Patients who leave the emergency department against medical advice

OBJECTIVE: Discharge against medical advice (DAMA) from the emergency department (ED) accounts for 0.1% to 2.7% of all ED discharges. DAMA carries a risk of increased mortality and readmissions. Our aim was to investigate the general characteristics of DAMA patients and the differences between them and non-DAMA patients. METHODS: We reviewed data collected by the National Emergency Medical Center between 2010 and 2011. Subjects were categorized into 2 groups, namely, the DAMA group and the non-DAMA group. We compared these groups with respect to age, gender, trauma or non-trauma status, type of hospital, health insurance, level of consciousness on admission, and diagnosis. RESULTS: Of 8,000,529 patients, 222,389 (2.78%) left against medical advice. The risk factors for DAMA across all age groups were as follows: no medical insurance (odds ratio [OR], 1.993), initial response to voice (OR, 2.753) or pain (OR, 2.101), trauma admission (OR, 1.126), admission to a local emergency medical center (OR, 1.215), and increased age. A high risk of DAMA was observed among patients with immune, endocrine, psychiatric, neurological, circulatory diseases, and external causes of morbidity and mortality. CONCLUSION: Although DAMA cases account for only a small percentage of hospital discharges, they are important because DAMA patients have high readmission and mortality rates. It is therefore important to understand the general characteristics and predictors of DAMA in order to improve patient outcome and minimize the economic burden on the healthcare system.

A Study on Heuristic Transportation Routes of Patients with Acute Dysbarism for the Best Prognosis

PURPOSE: Acute dysbarism is a potentially lethal injury associated with environmental medicine. Therefore, prompt treatment, including transportation of victims, is important for the best prognosis. The aim of this study was to examine transportation routes of patients with acute dysbarism for the best prognosis in Korea. METHODS: Geography of South Korea was analyzed using the geographic information system (GIS). The study examined two scenarios using transportation analysis, which relies on a GIS base and pressure variation during air and ground transportation. Given the practical assumptions, we propose some heuristic transportation routes based on the simulation of altitude, transportation time, and availability of related factors. RESULTS: Currently, transportation by ground to the treatment facilities always passes high altitude areas above 152 feet. Also, available helicopters for air transportation could not approach the treatment facilities due to the limitation of flying distance and insufficiency of medical staff and treatment equipment. Altitude variation and delayed time were identified during the period of transportation by ground from Ganneung or Incheon to Tongyoung. Heuristic algorism through the above facts recommends air transport along coasts as the best method for transportation from Ganneung or Incheon to Tongyoung. CONCLUSION: In Korea, transportation by ground was not expected to result in the best prognosis for patients with acute dysbarism. Transportation by air should be considered first as the method of transportation. Also, for the best treatment of patients with acute dysbarism, additional treatment facilities need to be established in the west coast region.

Implementation and Results of a Survey on Safe Community Programs in Gangbuk-gu, Korea: Focusing on Participants at a Local Public Health Center / 예방의학회지

OBJECTIVES: The purpose of this study was to investigate the current status of and problems with the Safe Community Programs in Gangbuk-gu, one of the 25 districts of the capital city of Korea. METHODS: The study subjects were 396 individuals who were involved in Safe Community Programs between 2009 and 2011. We examined the effectiveness and willingness of respondents to participate as a safety leader of the Safe Community Program with a questionnaire. We examined the injury death rates of Gangbuk-gu by using of the death certificate data of Korea's National Statistical Office. Descriptive statistics and chi-squared tests were used. RESULTS: The effectiveness of programs did not differ but active participation differed significantly among subjects (p<0.05). The injury death rate of Gangbuk-gu as a whole increased during the implementation period. However, senior safety, in particular, may be a helpful program for reducing injuries in Gangbuk-gu. CONCLUSIONS: This study suggests that the lack of active participation may be a major problem of Safe Community Programs in Gangbuk-gu. Therefore, Safe Community Programs should be expanded to the entire district of Gangbuk-gu and more active participation programs should be developed.

Injuries Associated with the 580 km University Student Grand Voluntary Road March: Focus on Foot Injuries

College student volunteers (n = 142) completed a 580 km road march for 21 consecutive days. Each volunteer carried a backpack that weighed 14.1 +/- 1.4 kg on the average. We investigated the incidence and location of blisters associated with the road march using a foot map along with other injuries. Overall, 95.1% of the subjects (135 of 142) sustained one or more injuries. All injured subjects had foot blisters, and 18% had other foot injuries. The most common locations of blister development were the right 5th toe (61%) and the left 5th toe (57%). The little toes seem to have been subjected to the greatest friction and shearing forces. March-related injuries, excluding foot injuries, were ankle pain (12.7%), knee pain (12.7%) and Achilles tendon pain (7.7%). Six subjects (4.2%) needed extra medical treatment for more than 2 weeks prior to returning to their daily lives after completion of the march due to associated injuries. The present study observed a very high incidence rate of injuries (95.1%) associated with the 580 km university students grand road march. These injuries posed an obstacle against completion of the road march and against returning to daily life. Active preventive interventions such as physical therapy and customized reinforced shoes and education program are recommended for reducing incidence rate and severity of injuries.

Recent 10-Year Experience of One Regional Emergency Center and Recommendation for Hyperbaric Oxygen Therapy (HBOT)

PURPOSE: The aim of this study is to investigate current status, indications, and complications of hyperbaric oxygen therapy. METHODS: A retrospective investigation of patients who underwent hyperbaric oxygen therapy at a university medical center from September 2004 to August 2013 was conducted based on patients' medical records and results of an email survey for 99 emergency centers. RESULTS: During the study period, a total of 233 patients underwent hyperbaric oxygen therapy. Indications for hyperbaric oxygen treatment of illness or injury were as follows: 1) 151 cases of acute carbon monoxide poisoning(65.4%), 2) flap wound management, including 42 cases(18.2%), 3) skin care transplanted, including 23 cases(10.4%), 4) Burger's disease, including 5 five cases(2.1%), respectively. Total application time* frequency was 1,088 and total time was 1,239 hours. Among 233 patients who underwent hyperbaric oxygen therapy, 32 patients(13.7%) had complications: 1) otalgia in 21 cases(9.0%), 2) mastoiditis? in six cases(2.6%), 3) hemotympanum in five cases(2.1%), respectively. There were only 8 emergency centers that currently had an operational hyperbaric oxygen chamber in 77 emergency centers(10.4%). CONCLUSION: Indications identified through this study showed difference from current indications worldwide. It seems necessary that physicians' perception regarding application of hyperbaric oxygen therapy for more indications be changed and improved. A hyperbaric chamber capable of providing respiratory assistance and intensive care is also needed. A good network for sharing treatment experiences and a specialized team for administration of hyperbaric oxygen therapy is also required.

The Clinical Characteristics and Prognosis after Acute Ingestion of Glacial Acetic Acid

PURPOSE: A retrospective study with a literature review was conducted to identify the clinical characteristics and prognosis after the acute ingestion of glacial acetic acid. METHODS: The medical records of 20 patients,who had presented to the emergency department of Ajou University Hospital complaining of the acute ingestion of glacial acetic acid between January 2006 and December 2011, were examined retrospectively. RESULTS: Among the 172 patients admitted for caustics injury, 20 patients ingested glacial acetic acid. The mean age of the patients was 55+/-23.5, and the mean volume of the acid was 84.5+/-71.3 ml. The clinical features included 1) oral ulcers in 12 patients (63.2%), 2) respiratory difficulties in 11 patients (57.9%), 3) oliguria in 8 patients (42.1%), 4) renal toxicity in 7 patients (36.8%), 5) hepatic failure in 7 patients (36.8%), 6) disseminated intravascular boagulopathyin 7 patients (36.8%), 7) low blood pressure in 8 patients (42.1%), and 8) mental changes in 9 patients (47.4%). Ten patients required endotracheal intubation. Nine patients were admitted to the intensive care unit, and 5 patients expired. CONCLUSION: The ingestion of glacial acetic acid can cause severe symptoms, such as metabolic acidosis, multiple organ failure and upper airway swelling frequently and has a high mortality rate. Therefore, aggressive treatment, including endotracheal intubation, should be considered at the early stages.

Characteristics of Patients Who Visit the Emergency Department with Self-Inflicted Injury

During visits to emergency medical facilities, the primary care of and risk identification for individuals who have attempted suicide is considered an important element in suicide prevention. With the ultimate goal of helping to prevent suicide, the aim of the present study was to determine the characteristics of patients with self-inflicted injuries who presented in the emergency department. Patients with self-inflicted injuries who visited 1 of 3 sentinel emergency medical centers from 2007 through 2009 were included in the study. The characteristics, methods, and reasons for suicide attempts were evaluated. Moreover, predictors of severe outcomes were evaluated. A total of 2,996 patients with self-inflicted injuries visited the three centers during a period of 3 yr. The male-to-female suicide ratio was 1:1.38 (P or = 50 age group. The reasons for attempting suicide varied among the age groups. The predictors of severe outcome are male gender, older age, and not having consumed alcohol.

The Applicability and Usefulness of Emergency Department Syndromic Surveillance Using a Computed Data Source for Epidemic Keratoconjunctivitis and Meningitis

PURPOSE: This study was designed to evaluate the applicability and usefulness of emergency department (ED) syndromic surveillance using a computerized data source for highly contagious, public health related diseases such as conjunctivitis and meningitis. METHODS: Between Jan 1 2007 and Dec 31 2008 we conducted a retrospective, observational study through consecutive enrollment of individuals at a university hospital with an ED census of about 156,000. ED patient data were obtained from a computerized data system, the National Emergency Department Information System (NEDIS). Predefined symptoms including red eye, eye injection / discharge / itching, headache, nausea, vomiting and predefined signs such as fever comparable with conjunctivitis and meningitis and ED discharge diagnosis were used as data for syndromic surveillance. Data about spinal tapping were used for agreement analysis. RESULTS: We enrolled 714 patients for ED syndromic conjunctivitis and 1,889 for ED syndromic meningitis during the study period. A positive correlation was demonstrated between ED syndromic conjunctivitis data and national ophthalmologic sentinel survey data (Pearson correlation = 0.696; p<0.001). The agreement (kapha value) between ED syndromic meningitis using chief complaints and ED discharge diagnosis and ED syndromic meningitis using chief complaints and spinal tapping order was 0.665 (p<0.001). Real outbreaks were recognized 2 to 4 weeks early by both ED syndromic surveillance of conjunctivitis and meningitis. CONCLUSION: ED syndromic surveillance methods are applicable and useful for surveillance of conjunctivitis and meningitis. Further study is needed to clarify the effectiveness of ED syndromic surveillance and the likelihood of early recognition in highly contagious public health related diseases.

Influence of the Werther Effect: An Increase of Intentional Carbon Monoxide Poisoning

PURPOSE: Suicide attempts are known to be influenced by mass media reports. The purpose of this study was to evaluate the effects of mass media reporting celebrity suicides on an increase of intentional carbon monoxide (CO) poisoning and suicide attempts. METHODS: We retrospectively reviewed the medical records of the consecutive patients who presented with suicide attempts to the Emergency Department of Ajou University Hospital during a 24 month period. We obtained the demographic data, any past history of suicide attempt and the methods of suicide attempts from the medical records of the suicide attempters. Time series analysis was conducted for evaluating the influence of mass media reporting of celebrity suicide on the suicide rates. RESULTS: We finally enrolled 770 patients during the study period. The total number of suicide attempts by CO poisoning was 18 and the average number of suicide attempts by CO was 0.33+/-0.73 per week. All of the suicide attempts by CO poisoning occurred after a celebrity committed suicide using CO from burning charcoal. CONCLUSION: This study showed that celebrity suicide by CO poisoning resulted in the Werther effect, which made the rate of intended CO poisoning increase, and the study provided further evidence for the need to actively restrain mass media reporting of suicide to decrease the Werther effect.

A Study on a current Legal Foundations for Emergency Medical Service in Public Facilities

PURPOSE: Our country has seen a rapid increase in economic growth, national land development and planning. As a consequence, cities were enlarged and became densely populated. Public facilities were also increased to adequately serve the increasing population. Within the past 10 years, a lot of accidents in public facilities have occurred but the legal foundations for emergency medical care and systems for these public facilities may be lacking. METHODS: From the current domestic laws, we defined the public facilities and the enrolled laws that govern these facilities. Adequacy of the enrolled laws were then analyzed using 7 reference points: education for all employees, education for security employees, education for customers, arrangement of medical persons, arrangement of security person, equipment for emergency care and penalty. RESULTS: There were 17 enrolled laws and only 'Juvenile Activity Promotion Act' fulfilled most of the reference points except for 2; the arrangement of medical persons and penalty. Fifteen of the enrolled laws fulfilled less than 3 reference points. CONCLUSION: In the current domestic laws governing public facilities, almost all of them practically lacked policies addressing emergency care and systems.

Comparison of Pain Scale on Two Different Manual Reduction Technique in Patients with Elbow Subluxation

PURPOSE: This research was done to assess the effectiveness of two manual reduction techniques for elbow subluxation and to determine which technique was less painful during trial of manual reduction. METHODS: A prospective, controlled, randomized survey was conducted on children who presented to the Emergency Department (ED) of an inner-city university hospital with clinical features and physical findings suggestive of an elbow subluxation between Mar 1, 2007 and February 28, 2008. We evaluated the success rate of each reduction technique and the pain scale during trial of manual reduction. We classified each group into 2 subgroups (under 3 years of age and over 3 years of age) for evaluating the pain score. The degree of pain was determined using the FLACC scale (under 3 years of age) and faces pain scale (over 3 years of age). RESULTS: One hundred and four children were enrolled in our study and they were equally divided into a supination group (SG) and a pronation group (PG). There was no statistically significant difference with regards to the demographic data between the two groups. The success rate for the SG was 85.7% and for PG was 91.7% (p=0.32). For patients under 3 years of age, the FLACC scale for the SG was 5.14 and for PG was 3.82 (p=0.01). For patients over 3 years of age, the face pain scale for the SG was 5.5 and for PG was 5.54 (p=0.83). CONCLUSION: Both reduction techniques are useful for reducing elbow subluxations. In case of children under 3 years old, we believe that the pronation technique is a better option due to lesser pain produced compared to the supination technique.

Syndromic Surveillances based on the Emergency Department / 예방의학회지

Due to heightened concerns regarding possible bioterrorist attacks, the Korea Center for Disease Control and Prevention introduced syndromic surveillance systems, which have been run by emergency departments in hospitals throughout Korea since 2002. These systems are designed to identify illness clusters before diagnoses are confirmed and reported to public health agencies, to mobilize a rapid response, and thereby to reduce morbidity and mortality. The Korea Center for Disease Control and Prevention performed drop-in syndromic surveillance successfully during the World Cup Football Games in 2002, the Universiad games in 2004, and the Asian Pacific Economic Cooperation meeting in 2005. In addition, sustainable syndromic surveillance system involving the collaborative efforts of 125 sentinel hospitals has been in operation nationwide since 2002. Because active data collection can bias decisions a physician makes, there is a need to generate an automatic and passive data collection system. Therefore, the Korea Center for Disease Control and Prevention plans to establish computerized automatic data collection systems in the near future. These systems will be used not only for the early detection of bioterrorism but also for more effective public health responses to disease.

Risk Factors Influencing the Occurrence of Injuries in Koreans Requiring Hospitalization

PURPOSE: This study focused on local communities and the factors influencing injuries requiring hospital admission that affect the quality of life for Koreans. MATERIALS AND METHODS: This study used data collected from 4,400 households during the 2001 Korea National Health and Nutrition Examination Survey (KNHANES). A stratified multistage probability sampling method was applied and the final sample included 7,924 subjects over 20 years old who had completed the questionnaire regarding factors influencing injuries requiring hospital admission. Multiple logistic regression analysis was used to estimate the risk factors influencing injuries. RESULTS: The incidence of injuries requiring hospital admission in Koreans was higher in men than in women at 2.3% (95% CI: 1.8-2.8) and 1.7% (95% CI: 1.3-2.1), respectively. Statistically significant factors affecting the occurrence of injuries requiring hospital admission were marital status (OR: 2.60, 95% CI: 2.22- 5.56), state of health (OR: 0.63, 95% CI: 0.43-0.92), frequency of heavy drinking (OR: 1.96, 95% CI: 1.01-3.79), normal physical activities (OR: 1.68, 95% CI: 1.07-2.65), and sleep (OR: 1.54, 95% CI: 1.01-2.35). CONCLUSION: The results of this study can be used to develop measures to prevent fatal injuries and be used as basic data for community health programs.

Fixation of Open Alveolar Bone Fractures: Easily Applicable Method in the Emergency Department

PURPOSE: The purpose of this clinical trial was to evaluate the fixation method for treating alveolar fractures in an emergency department. METHODS: The efficiency of using the fixation method was judged on the basis of clinical criteria. Stability, occlusion state, bleeding amount after fixation, operation time, and difficulties during procedural operation were recorded. RESULTS: Eight patients were enrolled in this study. In all instances, the fixation method was effective in bleeding control. Each patient had a noticeable decrement in bleeding. A wire was used for four of the eight patients, and nylon strings was used for the others. The average operation time was 6.3 minutes for the wire patients and 2.8 minutes for the Nylon string patients. No specific problem was identified during the procedural operation. However, the difference in the fixation material influenced the effectiveness of the procedure, the operation time, and the satisfaction of the doctor. CONCLUSION: In the emergency department, the fixation method using wire or nylon string in the treatment of alveolar fractures is effective in bleeding control.

The Etiology and the Efficacy of Diagnostic Tools for Adult Patients Presenting with New-onset Seizure in an Emergency Department

PURPOSE: This study was conducted to evaluate the etiology and the efficacy of diagnostic tools such as physical examination, laboratory studies, cranial computed tomography (CT) scans, and electroencephalograms (EEGs) in adult patients presenting with new-onset seizure in an emergency department. METHODS: This is a retrospective study of a 4-year period during which 67 patients were admitted to an emergeny department complaining of new-onset seizure. Among them, 61 patients were eligible for inclusion in this study, and we reviewed their medical records, laboratory data, CT scans and EEG findings. RESULTS: The etiologies of new-onset seizure were 1) unknown, 2) alcohol withdrawal, 3) ischemic stroke, and 4) central nervous system infection. An abnormal CT lesion was diagnosed in 27.5% of the patients with normal neurological examinations. An abnormal CT lesion was diagnosed in 30% of the patients whose EEG results had a focal-wave pattern. But, No statistical significance could be attached to the relationship between the CT lesion and EEG results (p>0.05). CONCLUSIONS: The principal etiologies of new-onset seizure were 1) unknown, 2) alcohol withdrawl, 3) ischemic stroke. A CT scan should be performed in all patients with newonset seizure. A focal-wave pattern in the EEG may consider a necessity for brain imaging.

Corneal Foreign Body Removal by Emergency Physicians

PURPOSE: This study was performed to evaluate the success rate and the safety in the treatment of corneal foreign body injury by an emergency physician trained in their removal. METHODS: Any patients presenting at the emergency department of a large university-based residency teaching hospital with corneal foreign body injuries during ninety months were included in this prospective study. Twenty patients were eligible. Junior residents participated in this study. They were taught to remove corneal foreign bodies by the attending emergency physician. Healing evaluation was performed by an ophthalmologist. Patients not presenting for a visit were contacted by telephone, and information was collected on the assessment of discomfort and the presence of symptoms. RESULTS: All corneal foreign bodies were successfully removed, and no adverse effects were noted. CONCLUSION: Corneal foreign body removal by emergency physician, if properly trained, appears to be successful and safe.

The Efficacy and Safety of Rectal Thiopental Sodium for Sedation of Children in the Emergency Department

PURPOSE: This study evaluated rectal administration of thiopental sodium provides an efficient and safe method of sedation for children in the emergency department. METHODS: A prospective, randomized, non-blind study was conducted for 18 months. Thiopental and midazolam were given by rectal administration. Chloral hydrate was given by either oral or rectal administration. Ketamine was given by intramuscular injection. The administration dose of thiopental was 25 mg/kg. We evaluated the induction time, the recovery time, the Ramsay scale, the sedative effects for the procedure and the adverse effects of each drug. RESULTS: Eighty-six (86) children were enrolled in this study. Thiopental was administered to 21 children, ketamine to 21 children, chloral hydrate to 21 children and midazolam to 23 children. The induction time for thiopental, chloral hydrate and ketamine groups were 7.6+/-4.0 min, 36.0+/-7.0 min and 7.4+/-3.8 min, respectively. The recovery time for thiopental, chloral hydrate and ketamine groups were 54.1+/-11.8 min, 76.2+/-11.4 min and 64.8+/-18.2 min, respectively. The differences in the induction time and the recovery time for each group are statistically significant (p<0.001). The Ramsay scale for thiopental, chloral hydrate, ketamine and midazolam groups were 5.4+/-1.0, 5.7+/-0.5, 6.0+/-0.2 and 1.7+/-0.7, respectively. In thiopental group, one child (4.7%) experienced desaturation and one child (4.7%) experienced a decrease in blood pressure, but, no child required hospitalization for any complication from these sedatives. CONCLUSION: Rectal administration of thiopental is efficacious and safe for sedation of pediatric patients in the Emergency Department.

Paradoxical Cerebral Air Embolism Immediately after Ingestion of 5% Hydrogen Peroxide

We report the case of a 58-year-old man who developed multiple cerebral infarctions after ingesting accidently a 5% hydrogen-peroxide detergent solution. A 3~5% hydrogen peroxide solution is commercially available as an oxidant and detergent. Neurologic examination of this patient revealed grade III weakeness in both upper and lower limbs and bilateral positive Babinski signs. CT and MRI revealed bilateral multiple brain infarctions in the anterior and the middle vascular territories. The likely mechanism of pathogenesis must be paradoxical cerebral air embolism. Decompression through Nasogastric tube and hyperbaric oxygenation therapy were used to treating this patient. In spite of our intensive care, the patient expired 21days after ICU admission.

Total Gastrectomy after Sodium-Silicate Ingestion: Early Surgical Treatment for Alkali Injury: A Case Report

Sodium silicate is generally used for laundering and dishwashing and for anti-fire and anti-water agents. Liquid forms of sodium silicate (water, glass) have extremely high pH values that the range from 12.5 to 13. Thus, ingestion of this material causes various caustic injuries to the digestive tract. Management of alkali ingestion includes decontamination, dilution, and surgical treatment. A widely performed surgical treatments for these cases are emergency laparotomies for repair of perforations and palliative care for stricture or obstruction of the injured hollow viscus organs. Recently, early and extensive surgical management based on an endoscopic evaluation was introduced for severe alkali injuries. Endoscopy is not only a safe and reliable tool for diagnosis but also is important in the treatment of and the prognosis for alkali ingestion. We report the case of a 48-year-old man presenting to the emergency department with an intentional ingestion of an anti-water agent for cement work. That agent contained sodium silicate. Fiberoptic endoscopy of the upper digestive tract showed severe alkali burns in the stomach, including edema, hemorrhage and necrosis. Surgery was performed to remove the necrotic tissue and to prevent progression to a critical status. We carried out a total gastrectomy, Roux-Y anastomosis, segmental resection of proximal jejunum and a feeding jejunostomy. After the operation, there were no complications associated with either the surgery or the caustic injury. The patient was discharged in good general condition with oral feeding status. In conclusion, for severe alkali ingstion, we recommend early surgical resection of injured organs identified by using an endoscopic evaluation.

Radiologic Intervention for Traumatic Epistaxis

We report a case in which traumatic epistaxis with a carotid cavernous fistula was successfully treated by using radiologic intervention. Since the inner facial bone is an anatomically weak structure and has numerous bleeding sites, traumatic epistaxis is profuse and can not be controlled well by using traditional treatments such as gauze, merocel(R), and foley balloon packing. Uncontrolled epistaxis may cause unstable vital signs and threaten the patient. In the case of failure through traditional treatments, angiographic embolization can be used as a treatment of choice because angiographic embolization can be done at a high success rate with few complications. Stroke, facial palsy, visual loss, and facial pain are the most common complications. In our case, we had tried traditional treatments first, but there was no marked improvement. After the angiographic embolization had been conducted, epistaxis was successfully controlled. The patient 's vital signs were stabilized, and he was admitted to the ICU.