The American journal of emergency medicine
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A prospective study was performed to determine acuity levels, waiting times, and reasons why patients who sought care in an emergency department (ED) left without being seen by a physician, and to evaluate whether timed telephone follow-up improved their health outcomes. A comparison and follow-up survey was conducted on all patients who registered for care in the ED at the Naval Medical Center, San Diego, CA, and left without being seen (n = 32) and a 20% systematic sampling of patients who waited until they were seen (n = 170) during a one-week period in Spring, 1993. Baseline demographics and health statuses on reporting to the ED were gathered on all patients waiting to be seen that agreed to participate in the study (n = 533). ⋯ Acuity levels were compared for patients seen versus LWBS for level I (1.5% v 3%, NS), level II (75% v 78%, NS), and level III (23.5% v 19%, NS). For the 25% that left before triage, level I was 9%, level II was 64%, and level III was 27%. Sixty-nine percent of patients who LWBS were seen for evaluation within 48 hours, 9% in an ED and 60% in a clinic.(ABSTRACT TRUNCATED AT 250 WORDS)
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Increasing numbers of states are recognizing the importance of developing policies to allow Do Not Resuscitate (DNR) orders to be recognized in the prehospital setting, especially by emergency medical personnel. The ethical issues involved in creating such policies have not been widely addressed. Using the experience of developing such a policy for the District of Columbia as a model, we discuss six major ethical issues involved in prehospital DNR order policy development. 1) Can the justification for the policy be grounded in the doctor's duty of beneficence? 2) Should the concept of futility be applied to prehospital DNR orders? 3) How specific should prehospital DNR orders be? 4) How can one maximize patient participation in the prehospital DNR decision? 5) How much consideration ought to be given to the scarcity of health care resources in the development and justification of such policies? 6) Should paramedics be empowered to pronounce DNR patients dead in the field? This discussion ought to be of benefit to all those involved in developing or revising prehospital DNR policies.
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To determine if out-of-hospital emergency medical services (EMS) time intervals are associated with unexpected survival and death in urban major trauma, a retrospective review was conducted of major trauma cases entered into an urban trauma system by an EMS system during a one-year period. Patients with unexpected death or unexpected survival were identified using TRISS methodology. The EMS response, on-scene time, transport time, and total EMS out-of-hospital time intervals were compared for the two groups using the unpaired t test (two-tailed analysis). ⋯ The mean EMS on-scene time interval (7.8 +/- 4.1 minutes v 11.6 +/- 6.5 minutes; P = .06) and the mean transport time interval (9.5 +/- 4.4 minutes v 11.7 +/- 4.0 minutes; P = .17) also favored the unexpected survivor group. Overall, the total EMS time interval was significantly shorter for unexpected survivors (20.8 +/- 5.2 minutes v 29.3 +/- 12.4 minutes; P = .02). It was concluded that a short overall out-of-hospital time interval may positively affect patient survival in selected urban major trauma patients.
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Randomized Controlled Trial Comparative Study Clinical Trial
LAT (lidocaine-adrenaline-tetracaine) versus TAC (tetracaine-adrenaline-cocaine) for topical anesthesia in face and scalp lacerations.
The study objective was to compare the topical anesthetic LAT (4% lidocaine, 1:2,000 adrenaline, 1% tetracaine) to TAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine) for efficacy, adverse effects, and costs. The study design was a randomized, prospective, double blind clinical trial set in an inner-city emergency department with an emergency medicine residency program. Adults with linear lacerations of the face or scalp were eligible for inclusion in the study. ⋯ Physicians found LAT statistically more effective than TAC (P = .0093, Interquartile Range 1 to 0 for LAT, 2 to 0 for TAC) but patients did not report a difference (P = .266, Interquartile Range 1 to 0 for both LAT and TAC). Our cost per application was $3.00 for LAT compared to $35.00 for TAC. Follow-up was accomplished in 91 of 95 patients (95%) with no reported complications for either medication.(ABSTRACT TRUNCATED AT 250 WORDS)
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To determine the sensitivity of an emergency physician's conventional evaluation compared with the validated Confusion Assessment Method (CAM) regarding the recognition of acute confusional states (delirium) in elderly Emergency Department (ED) patients, a cohort of 385 patients presenting to an urban teaching hospital ED was systematically assembled. Patients had to be conscious, able to speak and older than 64 years of age. After the ED physician had examined the patient and test results had been obtained, a series of geriatric assessment results, including one for the likely presence of delirium, was made available to the ED physician; however, no result was specifically highlighted. ⋯ The ED diagnosis included delirium or an acceptable synonym in 6 (17%) of these patients. In the 21 patients (62%) admitted to the hospital, the most common ED diagnosis was infection "rule out sepsis" (n = 7). Six of 13 patients discharged (46%) were diagnosed as "status post fall" without evidence of significant injury.(ABSTRACT TRUNCATED AT 250 WORDS)