Communicating advance directives from long-term care facilities to emergency departments.

Many residents of long-term care (LTC) facilities are transferred to Emergency Departments without advance directives (AD). The goal of this study was to describe an ideal model for the transfer of AD from LTC facilities to Emergency Departments. Health care providers were asked to describe their ideal model for the completion and transfer of the ADs of LTC residents. A grounded theory methodology was used to identify significant themes. The model we present as a result of this analysis acknowledges the importance of simplifying and standardizing ADs, but focuses more attention on the process of completing and transferring the AD. A key feature of this model is an emphasis on the education of LTC residents and their relatives about ADs and advance-care planning. This education should involve a variety of resources used in creative ways; it should begin as soon as LTC placement is being considered, and the emphasis should be on providing information and discussing options rather than pressuring residents to make a decision.

The patient vs. caregiver perception of acute pain in the emergency department.

The assessment and management of acute pain is an essential part of care received in the emergency department (ED). This study was undertaken to measure how ED caregivers interpret and treat acute pain. A convenience cohort of 71 patients in a tertiary care teaching hospital were asked to rate their pain on arrival to the ED using a visual analog scale (VAS) and numerical rating scale (NRS). These ratings were compared with those given by their nurse and physician. Both physicians and nurses gave statistically significantly lower NRS and VAS pain ratings than those reported by the patients. Nurses' NRS pain ratings were found to be lower than physicians' ratings of the same patients. On chart review, no pain scale assessments were employed, and only one chart noted that a patient's pain had been relieved after treatment. Approximately half the patients (49%, n = 35) felt on discharge from the ED that their pain had not been relieved. Pain assessment and treatment in the ED appears to be inadequate. The integration of pain assessment before and after treatment is essential in monitoring the effectiveness of pain management in the ED.

Ovarian hyperstimulation syndrome: imperatives for the emergency physician.

Ovarian Hyperstimulation Syndrome (OHSS) is a serious disorder complicating the use of ovary-stimulating drugs in assisted reproduction programs. While its pathogenesis is not fully understood, it is believed that human chorionic gonadotropin (hCG) stimulation is vital to the development of OHSS. Further evidence suggests that the renin-angiotensin pathway, vascular endothelial growth factor, endothelin-1, and cytokines all play a role in altering ovarian capillary permeability, leading to increased interstitial fluid. OHSS can produce a myriad of symptoms and signs involving numerous body systems, up to and including hypovolemic shock and acute renal failure. As growing numbers of women opt for assisted reproduction, it becomes increasingly important for emergency physicians to be able to recognize this condition. Clinical classification into mild, moderate, severe, and critical forms of OHSS can help the physician plan appropriate investigations, admission requirements, and acute management. Two cases of OHSS, representing the spectrum of this problem, are presented along with a review of the literature.

Primary care physician and patient factors that result in patients seeking emergency care in a hospital setting: the patient's perspective.

Much has been written about "abuse" and "overutilization" of Emergency Departments (EDs). We undertook to study, from the patient's perspective, physician and patient factors that influence the patient's decision to seek ED care. The study was designed as a convenience cohort, multi-centre survey, conducted in 13 hospitals in the Greater Toronto Area. In our study group of 948, most ambulatory patients (93%) seeking care in an ED have a primary care physician. From the patient's perspective, most (76%) primary care physicians are not educating their patients about which situations warrant ED care and up to 54% are not informing their patients about which services are offered in the office. As many as 55% of patients presented to the ED because it was more convenient. Only a minority (23%) of patients felt their acuity of illness warranted an ED visit. Primary care physicians need to play a stronger role in educating their patients about the utilization of emergency care and the services offered in the office setting.

Advanced life support vs basic life support field care: an outcome study.

OBJECTIVE: To determine whether the provision of advanced life support (ALS) field care has any impact on patient outcome in the urban Canadian environment. METHODS: A convenience cohort study was conducted of all emergent ambulance transfers of adults to an urban Canadian hospital from May 22 to July 31, 1996. Data were collected from ambulance call reports regarding presenting complaint and field interventions applied, and from hospital records regarding time in the ED, hospital length of stay (LOS), and discharge disposition. Patient outcomes were compared within 7 presenting complaint groups (chest pain, altered level of consciousness, shortness of breath, abdominal pain, motor vehicle crash, falls, and other) by field care level: level 1--BLS (basic life support) vs levels 2 and 3--ALS. RESULTS: The study population consisted of 1,397 patients. No significant differences were seen between BLS and ALS patients on baseline demographics. ED triage score did not depend on field care level for any group, implying that those in the ALS group were not inherently sicker. Outcome measures (ED LOS, admission rates, and hospital LOS) showed no significant differences between BLS and ALS for each presenting complaint group. Discharge dispositions were analyzed by chi2 but were not varied enough to allow reliable analysis. Observation of trends suggested no difference between BLS and ALS. CONCLUSIONS: There was no beneficial impact on the measured patient outcomes found in association with the provision of ALS vs BLS field care in Metropolitan Toronto for patients who were brought to a nontrauma center.

Establishing an approach to syncope in the emergency department.

A pilot study was conducted to enumerate the most common evaluations done in the emergency department (ED) of a community hospital in assessing patients presenting with a first episode of syncope and to determine the feasibility of defining a clinically useful set of investigations to identify the subset of syncopal patients that can be safely discharged from the ED. The study was conducted as a retrospective chart review of patients seen during an 8 week period. In the course of the study, 33 consecutive adult patients presenting to the ED with first episodes of syncope were identified. Patients were excluded if they had previous recurrent syncopal episodes or a known disorder leading to syncope. ED charts of the participants were reviewed to determine the types of investigations for syncope done by unblinded emergency physicians, which investigations showed abnormal results, and which were useful in determining etiology of syncope or in deciding which patients needed admission. The average number of investigations performed on each patient was 7 +/- 4, with a range of 1-17 investigations. Twelve percent of syncopal patients (4/33) were deemed, retrospectively, to have required hospital admission based on a review of their charts and follow-up interviews. Without specific clinical indicators, laboratory and radiologic investigations were not useful in determining either the etiology of the syncopal episode or the need for admission. In this small study, few patients presenting with new onset syncope required admission. The number and types of investigations performed on these patients was inconsistent. Further study is needed to determine whether syncopal patients requiring admission can be identified in the ED with a small number of standard inexpensive laboratory investigations.

Non-life-threatening blunt chest trauma: appropriate investigation and treatment.

Non-life-threatening blunt chest trauma is a commonly occurring phenomenon. No clear guidelines exist in the literature regarding the appropriate investigation and treatment, and most clinicians' practice patterns are based on anecdote, individual experience, and the theoretical risk of complications. A prospective study was undertaken of all patients with non-life-threatening blunt chest trauma presenting to a high-volume, community-based teaching hospital emergency department. No clinical features were found to have a high enough positive predictive value for rib fracture or any other injury to warrant their use as a screening tool for further investigations. No significant lung injury was detected in the study cohort of patients, on either an immediate or delayed basis. In the absence of compelling evidence of an underlying lung injury, the performance of chest or rib radiography is of no benefit, and considerable cost savings can potentially be realized.

Hematoma of the rectus abdominis muscle: case report and review of the literature.

Hematoma of the rectus abdominis muscle, although a well-described clinical entity, is commonly misdiagnosed. A case of abdominal pain associated with the subjective perception of a "lump," which proved to be a rectus abdominis hematoma, is presented. The pathoanatomy, presenting symptoms, investigation, and treatment options for the condition are reviewed.

Rattlesnake bite in a patient with horse allergy and von Willebrand's disease: case report.

Massasauga rattlesnakes are the only poisonous snakes in Ontario. While death from bites of this species is rare, the bite could cause a coagulopathy. I report a case of rattlesnake bite in a patient with asthma, horse allergy, and a documented congenital clotting abnormality.

Stercoral perforation of the colon: case report and review of the literature.

Stercoral perforation of the colon is a rarely reported illness, with 67 cases reported in the literature (1). A literature review revealed no case reports in the Emergency Medicine literature. A case report of a 47-year-old female with a history of chronic constipation and sudden onset of severe abdominal pain with physical signs of peritonitis is presented. Initial hematologic and radiologic investigations were normal. After 12 h of hospitalization, a fever developed, and the signs of peritonitis continued, but her abdominal X-ray studies and white blood count remained normal. Because of her persistent abdominal findings, laparotomy was carried out, at which time a stercoral perforation of the rectum was found. A colostomy was performed. This condition is notoriously covert, but if undetected may be life-threatening. A review of the literature will highlight suspected etiologies, diagnostic tests of choice, and a preferred treatment plan.