Outcome study of minors after parental refusal of paramedic transport.

OBJECTIVE: Patient refusal of paramedic transport against medical advice (AMA) has significant medical-legal implications. Previous studies have investigated patient outcomes after refusal of transport, but none has focused on these events in minors. This study was performed to evaluate the outcomes of this patient population after refusal of transport as well as the significance of base hospital physician discussion with parents in the decision to refuse transport. METHODS: This was a retrospective telephone follow-up survey involving parents of minors for whom transport was refused after accessing emergency medical services (EMS) via the 911 system. Data were initially obtained from paramedic run records and each family was subsequently contacted by telephone and surveyed with regard to their experiences with the field medics in addition to the medical follow-up sought for their child and patient outcomes. RESULTS: Eighty-nine patients met criteria for survey. Telephone contact was made with 44 parents, of whom 32 (73% of those contacted, 36% overall) participated. Twenty-seven (84%) received medical follow-up, either at an emergency department or in a private physician's office. Most patients (89%) who were evaluated and/or treated by a physician were subsequently released, while three children were admitted to the hospital, all three with respiratory or cardiac chief complaints. CONCLUSIONS: Children whose parents refused EMS transport received medical follow-up in the majority of cases, with a small group requiring admission.

Exercise-associated hyponatremia in marathon runners: a two-year experience.

This study was conducted to better define the pathophysiology, risk factors, and therapeutic approach to exercise-associated hyponatremia. Medical records from all participants in the 1998 Suzuki Rock 'N' Roll Marathon who presented to 14 Emergency Departments (EDs) were retrospectively reviewed to identify risk factors for the development of hyponatremia. Hyponatremic patients were compared to other runners with regard to race time and to other marathon participants seen in the ED with regard to gender, clinical signs of dehydration, and use of nonsteroidal anti-inflammatory drugs (NSAIDs). An original treatment algorithm incorporating the early use of hypertonic saline (HTS) was evaluated prospectively in our own ED for participants in the 1999 marathon to evaluate improvements in sodium correction rate and incidence of complications. A total of 26 patients from the 1998 and 1999 marathons were hyponatremic [serum sodium (SNa) < or =135 mEq/L] including 15 with severe hyponatremia (SNa < or = 125 mEq/L). Three developed seizures and required intubation and admission to an intensive care unit. Hyponatremic patients were more likely to be female, use NSAIDS, and have slower finishing times. Hyponatremic runners reported drinking "as much as possible" during and after the race and were less likely to have clinical signs of dehydration. An inverse relationship between initial SNa and time of presentation was observed, with late presentation predicting lower SNa values. The use of HTS in selected 1999 patients resulted in faster SNa correction times and fewer complications than observed for 1998 patients. It is concluded that the development of exercise-associated hyponatremia is associated with excessive fluid consumption during and after extreme athletic events. Additional risk factors include female gender, slower race times, and NSAID use. The use of HTS in selected patients seems to be safe and efficacious.

Are heroin overdose deaths related to patient release after prehospital treatment with naloxone?

OBJECTIVE: Naloxone is frequently used by prehospital care providers to treat suspected heroin and opioid overdoses. The authors' EMS system has operated a policy of allowing these patients, once successfully treated, to sign out against medical advice (AMA) in the field. This study was performed to evaluate the safety of this practice. METHODS: The authors retrospectively reviewed all 1996 San Diego County Medical Examiner's (ME's) cases in which opioid overdoses contributed to the cause of death. The records of all patients who were found dead in public or private residences or died in emergency departments of reasons other than natural causes or progression of disease, are forwarded to the ME office. ME cases associated with opiate use as a cause of death were cross-compared with all patients who received naloxone by field paramedics and then refused transport. The charts were reviewed by dates, times, age, sex, location, and, when available, ethnicity. RESULTS: There were 117 ME cases of opiate overdose deaths and 317 prehospital patients who received naloxone and refused further treatment. When compared by age, time, date, sex, location, and ethnicity, there was no case in which a patient was treated by paramedics with naloxone within 12 hours of being found dead of an opiate overdose. CONCLUSIONS: Giving naloxone to heroin overdoses in the field and then allowing the patients to sign out AMA resulted in no death in the one-year period studied. This study did not evaluate for return visits by paramedics nor whether patients were later taken to hospitals by private vehicles.

Outcome study of prehospital patients signed out against medical advice by field paramedics.

STUDY OBJECTIVE: To describe the incidence and demographic data of prehospital patients who contact paramedics by way of the 911 system, refuse transport against medical advice (AMA), then call 911 and are subsequently reevaluated by paramedics in the following 48 hours. METHODS: We conducted a retrospective observational review of records using the San Diego County Quality Assurance Network database for prehospital providers. All paramedic 911 responses that made base hospital contact over a 3-month period were reviewed to identify patients who signed out AMA. The main outcome measure was to identify patients who signed out AMA and then called 911 again within 48 hours. The demographics, complaints, treatments, and dispositions of these patients are described. RESULTS: Of 6,512 total 911 responses reviewed, 443 (7%) involved patients who signed out AMA. Of these patients, 156 cases (35.2%) were listed as trauma and 287 (64.8%) were medical, with cardiac chest pain, seizure, and respiratory distress/shortness of breath the most frequently noted medical subcategories. Fifty-one (11.5%) such patients received treatment; 34 received dextrose, 12 naloxone, 4 albuterol, and 1 a splint. Patient names were available in 5,515, of the total 6,512 responses and 431 of the 443 AMA cases, permitting computer searching of reevaluations by paramedics. Of the 431 AMA patients for whom a name was available, 10 (2%) called 911 again within 48 hours. All 10 callbacks were made for a related chief compliant, and all 10 of these patients were transported (4 admitted to hospital, 1 died en route, 1 transferred to another facility, 4 discharged from the ED). Of these 10 patients, 7 (70%) were older than 65 years, compared with 17% of all AMA patients older than 65 years. CONCLUSION: On the basis of our findings, patients over the age of 65 years have a propensity to recontact paramedics and should be aggressively encouraged to seek emergency medical treatment. Future prospective studies should be mounted to examine at patient outcome and to assess why patients sign out AMA after making contact with paramedics.

Contact dermatitis associated with capsaicin: Hunan hand syndrome.

"Hunan hand" is a contact dermatitis resulting from the direct handling of chili peppers containing capsaicin. Capsaicin also is found in an over-the-counter topical agent for treatment of postherpetic neuralgia, diabetic neuropathy, and arthritis. We present the case of a patient with capsaicin-induced dermatitis and discuss the pathophysiology, therapy, and current uses of capsaicin.

The impact of a regionalized trauma system on trauma care in San Diego County.

A review of autopsy reports on traumatic deaths in 1986 was conducted to determine the impact on trauma mortality of the regionalized trauma system instituted in San Diego County in 1984. Determination of preventable death was made by a panel of experts and compared with an identical review of traumatic deaths in 1979, five years before the institution of regionalized trauma care. Of 211 traumatic deaths reviewed from 1986, two (1%) were classified as preventable, compared with 20 of 177 (11.4%) deaths in 1979 (P less than .001). A breakdown of trauma deaths into central nervous system and noncentral nervous system categories revealed the overall decline was in large part a consequence of the decline in non-central nervous system deaths from 16 of 83 in 1979 to one of 62 in 1986 (P less than .005). The decrease in central nervous system-related preventable deaths from four of 94 in 1979 to one of 149 in 1986 (P less than .10) was not statistically significant. Although it is likely the trauma system introduced in 1984 contributed to the decline in preventable death, it is not possible to isolate this variable from other changes that occurred during the interval between studies. A review of trauma deaths over the same time interval in a community with similar demographics but without a trauma system might help determine the relative contribution of the trauma system.

An autopsy study of traumatic deaths; San Diego County, 1979.

All traumatic deaths in San Diego County were analyzed for the year of 1979. Death certificates, coroner's reports, and autopsy data served as the basis for this review. A total of 177 deaths were studied, of which 94 were associated with CNS injury and 83 were not. Sixteen (20 percent) of the deaths not CNS-associated and four (5 percent) of the CNS-associated deaths were classified as preventable. One hundred seventeen deaths were due to motor vehicle accidents, of which 11 of 35 (31 percent; all not CNS-associated) were deemed preventable. Preventable causes of death included hemorrhage, unrecognized hemopneumothorax, and unrecognized epidural hematoma.