JACEP
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The effectiveness of patient triage by a specially trained registered nurse in the emergency department of an urban county hospital, San Francisco General Hospital, was evaluated over a three-month period. Ambulatory patients thought to have nonemergent illnesses were directed to the Walk-In Service for physician evaluation and treatment; the remainder were seen in the Emergency Service. In three months, 11,329 patients registered for care, and 4,150 (37%) were referred to the Walk-In Service. ⋯ There were no deaths. Error in triage was about equally divided between mistaken diagnosis and underestimated severity of illnes. The overall accuracy of triage was 98%.
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Arthrocentesis and the subsequent evaluation of synovial fluid is often the definitive diagnostic procedure for the patient presenting with a joint effusion or intrasynovial hemorrhage. The difficulty of performing arthrocentesis varies with the joint in question, but those joints most frequently involved are easily entered. ⋯ This categorization of the effusion may permit specific diagnosis or the narrowing of the differential diagnosis. Criteria are established on the basis of joint fluid features to differentiate septic arthritis, which requires inpatient treatment, from those entities for which the patient may reasonably be treated as an outpatient.
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The Cincinnati General Hospital Emergency Department has a training program for emergency medicine residents on a multidisciplinary emergency psychiatry team. This essential training should occur in the emergency department setting rather than in psychiatric inpatient units of state hospital settings. ⋯ Some observations are made about how the emergency medicine residents deal with emotionally disturbed patients. Finally, 80% of emergency medicine residents responded to questionnaire on their reactions to the multidisciplinary emergency psychiatry team.
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Shock continues to be associated with a high mortality rate primarily because of delays in diagnosis and therapy. To diagnose shock early, and thereby increase the chances of reversal before there is extensive deterioration of vital organs, one should look for any decrease in pulse pressure, urine output, urine sodium concentration, alertness or any increase in urine osmolarity, tachypnea or tachycardia. Systolic hypotension, oliguria, metabolic acidosis and a cold clammy skin are late signs of shock. ⋯ The resuscitation from the shock process itself involves correction of pathophysiologic changes, based on objective trends and responses rather than isolated measurements. A suggested outline of therapies in order of their use includes: 1) correction of the primary problem; 2) ventilation and oxygen; 3) fluid-loading: 4) inotropic agents; 5) correction of acid-based and electrolyte abnormalities; 6) steroids ("physiologic" or "pharmacologic" doses); 7) vasopressors (especially in elderly, severely hypotensive patients); 8) vasodilators (if excess vasoconstriction); 9) diuretics (if oliguric in spite of the above), and 10) heparin (if DIC). The most common errors are 1) late diagnosis; 2) inadequate control of the primary problems; 3) inadequate fluid loading; 4) delayed ventilator assistance, and 5) excessive reliance on and use if vasopressors and diuretics.