Biomedical subjects

Cameron S Crandall

Publications and source records attributed to Cameron S Crandall.

12 recordsLinked to original sources

PubMed2007

Unanticipated death after discharge home from the emergency department.

STUDY OBJECTIVE: We measured the frequency of unanticipated death among patients discharged from the emergency department (ED) and reviewed these cases for patterns of potential preventable medical error. METHODS: This was a retrospective cohort of ED patients who were discharged to home from an urban tertiary-care facility after their evaluation, with subsequent case review. Subjects were aged 10 years and older, representing 387,334 visits among 186,859 individuals, February 1994 through November 2004. The main outcome was mortality. Deaths were assessed for relatedness to the last ED visit, whether the death was expected, and whether there was possible medical error. Deaths that were unexpected and related to the ED visit were analyzed using grounded theory to identify common themes among these cases. Error cases were identified as a subset of this group. RESULTS: We identified and reviewed 117 patients, or 30.2 deaths within 7 days of discharge per 100,000 ED discharges home (95% confidence interval [CI] 25.2 to 36.2 deaths). Of the 117 cases, 58 (50%) were unexpected but related to the ED visit and 35 (60%) of these had a possible error. For the unexpected, related group, there were 15.0 deaths within 7 days per 100,000 discharges home (95% CI 11.6 to 19.4 deaths); for the possible error group, there were 9.0 (95% CI 6.5 to 12.6 deaths). Four themes repeatedly emerged: atypical presentation of an unusual problem, chronic disease with decompensation, abnormal vital signs, and mental disability or psychiatric problem or substance abuse that may have made it less likely that the patient would return for worsening symptoms. CONCLUSION: Monitoring of death records can identify unanticipated deaths after health care encounters. Further hypothesis-driven research is needed to identify, prevent, or mitigate problems in care and reduce the rate of death after ED visit.

Adolescent↗

PubMed2006

Analysis of patients treated during four Disaster Medical Assistance Team deployments.

To aid disaster planning, a retrospective review of patients seen by New Mexico 1 Disaster Medical Assistance Team (NM-1 DMAT) after four disasters was conducted. Data analyzed included age, gender, past medical history, chief complaint, diagnosis, diagnostic testing, treatment, triage category, disposition, and time to presentation after the disaster. Data were analyzed for differences between patients presenting early vs. late after a disaster and to test if availability of diagnostic testing changed patient disposition. The results showed that the majority of patients presented with upper respiratory tract infection symptoms, wounds, and musculoskeletal pain. The needs of patients were similar whether they presented early or late. The same proportion of patients was transferred to hospitals when diagnostic testing was available vs. not available, despite a higher level of acuity when diagnostic testing was available. In conclusion, DMATs should be prepared to see high volumes of low acuity patients. Patient needs do not change with time. Diagnostic testing may be useful.

Adolescent↗

PubMed2006

The influence of site of collection on postmortem morphine concentrations in heroin overdose victims.

When assaying for postmortem morphine concentration, significant site sampling variability exists between central and peripheral sampling sites and even within sampling regions of the body. To study the variation, 76 suspected heroin overdoses were identified. Each had femoral artery (FA) and vein (FV), left and right ventricle and pooled heart blood samples obtained at autopsy. Forty-four tested positive for morphine. Morphine concentrations were determined by gas chromatography/mass spectrometry, with sampling site differences reported as log-transformed ratios and compared by signed rank test. The mean FA to FV ratio for total morphine was 1.2 (range 0-4.5). The ratio for left heart to right heart total morphine was 1.1 (range 0.4-3.2). Left ventricular to FV total morphine ratio was 2.0 (range 0.6-6.9). In these opioid overdose deaths, FA and FV morphine concentrations are usually similar, although up to 4.5-fold differences were noted. Centrally obtained morphine concentrations are on average twice as high compared with peripheral morphine concentrations. Left and right ventricular morphine concentrations were usually similar, although up to 3.2-fold differences were noted (left side higher).

Adolescent↗

PubMed2006

Changes in metabolic and hematologic laboratory values with ascent to altitude and the development of acute mountain sickness in Nepalese pilgrims.

OBJECTIVE: During August of each year, thousands of Nepalese religious pilgrims ascend from 2050 m to 4500 m in 1 to 3 days. Our objectives were to evaluate the incidence of acute mountain sickness (AMS) among this large group of native people, to explore changes in serum electrolytes as subjects ascend to high altitude, and to attempt to determine whether decreased effective circulating volume is associated with the development of AMS. METHODS: This was a prospective study with 2 parts. In the first part, demographic, physiologic, and laboratory data were collected from a cohort of 34 pilgrims at both moderate (2050 m) and high altitude (4500 m). Changes that occurred with ascent were compared in subjects who did and did not develop AMS. The second part was a cross sectional study of a different group of 57 pilgrims at the high-altitude site to further determine variables associated with AMS. RESULTS: In the cohort of 34 subjects, Lake Louise score, heart rate, respiratory rate, blood urea nitrogen (BUN), BUN:creatinine ratio, and pH increased at high altitude, whereas oxygen saturation, bicarbonate, creatinine, and PCO2 decreased. Sixteen of these 34 subjects (42%) were diagnosed with AMS; these patients had a statistically significantly lower hematocrit, oxygen saturation, and self-reported water consumption than those without AMS. Of the 57 subjects enrolled in the cross sectional study, 31 (54%) were diagnosed with AMS. These pilgrims had higher heart rates and BUNs than did their non-AMS counterparts. CONCLUSIONS: Fifty-two percent of the subjects developed AMS. With ascent to altitude, subjects showed some evidence of decreased effective circulating volume, though there were no clinically significant changes. The data did not show whether decreased circulating volume is a significant risk factor in the development of AMS at high altitude.

Acute Disease↗

PubMed2004

Previous emergency department use among homicide victims and offenders: a case-control study.

STUDY OBJECTIVE: We differentiate risk factors for future homicide victimization and offending, and we measure emergency department (ED) use among homicide victims, offenders, and controls. METHODS: The design was a matched case-control study conducted in Bernalillo County, NM, and its university-affiliated health sciences center and hospital. All Bernalillo County homicide victims (N=124) and offenders (N=138) identified between January 1996 and December 2001 who were linked to university physician billing records and who had health care use during the 3 years before the homicide incident were included as cases. Randomly selected age-matched (+/-1 year) and sex-matched subjects with health care use within 3 years of their matched pair's homicide were included as controls. Main outcome measures were the number and type of ED visits by cases and controls. RESULTS: Among the 124 victims and 138 offenders who used health care, most were men (80%) and averaged 27.7 years of age. Victims and offenders had similar health care use and were grouped for final analyses. Cases (victims and offenders) were more likely to have had an ED visit within 3 years of the homicide (85%) compared with controls (59%) (odds ratio [OR] 4.3; 95% confidence interval [CI] 3.0 to 6.2). Within previous ED visits, assault (OR 4.5; 95% CI 2.9 to 7.0), firearm injury (OR 13.6; 95% CI 4.9 to 37.7), and substance abuse (OR 3.7; 95% CI 2.2 to 6.0) were associated with future homicide. ED visits clustered closer to the homicide incident for cases (median days before the homicide -402 days; 95% CI -434 to -364) compared with controls (median -487 days; 95% CI -498 to -474). CONCLUSION: Patients with ED visits for assault, firearm injuries, and substance abuse are at increased risk for homicide and often have an escalating number of visits leading up to the homicide event. ED-based identification and referral programs similar to those used for intimate partner violence or other preventive strategies should be considered for this high-risk population.

Adolescent↗

PubMed2003

Use of a self-selected scheduling method in a large academic emergency medicine group.

We describe a method for scheduling shifts in a large academic emergency medicine group. The method starts with a survey of the faculty to assign shift equivalent values to each of the 13 different shifts used during the week. A weekday day shift is assigned a value of 1.0, and the shifts range in value up to 2.1 units. Each faculty member is then assigned a shift allocation for the academic year equally divided among the various shift types. Faculty members can request reallocation of shift types on the basis of the individual shift equivalent values. Once the number of the different shifts are allocated as required by the schedule, a lottery is held whereby individual faculty members choose specific shifts in turn for the upcoming year. The lottery selection is done by the faculty members accessing a common server from their office computers during a specified period. The lottery process continues until all shifts are filled. The creation of shift equivalent values facilitates the initial allocation of shifts and subsequent trades between faculty members.

Academic Medical Centers↗

PubMed2003

Different medical needs between hurricane and flood victims.

OBJECTIVE: Through the review of patient records seen by the New Mexico-1 Disaster Medical Assistance Team (NM-1DMAT) after various disasters, we hoped to find patterns that might help in disaster planning. Our hypothesis was that flood and hurricane victims have different medical conditions and needs. METHODS: We conducted a retrospective review of patient records for NM-1DMAT deployments to Hurricane Andrew in Florida (August 1992) and the Houston, TX flood caused by Tropical Storm Allison (June 2001). We compared age, gender, chief complaint, medical history, diagnosis, diagnostic testing, treatment rendered, triage category, and patient disposition. RESULTS: We found several differences between the patients presenting after Hurricane Andrew and those presenting after Tropical Storm Allison. The chief complaint, diagnosis, presence of medical history, diagnostic testing, treatment rendered, triage category, and disposition all differed between the 2 disasters. The mean ages in both groups were similar. CONCLUSIONS: The needs of the patients differed in several areas between Hurricane Andrew and the Houston flood. This information should be tested in a future hurricane or flood and taken into account when planning for deployments.

Adult↗

PubMed2003

Rural and urban fatal pedestrian crashes among United States American Indians and Alaskan Natives.

The Fatality Analysis Reporting System (FARS) and the Web-based Injury Statistics Query and Reporting System (WISQARS) were used to compare fatal pedestrian crashes in American Indians and Alaskan Natives (AI/AN) between urban and rural locations for 2000-2001. There were significant differences between urban and rural crashes for driver, pedestrian, environmental, and engineering factors. Rural pedestrian crashes more often occurred on highways (p<0.0001) lacking traffic control devices (p<0.0001) and artificial lighting (p<0.0001). Alcohol was a significant cofactor in both environments (40% urban vs. 55% rural; p=0.0239). Prevention of AI/AN deaths should include engineering countermeasures specific to the needs of rural (lighting) and urban (medians with barriers) environments and address drinking behavior in both populations.

Accidents, Traffic↗

PubMed2002

Prevalence and risk factors associated with hepatitis C in ED patients.

The objective of this study was to measure the prevalence of and identify risk factors associated with hepatitis C virus (HCV) in emergency department (ED) patients. Adults presenting to an urban university teaching hospital, having blood drawn as part of their routine evaluation, had an extra tube drawn and tested for HCV. English-speaking adults consenting to participate in the survey portion of the study were administered an in-depth risk factor questionnaire. A case-control analysis was used to identify risk factors in HCV+ compared with HCV- subjects. Contingency table analyses using the Fisher exact test, odds ratios (OR), and 95% confidence intervals (CI) were used for risk factor identification. Of 223 blood samples, 38 (17%) were positive for antibodies for HCV. One hundred twenty-one subjects (54%) agreed to the risk factor survey, 18 (15%) of whom were HCV+. Of the 18 HCV+ survey participants, 12 new diagnoses of HCV were made. A history of injection drug use was the most significant risk factor associated with HCV (OR 858.5, CI 61.8-22,026.5). A high prevalence of HCV is found in selected urban ED patients. Most of these patients have a constellation of risk factors including a history of injection drug use. Efforts to identify at risk patients for serologic testing and follow-up should be initiated. Identifying undiagnosed HCV can lead to interventions to decrease transmission as well as reduce the morbidity and mortality of disease.

Adult↗

PubMed2002

Introducing a simple, weight-based, color-coded, medication dosing device.

OBJECTIVE: To compare the time required to withdraw various pediatric resuscitation medications using traditional techniques and the Per-Kilo Doser (PKD), a new weight-based dosing device. METHODS: Seven emergency department nurses were each videotaped as they withdrew medications for four different pediatric resuscitation scenarios. In random order, each nurse performed a total of eight timing trials-four with traditional techniques and four with the PKD. The videotapes were later reviewed and timed by two reviewers who were unaware of the study purpose. The time to drug withdrawal (announcement of medication and dose to be withdrawn until the nurse completed medication withdrawal) was measured in seconds. Nonparametric and exact techniques were used to determine statistical significance. RESULTS: Using traditional techniques, the mean time to drug withdrawal was 71.8 seconds; using the PKD, the mean time to drug withdrawal was 43.1 seconds. The mean time difference between the PKD and traditional techniques was 29.2 seconds (95% CI, 16.7-41.7). CONCLUSION: The PKD decreases medication withdrawal time.

Body Weight↗

PubMed2000

Octreotide: an antidote for sulfonylurea-induced hypoglycemia.

STUDY OBJECTIVES: Sulfonylurea agents are widely used as therapy for hyperglycemia in type 2 diabetes mellitus. In overdose, these agents can produce sustained and profound hypoglycemia that is refractory to treatment with dextrose alone. Our objective was to determine whether treatment with octreotide decreases glucose requirements and the number of hypoglycemic episodes in patients with sulfonylurea-induced hypoglycemia. METHODS: We retrospectively reviewed the charts of patients treated with octreotide for sulfonylurea-induced hypoglycemia from 1995 through 1998. The study took place in a large urban teaching hospital in the United States. We measured the number of episodes of hypoglycemia reported and the amount of dextrose used before and after treatment with octreotide. Using a failure time analysis, we compared the risk of hypoglycemia before and after octreotide administration. RESULTS: The age range of the 9 patients was 20 to 65 years. Six patients ingested glyburide and 3 ingested glipizide. The number of hypoglycemic events recorded per patient before octreotide (mean 3.2) was greater than the number of hypoglycemic events recorded per patient after octreotide (mean 0.2, P =.008). Similarly, the number of ampules of 50% dextrose administered per patient before octreotide (mean 2.9) was greater than the number of ampules administered per patient after octreotide (0.2, P =.004). The risk of recurrent hypoglycemia before octreotide treatment was 27 times the risk of the group after octreotide treatment (P <.001). Stabilization of blood glucose concentration and cessation of rebound hypoglycemia occurred immediately after the administration of octreotide in all 9 patients. CONCLUSION: Octreotide appears to be safe and effective in preventing rebound hypoglycemia after sulfonylurea ingestion. Octreotide in combination with dextrose should be considered for first-line therapy in the treatment of sulfonylurea-induced hypoglycemia.

Adult↗

PubMedDate not supplied

The influence of collection site and methods on postmortem morphine concentrations in a porcine model.

This study was to determine the relationship of antemortem to postmortem morphine concentrations in heart and femoral blood in a porcine model following acute intravenous opiate overdose. The study involved 20 swine; each was sacrificed 10 min after injection of 2 mg/kg body weight of morphine. Drug concentrations were assayed from vitreous humor and blood isolated from the femoral vein and artery and left and right ventricles at various times postmortem. Comparisons were made between antemortem and postmortem values to determine agreement and reliability. Both free and total postmortem values varied significantly among animals, sampling sites, and over time. Free postmortem values were generally higher in comparison with antemortem values, whereas postmortem total morphine values were similar to or slightly lower than antemortem values. The effect of time on postmortem values was small. These results demonstrate a significant amount of variability in free and total morphine measurements both over time and within and between sites. Furthermore, a comparison of antemortem to postmortem values demonstrates a lack of consistency relative to the dose of morphine administered. Concentrations of morphine in the femoral vein were typically the lowest observed. This observation is not surprising given the transformation that occurs prior to the drug reaching the femoral vein. Values associated with diffuse tissues, relative to femoral veins, demonstrate more stochastic variation.

Analgesics, Opioid↗