased incidence and severity of occipital and lumbosacral pain in particular.

Critical Pathway for the Emergency Department Management of Acute Asthma: Effect on Resource Utilization

STUDY OBJECTIVE To determine the effect of a critical pathway on resource utilization in asthmatic patients. METHODS The study combined a prospective analysis of 149 patients with asthma treated by a pathway protocol with a retrospective analysis of 97 patients with asthma treated by conventional means. The setting was a community hospital. RESULTS Among patients treated by protocol, oxygen use declined by 19% (P = .001), handheld nebulizer treatments by 33% (P = .001), saline locks by 15% (P = .011), and intravenous steroid administration by 13% (P = .034). There was an increase in the use of metered-dose inhalers with spacer by 64% (P = .001) and oral steroids by 18% (P = .027). CONCLUSION A critical pathway, based primarily on national guidelines, can be an effective means of treating asthma patients in terms of resource utilization.

Reference accuracy in the emergency medicine literature

STUDY OBJECTIVE To determine the incidence and nature of errors in the citation and quotation of references contained in the emergency medicine literature. DESIGN A retrospective analysis of a random sample of articles and references found in the three major emergency medicine journals. SETTING A university/county hospital. METHODS We examined single issues of three emergency medicine journals: Annals of Emergency Medicine, Journal of Emergency Medicine, and American Journal of Emergency Medicine. INTERVENTIONS None. MEASUREMENTS Four independent reviewers assessed 145 references from 46 referring authors for citational and quotational accuracy. MAIN RESULTS Major and minor citation errors were found in 10.3% and 17.2% of reference listings, respectively. Qualitative quotational errors were found in 35.2% of references. Eighty-two percent of these errors were considered to be major. Quantitative quotational errors were found in 47% of references reviewed. Secondary rather than primary reference sources were used in 41.4% of references reviewed. CONCLUSION This study demonstrates a substantial error rate in the citation and quotation of reference sources in the emergency medicine literature. In addition, verification of primary source material was not done by a large percentage of the authors reviewed. Recommendations for improving the accuracy of the emergency medicine literature are offered.

Evaluation and management of acute uvular edema

Acute uvular edema is a potentially life-threatening condition with a variety of causes. Other upper airway structures, most notably the epiglottis, may also become involved, and complete or partial airway obstruction may ensue rapidly. An accurate diagnosis may be essential in establishing effective treatment.

Cost analysis of stapling versus suturing for skin closure

A randomized, prospective study was performed to test the null hypothesis that there is no difference between the cost of stapling and suturing for skin closure of selected linear lacerations. Appropriate wounds were randomly assigned to be closed by staples or sutures. Wound lengths, skin closure times, and the number of staples or the number and types of sutures used were recorded. Costs for materials and labor were calculated. The average total cost per case was

Crohn’s disease: a rare cause of upper airway obstruction

17.69 (with suture kit) and