Vaishal M. Tolia

Twenty per Hour: Altered Mental State Due to Ethanol Abuse and Withdrawal

This article discusses the physiology and clinical syndromes involved in ethanol absorption, intoxication, and withdrawal, with special emphasis on the evidentiary backing for common treatments, as well as some discussion of the medicolegal sequelae of treatment of ethanol abusers in the emergency department.

Cowpox: What do a Dairymaid and a Lab Technician Have in Common?

Figure 1. Palmar view of left index finger. A 32-year-old woman was working in a local biotechnology laboratory and, while attempting to inoculate amouse with a cowpox viral strain currently being developed as a live vaccine against smallpox, accidentally selfinoculated the tip of her right index finger with a needle. The patient was seen that day in the Occupational Medicine clinic for the needle-stick and was instructed to return to the Emergency Department (ED) if she developed any symptoms. The patient presented to the ED 5 days later with a lesion on the fingertip (Figures 1, 2). She was noted to have focal edema as well as red streaking up her left forearm without fevers, chills, or other constitutional symptoms. The Figures depict an isolated cowpox lesion. The cowpox virus used at this biotech laboratory is tagged with fluorescent antibodies, which allowed confirmation of viral inoculation by direct observation under a fluorescent lamp. An Infectious Disease specialist was also consulted, confirming the lesion to be that of cowpox. Cowpox is a skin disease caused by the cowpox virus, which received its name from the lesions that developed on the hands of dairymaids after touching the udders of infected cows. Cowpox virus is similar to the smallpox virus (Variola), and inoculation provides immunity against the much deadlier disease of smallpox. This latter disease was announced to be eradicated in the 1980s after an extensive world-wide

EDTITRATE (Emergency Department Telemedicine Initiative to Rapidly Accommodate in Times of Emergency)

Objective Emergency Department (ED) patient volumes are unpredictable, which can result in service delays and patients leaving without care. We initiated a programme of emergency physician (EP) telepresence in the ED with the objectives of assessing feasibility, safety, patient and provider acceptance, and throughput time. Methods This was a prospective convenience study. Patients presenting to the ED during operation of the study who were planned for placement in the waiting room were considered for enrolment. A faculty EP conducted patient evaluations via telepresence with confirmatory evaluation by the onsite faculty EP prior to disposition. Patient care was either taken to completion by the telemedicine EP or initiated and handed off to the onsite team. Measures included patient demographics, triage class (ESI 1–5), throughput time and a single question satisfaction survey (rating 1–5, 5 most favourable) completed by patients, registered nurses and EPs. Patients were called within 3 days and the electronic health record reviewed at 7 days looking for unscheduled visits and adverse events. Results In total, 130 patients were enrolled. Mean triage class was 3.9 with a median throughput of 150 minutes (IQR = 116.5, 206). Non-telemedicine patients during the same time period with similar triage classes had a median throughput of 287 minutes (IQR = 199, 408). Mean satisfaction scores were: patient 4.91, nurse 4.75, onsite EP 4.47 and telemedicine EP 4.79. There was one potential misdiagnosis and no adverse events. Conclusion Patient evaluation by EP via telepresence is feasible, safe, readily accepted by patients and providers and associated with reduced throughput time.

Academic practice of emergency medicine in the nation's Veteran's Affairs Hospitals ☆

Section of Emergency Medicine, Jesse Brown VA Medical Center, Chicago, IL 60612, USA Department of Emergency Medicine, University of Illinois-Chicago, Chicago, IL 60612, USA Department of Emergency Medicine, University of California-San Diego, San Diego, CA 92101, USA Division of Epidemiology and Biostatistics, School of Publich Health, University of Illinois-Chicago, Chicago, IL 60612, USA University of Illinois-Chicago College of Medicine, Chicago, IL 60612, USA

Effect of a Computerized Alert on Emergency Department Hepatitis A Vaccination in Homeless Patients During a Large Regional Outbreak

BACKGROUND While the overall incidence of hepatitis A has declined markedly since the introduction of a vaccine, sporadic cases and outbreaks of the disease continue to occur. OBJECTIVE Our aim was to evaluate the effectiveness of an electronic health record (EHR) provider alert as part of an outbreak-control vaccination program implemented in the emergency department (ED). METHODS We conducted a retrospective study assessing the impact of a Best Practice Alert (BPA) built into an EHR to prompt providers when a patient was homeless to consider hepatitis A vaccination in the ED. Data were collected over three 6-month time periods: a historical control period, a pre-intervention period, and an intervention period. RESULTS There were no vaccinations given in the ED in the historical period, which increased to 465 after the implementation of the BPA. During the implementation period, there were 1,482 visits identified among 1,131 patients that met the inclusion criteria. Of these, there were 1,147 (77.5%) visits where the patient either received the vaccine in the ED, had already received the vaccine, or it was not indicated due to the current medical issue. There were also 333 (22.5%) visits where the BPA was active for potential vaccination eligibility, but did not receive it in the ED. CONCLUSIONS We leveraged an informatics tool developed within our EHR to identify high-risk patients and remind providers of the availability of vaccination in the ED. Using these tools enabled providers to increase vaccination efforts within our ED to help control the community-wide outbreak.