Biomedical subjects
K Wrenn
Publications and source records attributed to K Wrenn.
The lowly nasogastric tube: still appropriate after all these years (at times).
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The use of structured, complaint-specific patient encounter forms in the emergency department.
STUDY OBJECTIVE: To assess the effect of preprinted, structured, complaint-specific patient encounter forms on documentation, use of testing, and treatment compared with free-text record keeping. DESIGN: Nonrandomized case-control trial. SETTING: University-affiliated, tertiary referral hospital emergency department. METHODS: The records of all patients with lacerations, pharyngitis, asthma, or isolated closed-head injury during an eight-month period were reviewed. INTERVENTION: Use of structured complaint-specific patient encounter forms versus traditional free-text record keeping. MAIN OUTCOME MEASURE: The null hypothesis was that there would be no differences in documentation, test use, or practice when the structured forms were used compared with free-text record keeping. RESULTS: Differences in documentation that favored the use of the structured forms for all four problems studied were seen consistently. Not only was documentation improved, but test use also was affected in a way that decreased use. In addition, in certain areas (eg, treatment of pharyngitis), clinical practice also was changed. CONCLUSION: Structured, problem-specific ED records improve documentation and affect both resource use and clinical practice. These forms may be useful for improving communication and reimbursement as well as for medicolegal documentation. They provide a method for standardized quality assurance review and clinical data abstraction. Finally, they provide a method for active dissemination of clinical standards.
Are baseline prothrombin time/partial thromboplastin time values necessary before instituting anticoagulation?
STUDY OBJECTIVES: To determine whether baseline prothrombin time (PT) or partial thromboplastin time (PTT) values provide information that is useful to the clinician before initiating anticoagulation and whether emergency physicians elicit historical information about bleeding disorders before beginning anticoagulant therapy. DESIGN: A three-year retrospective review of the records of 199 patients admitted through the ED with an ICD-9-CM diagnosis of deep-vein thrombosis or pulmonary embolus using a predesigned study sheet that included historical questions, baseline PT and PTT values, treatment given, timing of treatment, and underlying medical problems. SETTING: University-affiliated tertiary-care hospital. MEASUREMENTS AND MAIN RESULTS: Deep-vein thrombosis was the primary diagnosis in 75% of patients. Pertinent historical items were not documented in 92% to 100% of patients. Baseline PT and PTT values were obtained in 94% of patients. An elevated baseline PT was found in 26 patients, all of whom were taking warfarin. An elevated baseline PTT was found in 21 patients. These results were attributed to laboratory error (one), warfarin use (nine), heparin therapy before baseline tests (five), anticardiolipin antibodies (five, one of whom was on warfarin therapy), and unknown causes (three). Heparin therapy was not altered for any patient. CONCLUSION: Emergency physicians rarely document pertinent questions about bleeding disorders before initiating anticoagulation therapy. Baseline PT and PTT values are almost routinely obtained despite the fact that they do not alter therapy or serve as sensitive or specific screening tests. Routine baseline PT and PTT values are rarely needed before initiating anticoagulation. Eliminating such routine testing would result in significant cost savings.
Potential misuse of ipecac.
STUDY OBJECTIVE: To evaluate the use of ipecac by health care professionals. DESIGN: A descriptive case series based on a one-year review of all calls to a poison center. SETTING: A university hospital-affiliated regional poison center. INTERVENTIONS: The use of ipecac was judged appropriate or inappropriate based on the consensus of three professionals associated with the poison center using predetermined contraindications. MEASUREMENTS AND MAIN RESULTS: In 20% of cases in which ipecac was used, its use was inappropriate. The most common inappropriate situation was that too much time had elapsed from the time of ingestion. Among adults the most common contraindication was the ingestion of a substance known to cause altered mental status. Among children, the most common contraindication was the ingestion of a nontoxic substance or amount of substance. The poison center recommended ipecac inappropriately less often than emergency departments and usually in children ingesting a nontoxic substance. EDs recommended ipecac inappropriately with a broader range of contraindications and more often in adults. CONCLUSION: Ipecac has potentially adverse consequences and should not be used reflexively. Providers of emergency care should be educated about possible contraindications to its use.
Bromocriptine for cocaine users.
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Do-not-resuscitate orders in the emergency department.
PURPOSE: To evaluate the nature of the decision to write a do-not-resuscitate (DNR) order in the Emergency Department (ED). PATIENTS AND METHODS: This is a prospective evaluation of 37 consecutive patients for whom a DNR order was written by personnel assigned to the ED of a large inner-city teaching hospital. For each patient, information was collected including who was involved in the decision, the difficulty the family or patient had in agreeing to the DNR order, acute and chronic problems, how often the patient could enter into the process, and the ultimate outcome. RESULTS: DNR orders were usually initiated by house officers assigned to the ED (65%), and the family was usually involved (89%, mean of 1.4 family members per patient). There were no cases where significant resistance to the DNR order was exhibited by the family. The patients were generally elderly, demented, and debilitated with multiple chronic medical problems or young with malignancy or the acquired immunodeficiency syndrome and had become critically ill and unstable. Only five patients were able to enter into the decision. Discussion of DNR status had occurred previously in only 14% of patients. CONCLUSION: Because there remains considerable reluctance on the part of physicians to discuss the DNR issue before patients become critically ill, it is often necessary for ED physicians to write a DNR order. Although the ED is not an ideal setting for discussion of DNR orders and patients and families do not generally initiate this discussion, DNR orders can be written by ED physicians after consultation with the family.
Students and their teachers.
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Tapping the child's perspective.
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Profound alkalemia during treatment of tricyclic antidepressant overdose: a potential hazard of combined hyperventilation and intravenous bicarbonate.
Two patients with cardiovascular and neurologic toxicity from intentional tricyclic antidepressant overdose received bicarbonate infusions in association with hyperventilation for alkalinization. Both patients developed profound alkalemia. One patient died, and the other patient's alkalemia resolved prior to her death. Bicarbonate infusions have become the standard of care for symptomatic tricyclic antidepressant toxicity. Severe alkalemia (pH greater than 7.60) in other settings has been reported to correlate with higher rates of mortality. Careful monitoring of the pH is imperative when bicarbonate therapy is used. It is probably prudent to keep the pH level in the range 7.45 to 7.60. Capnography may also be useful in monitoring patients during alkalinization.
Expanding the focus of emergency medicine.
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Aminophylline therapy for acute bronchospastic disease in the emergency room.
OBJECTIVE: To assess the role of aminophylline in the treatment of acute exacerbations of bronchospastic disease when used in addition to inhaled beta-agonists and intravenous corticosteroids. DESIGN: Randomized, double-blind, placebo-controlled intervention study. PATIENTS: One hundred thirty-three adult patients with either asthma or chronic obstructive pulmonary disease who presented to the emergency department with asthma or wheezing. INTERVENTIONS: All patients received therapy with both aerosolized metaproterenol and intravenous methyl-prednisolone. Patients were randomly assigned to receive either a loading dose of aminophylline followed by a routine infusion (n = 65) or an equal volume of placebo as a loading dose and infusion (n = 68). MEASUREMENTS AND MAIN RESULTS: At discharge from the emergency department, the median serum theophylline concentration for the aminophylline group was 54 mumol/L (9.7 mg/L). The two groups showed no differences (P greater than 0.2) in measurements of forced expiratory volume at 1 second (FEV1), forced vital capacity (FVC), or peak expiratory flow rate (PEFR) at baseline or at 60 or 120 minutes after aminophylline administration. Neither patient satisfaction nor physician assessment of response to therapy differed between the two groups. There was no difference (P greater than 0.2) in the frequency of side effects, except for a trend toward a higher frequency of nausea (P = 0.13) in the aminophylline group. There was, however, a threefold decrease in the hospital admission rate for patients treated with aminophylline (6%) compared with placebo recipients (21%) (P = 0.016). CONCLUSION: Aminophylline, in doses producing levels just below the commonly accepted therapeutic range, appears to decrease hospital admissions in patients with acute exacerbation of asthma or chronic obstructive pulmonary disease. This finding, if confirmed in larger studies, may represent a substantial cost savings.
Immersion foot. A problem of the homeless in the 1990s.
The syndrome of immersion foot is being seen with increasing frequency among the homeless population. It represents the effects of injury by water absorption in the stratum corneum of the skin of the feet. The taxonomy of this disorder is confusing and the many colorful pseudonyms should probably be dropped in favor of a simple classification based on the temperature of the water and the duration of exposure. When uncomplicated by infection or ischemic injury, immersion foot will quickly resolve with conservative measures only. More complicated cases may require antibiotics and surgical treatment. This syndrome may be exacerbated by disturbances of cognition, peripheral neuropathy, peripheral vascular disease, or the use of tobacco or vasoconstrictor drugs such as cocaine. A major contributing factor seems to be lack of shelter in the homeless population. Attention to foot care problems among the homeless and education concerning preventive measures are incumbent on physicians who care for the indigent.
Isopropyl alcohol intoxication.
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Management strategies in wide QRS complex tachycardia.
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