Vincent P. Verdile

Emergency department telephone advice

Emergency department personnel are frequently asked to give advice to members of the community who telephone for advice or information about a wide variety of medical problems. A study was designed to determine the consistency and accuracy of directions given to adults who call EDs seeking advice about a problem. Forty-six EDs were selected and telephoned for advice by a research assistant who presented a scenario that could have reasonably been interpreted as a patient experiencing myocardial ischemia. Nine percent of the calls were answered and managed only by ED unit secretaries. Fifty-six percent of the respondents failed to ask the caller any questions about the patient or the chief complaint. Only four ED respondents instructed the caller to call 911 and have the patient brought to the ED. The data suggest that telephone advice given by some EDs is nonstandardized and may be inadequate to the point of jeopardizing the welfare of the caller.

The Outcome of Patients Refusing Prehospital Transportation

Objective: To study the natural outcome of patients refusing prehospital transportation (PT). Methods: A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once. Results: Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization. Conclusion: As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.

Nasotracheal intubation using a flexible lighted stylet.

Nasotracheal intubation is an essential skill for clinicians involved in the care of acutely ill or injured patients. Unfortunately, it has the dangers and difficulties of any blind technique. Although usually performed in the awake patient, nasotracheal intubation has also been used in the apneic patient. Transillumination of the soft tissues of the neck with a lighted stylet has been shown to be a reliable method of orotracheal intubation. The usefulness of a longer, flexible lighted stylet as an aid to nasotracheal intubation in the apneic patient has been examined. Eighty patients, who were paralyzed, apneic, and about to undergo nasotracheal intubation for elective ear, nose, and throat or maxillofacial surgery were randomized to be nasotracheally intubated blindly or with a stylet by an emergency medicine resident or anesthesiologist. Sixty-three percent intubated in the lighted-stylet group and 41% in the blind nasotracheal intubation group were successfully intubated. There were no significant differences in the time needed to intubate or the number of attempts. There were notable differences in the success rates of individual intubators with each technique. Although not statistically significant, our results suggest a useful role for the lighted stylet in nasotracheal intubation in the apneic patient.

Coma reversal with cerebral dysfunction recovery after repetitive hyperbaric oxygen therapy for severe carbon monoxide poisoning

The accepted beneficial effects of hyperbaric oxygen (HBO) include a greatly diminished carboxyhemoglobin (COHgb) half-life, enhanced tissue clearance of residual carbon monoxide (CO), reduced cerebral edema, and reversal of cytochrome oxidase inhibition, and prevention of central nervous system lipid peroxidation. Debate regarding the criteria for selection of HBO versus 100% normobaric oxygen therapy continues, and frequently is based solely on the level of COHgb saturation. Patients who manifest signs of serious CO intoxication (unconsciousness, neuropsychiatric symptoms, cardiac or hemodynamic instability) warrant immediate HBO therapy. An unresponsive 33-year-old woman was found in a closed garage, inside her automobile with the ignition on. Her husband admitted to seeing her 6 hours before discovery. 100% normobaric oxygen was administered in the prehospital and emergency department settings. The patient had an initial COHgb saturation of 46.7%, a Glasgow coma score of 3, and was transferred for HBO therapy. Before HBO therapy, the patient remained unresponsive and demonstrated decerebrate posturing and a positive dolls eyes (negative oculocephalic reflex). The electroencephalogram pattern suggested bilateral cerebral dysfunction consistent with a toxic metabolic or hypoxic encephalopathy. The patient underwent HBO therapy at 2.4 ATA for 90 minutes twice a day for 3 consecutive days. On day 7, the patient began to awaken, was weaned from ventilatory support, and was not soon verbalizing appropriately. A Folstein mental status examination showed a score of 26 of 30. Neurological examination demonstrated mild residual left upper extremity weakness and a normal gait. There was no evidence of significant neurological sequelae at 1 month follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasotracheal intubation in traumatic craniofacial dislocation: use of the lighted stylet.

The coexistence of facial trauma and suspected cervical spine injury represents a difficult problem in airway management. The successful use of guided nasotracheal intubation using a flexible lighted stylet is described, and its application to the critically injured patient is emphasized.

Polyarticular symmetric tophaceous joint inflammation as the initial presentation of gout

A 76-year-old woman suffered from bilateral distal index finger pain and swelling. The patient had been initially treated with antibiotics for herpetic whitlow complicated by a secondary bacterial infection. Gout was diagnosed through clinical history, physical examination and identification of monosodium urate crystals in the joint aspirate. Gout appearing as polyarticular, symmetric tophi involving the periungual region and distal interphalangeal joint has not been previously described.

Prehospital and Emergency Department Verification of Endotracheal Tube Position Using a Portable, Non-Directable, Fiberoptic Bronchoscope

Verification of endotracheal tube (ETT) location in prehospital setting and the emergency department (ED) is a challenging task. Unrecognized esophageal intubations with potentially dangerous consequences may occur more frequently in these environments than in less hectic settings. To evaluate the capabilities of a portable, non-directable, fiberoptic bronchoscope (Visicath; Saratoga Medical, Saratoga, Calif., USA) to detect appropriate ETT placement, a prospective series of 22 intubated prehospital, air-medical, or ED patients underwent fiberoptic verification (FOV) of a newly placed ETT. Each patient was intubated under urgent circumstances. The time required for FOV, ETT location, the relative difficulty of intubation, and the changes in management as a result of FOV were recorded. A total of 24 FOVs were performed, twenty-one tracheal (88%), and two esophageal (8%) intubations were identified. Position could not be identified in one case (4%). FOV confirmed placement in 23 intubations (96%) in less than 25 seconds. Seven intubations (29%) were judged to be difficult. FOV resulted in five minor changes in management (22%) and was the sole confirmation method for five intubations. We conclude that fiberoptic verification is a promising method of ETT position in air-medical and ED intubations.

Puncture wounds to the foot

Puncture wounds to the foot are common presenting problems in most busy emergency departments. Although seemingly benign, the sequelae after simple puncture wounds to the foot can include cellulitis, retained foreign bodies, or even osteomyelitis. Inadequate scientific research on this topic has left only anecdotal or retrospective reports for review in the medical literature. Antibiotics, radiographs, or surgical exploration in the management of puncture wounds to the foot all lack clinical studies to support their use. This review summarizes the literature and points to the inconsistencies in the management of puncture wounds to the foot.

Medical Coverage of a Marathon: Establishing Guidelines for Deployment of Health Care Resources

Introduction: Few prearranged events provide better opportunities for emergency health system coordination and planned disaster management than does medical coverage of a major city marathon. No guidelines exist as to the appropriate level of care that should be provided for such an event. Methods: The medical coverage for 2,900 marathon runners and an estimated 500,000 spectators along a 26.2-mile course over city streets for the 1986 Pittsburgh Marathon was examined prospectively. Support groups included physicians, nurses, and medical students from area hospitals and emergency departments and podiatrists, physical therapists, athletic trainers, and massage therapists from the Pittsburgh area. Emergency medical services were provided by city and county advanced life support (ALS) and basic life support (BLS) units, the American Red Cross, and the Salvation Army. A total of 641 medical volunteers participated in the coverage. Data were collected by volunteers as to acute medical and sports medical complaints of all patients, their vital signs, and the treatment provided. Medical care was provided at 20 field aid-stations along the race route (including a station every mile afier the 12-mile mark, and at four stations at the finish line). Results: Race day weather conditions were unusually warm with a high temperature of 86°F (30°C), relative humidity of 64%, partly sunny with little ambient wind, and a high wet bulb-globe temperature of 78°F (25.6°C). Records were obtained on 658/2,900 (25%) runner-patients of which 52 (8%) required transportation to area hospitals after evaluation at aid-stations: three were admitted to intensive care units. Analysis showed that 379/658 (58%) of the patients were treated at the finish line medical areas, and of the remaining 279 patients treated on the course, 218/279 (78%) were seen at seven, mile-aid-stations between 16.2 and 22.8 miles. The conditions of heat and humidity constitute a near “worst-case” scenario and the numbers of medical personnel that should be available to deliver acute care of hyperthermia/hypothermia and fluid/electrolyte disorders are recommended. Also it is recommended that approximately 50% of medical personnel and equipment should be deployed in the finish line area and that 80% of the remaining resources on the race course be deployed in aid-stations located every mile between miles 16 and 23.