Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Background: Health literacy is an important predictor of healthcare outcomes, but research on this topic has largely been absent from the emergency medicine literature.

Objectives: We measured the prevalence of health literacy in parents or guardians of pediatric patients seen in the emergency department (ED).

Methods: This was an observational study conducted in a Midwestern urban, university-based, tertiary, Level 1 trauma center ED with 33,000 visits/year. Using convenience sampling during a three-month period, English-speaking parents or guardians of pediatric patients (< 19 yrs.) were asked to complete the short version of the Test of Functional Health Literacy for Adults (s-TOFHLA). Parents/guardians were excluded if they had uncorrected visual impairment, required an interpreter, had altered mental status, or if the patients they accompanied were the subjects of a medical or trauma activation.

Results: Of the 188 parents or guardians approached, six did not consent or withdrew, one was excluded, leaving 181 (96.3%) in the study. Of these, 19 (10.5%) had either "marginal" or "inadequate" health literacy, while 162 (89.5%, 95% CI: 84.1%, 93.6%) had "adequate" health literacy.

Conclusions: A large majority (89.5%) of English-speaking parents or guardians of pediatric patients evaluated in the ED have adequate health literacy. This data may prompt ED professionals to adjust their communication styles in the evaluation of children. Future multi-center studies are needed to confirm the findings in this pilot study. [WestJEM.2008:9:130-134]

Background: The clinical presentation of Bordetella pertussis can overlap with that of respiratory syncytial virus (RSV); however, management differs.

Hypothesis: First, the prevalence of B. pertussis is less than 2% among patients screened for RSV, and second the prevalence of B. parapertussis is also less than 2% among these patients.

Methods: Nasal washings submitted to a clinical laboratory for RSV screening were tested for B. pertussis and B. parapertussis, using species-specific real-time polymerase chain reaction (PCR) assays. These were optimized to target conserved regions within a complement gene and the CarB gene, respectively. A Bordetella spp. genus-specific real-time PCR assay was designed to detect the Bhur gene of B. pertussis, B. parapertussis, and B. bronchiseptica. RSV A and B subtypes were tested by reverse transcription-PCR.

Results: Four hundred and eighty-nine clinical samples were tested. There was insufficient material to complete testing for one B. pertussis, 10 RSV subtype A, and four RSV subtype B assays. Bordetella pertussis was detected in 3/488 (0.6%) (95% CI 0.1% to 1.8%), while B. parapertussis was detected in 5/489 (1.0%) (95% CI 0.3% to 2.4%). Dual infection of B. pertussis with RSV and of B. parapertussis with RSV occurred in two and in three cases respectively. RSV was detected by PCR in 127 (26.5%).

Conclusion: The prevalence of B. pertussis in nasal washings submitted for RSV screening was less than 2%. The prevalence of parapertussis may be higher than 2%. RSV with B. pertussis and RSV with B. parapertussis coinfection do occur.

[WestJEM. 2008;9:135-140.]

Objective: Residency applicants consider a variety of factors when ranking emergency medicine (EM) programs for their NRMP match list. A human cadaver emergency procedure lab curriculum is uncommon. We hypothesized that the presence this curriculum would positively impact the ranking of an EM residency program.

Methods: The EM residency at Nebraska Medical Center is an urban, university-based program with a PGY I-III format. Residency applicants during the interview for a position in the PGY I class of 2006 were surveyed by three weekly electronic mailings. The survey was distributed in March 2006 after the final NRMP match results were released. The survey explored learner preferences and methodological commonality of models of emergency procedural training, as well as the impact of a procedural cadaver lab curriculum on residency ranking. ANOVA of ranks was used to compare responses to ranking questions.

Results: Of the 73 potential subjects, 54 (74%) completed the survey. Respondents ranked methods of procedural instruction from 1 (most preferred or most common technique) to 4 (least preferred or least common technique). Response averages and 95% confidence intervals for the preferred means of learning a new procedure are as follows: textbook (3.69; 3.51-3.87), mannequin (2.83; 2.64-3.02), human cadaver (1.93; 1.72-2.14), and living patient (1.56; 1.33-1.79). Response averages for the commonality of means used to teach a new procedure are as follows: human cadaver (3.63; 3.46-3.80), mannequin (2.70; 2.50-2.90), living patient (2.09; 1.85-2.33), and textbook (1.57; 1.32-1.82). When asked if the University of Nebraska Medical Center residency ranked higher in the individual’s match list because of its procedural cadaver lab, 14.8% strongly disagreed, 14.8% disagreed, 40.7% were neutral, 14.8% agreed, and 14.8% strongly agreed.

Conclusion: We conclude that, although cadaveric procedural training is viewed by senior medical student learners as a desirable means of learning a procedure, its use is uncommon during medical school, and its presence as part of a residency curriculum does not influence ranking of the residency program.

[WestJEM. 2008;9:141-145.]

Introduction: The development of tinnitus and/or hearing loss (THL) in patients receiving chronic salicylate therapy has been demonstrated. However, to date, little scientific data validates this relationship in the large single overdose setting.

Objective: To correlate salicylate levels in patients with the subjective complaint of THL, following an acute salicylate overdose.

Methods: A retrospective chart review of cases of acute salicylate toxicity and THL reported to the Illinois Poison Control Center (IPC) from 2001-2002 was performed. Data abstracted included age, gender, ingestion time, salicylate levels, and arterial blood gases.

Results: Ninety-nine cases of THL were reviewed and analyzed with mean age of 23.7 years (SD: 10.9), 30.3% male, and 82.2% intentional overdoses. The average dose ingested was 20.0 grams (SD:20.2) and the mean time from ingestion to medical care was 12.4 hours (SD: 11.1). The mean initial ASA level was 48.3 mg/dl (SD: 16.4) with 86.9% having initial level ≥ 30mg/dl and 40.4% ≥ 50 mg/dl. 85.9% of cases presented to the hospital with their ASA level at or past peak. The mean pH was 7.45, pO2 = 108, pCO2 = 28.0, and HCO3 = 19.9.

Conclusion: In this limited study, 85.9% of patients presenting with tinnitus and/or hearing loss following a single salicylate ingestion had initial salicylate levels at or past their peak and 86.9% were in the toxic range.

[WestJEM. 2008;9:146-149.]

Objective: Methanol poisoning by ingestion is well represented in current emergency medicine literature. Much less described, however, is poisoning via intentional inhalation of methanol-containing products such as carburetor cleaner. This study intends to explore the exposure routes and treatment patterns of methanol cases reported to Texas Poison Centers.

Methods: All cases of methanol exposures from January 2003 to May 2005 were collected from the Texas Poison Center Network database “Toxicall.” Inclusion criteria were 1) methanol as primary exposure, and 2) documented route of exposure. Exclusion criteria were unknown, dermal, and eye exposures. Data was extracted from documented calls to Texas Poison Centers and analyzed using descriptive statistics.

Results: A total of 203 cases were collected from 6 regional Poison Centers. Eighty seven cases had inhalation as the route of exposure, while 81 were methanol ingestions. Carburetor cleaner was responsible for nearly all the inhalational cases (79/87) while ingestions involved mostly windshield washer fluid (39/81) and carburetor cleaner (20/81). Seventy-eight percent of the inhalational exposures were intentional while most of the ingestions were accidental (49/75) and suicidal (18/75). An anion gap was documented in 31 of the inhalational cases and in 10 of the ingestions. Dialysis, use of fomepizole, and vision loss were documented for both types of exposure. Fifty-six percent of the inhalational group was admitted compared to 46% of the ingestion group.

Conclusion: We propose that the results obtained from our review show inhalational exposure involving methanol (e.g., “huffing”) represents a significant source of toxicity in the studied population. This is in contrast to previous literature that proposed inhalational toxicity was rare and aggressive treatment usually not necessary in cases of inhalation of methanol-containing carburetor cleaners.[WestJEM. 2008;9:150-153.]

A 37-year-old woman experienced a witnessed generalized seizure in the Emergency Department three hours after ingesting approximately 1400 mg of fluoxetine in a suicide attempt. Although the majority of fluoxetine ingestions are benign, seizures may occur after large intentional overdoses.

[WestJEM. 2008;9:154-156]

Abrus precatorius seeds contain one of the most potent toxins known to man. However, because of the seed’s outer hard coat the vast majority of ingestions cause only mild symptoms and typically results in complete recovery. If the seeds are crushed and then ingested, more serious toxicity, including death, can occur.

We present a case of a man who survived an intentional ingestion of crushed Abrus seeds after he was treated with aggressive gastric decontamination and supportive care.

[WestJEM. 2008;9:157-159.]

A 29-year-old man with no history of diabetes ingested over 60 grams of metformin in a suicide attempt. He presented to the emergency department with acute renal insufficiency, severe lactic acidosis, and rapidly-progressive hyperglycemia. The patient’s peak serum glucose level of 707 mg/dL is the highest yet reported in a case of metformin toxicity. Treatment included sodium bicarbonate infusion and hemodialysis, but the patient suffered several cardiac arrests with pulseless electrical activity and ultimately expired 25 hours after the ingestion.

[WestJEM. 2008;9:160-164.]

Objective: This report aims to illustrate the history and current status of Japanese emergency medical services (EMS), including development of the specialty and characteristics adapted from the U.S. and European models. In addition, recommendations are made for improvement of the current systems.

Methods: Government reports and academic papers were reviewed, along with the collective experiences of the authors. Literature searches were performed in PubMed (English) and Ichushi (Japanese), using keywords such as emergency medicine and pre-hospital care. More recent and peer-reviewed articles were given priority in the selection process.

Results: The pre-hospital care system in Japan has developed as a mixture of U.S. and European systems. Other countries undergoing economic and industrial development similar to Japan may benefit from emulating the Japanese EMS model.

Discussion: Currently, the Japanese system is in transition, searching for the most suitable and efficient way of providing quality pre-hospital care.

Conclusion: Japan has the potential to enhance its current pre-hospital care system, but this will require greater collaboration between physicians and paramedics, increased paramedic scope of medical practice, and greater Japanese societal recognition and support of paramedics.

[WestJEM. 2008;9:166-170.]

This case report describes an atypical presentation of an atypical disease entity: Emphysematous Cystitis, a rapidly progressive, ascending urinary tract infection, in an emergency department (ED) patient whose chief complaint was abdominal pain and who had a urinalysis not consistent with the diagnosis of cystitis. [WestJEM. 2008;9:171-173.]

Methicillin-resistant Staphylococcus aureus (MRSA) infections have grown to epidemic proportions in the United States. With the development of increasing drug resistance of MRSA to traditional antimicrobials, there has been a search for a more effective antibiotic treatment. Linezolid is one of the most effective oral medications used for outpatient treatment of MRSA infections. We present a case of pancytopenia after outpatient treatment with linezolid. Myelosuppression is a rare but serious side effect of linezolid of which emergency physicians need to be aware in order to provide early intervention.

[WestJEM. 2008;9:177-178.]

Alameda County Medical Center; University of California, San Francisco; Washington University, St. Louis