Factors associated with emergency department avoidance during the COVID-19 pandemic and alternatives sought: a cross-sectional, telephone-based survey of frequent emergency department users in Beirut, Lebanon.

OBJECTIVES: To explore avoidant behaviour of frequent emergency department (ED) users, reasons behind ED avoidance and healthcare-seeking behaviours in avoiders during the COVID-19 pandemic. DESIGN AND SETTING: Cross-sectional, telephone-based survey administered between March and August 2021 at a tertiary care centre in Beirut, Lebanon. PARTICIPANTS: Frequent ED users (defined as patients who visited the ED at least four times during the year prior to the first COVID-19 case in Lebanon). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was ED avoidance among frequent ED users. Secondary outcomes included reasons behind ED avoidance and healthcare-seeking behaviours in avoiders. RESULTS: The study response rate was 62.6% and 286 adult patients were included in the final analysis. Within this sample, 45% (128/286) of the patients reported avoidant behaviour. Male patients were less likely to avoid ED visits than female patients (adjusted OR (aOR), 0.53; 95% CI 0.312 to 0.887). Other independent variables associated with ED avoidance included university education (aOR, 1.76; 95% CI 1.004 to 3.084), concern about contracting COVID-19 during an ED visit (aOR, 1.31; 95% CI 1.199 to 1.435) and underlying lung disease (aOR, 3.39; 95% CI 1.134 to 10.122). The majority of the patients who experienced acute complaints and avoided the ED completely (n=56) cited fear of contracting COVID-19 as the main reason (89.3% (50/56)). Most of the ED avoiders (83.9% (47/56)) adopted alternatives for seeking acute medical care, including messaging/calling a doctor (46.4% (26/56)), visiting a clinic (25.0% (14/56)), or arranging for a home visit (17.9% (10/56)). Of the avoiders, 64.3% (36/56) believed that the alternatives did not impact the quality of care, while 30.4% (17/56) reported worse quality of care. CONCLUSIONS: Among frequent ED users, ED avoidance during COVID-19 was common, especially among women, those with lung disease, those with university-level education and those who reported fear of contracting COVID-19 in the ED. While some patients resorted to alternative care routes, telemedicine was still underused in our setting. Developing strategies to reduce ED avoidance, especially in at-risk groups, may be warranted during pandemics.

Alpha Lipoic Acid Toxicity: The First Reported Mortality in an Adult Patient After Multiorgan Failure.

BACKGROUND: Alpha lipoic acid (ALA) is an anti-oxidant found in many over-the-counter supplements and is used in treatments for diabetes, hypertension, and obesity. Although it is a safe oral molecule, there have been eight cases of ALA toxicity reported. Three reported cases were among adult patients and five were among pediatric patients. A 14-year-old girl died after ingestion of 6 g of ALA leading to multi-organ failure. CASE REPORT: A 42-year-old woman presented to the emergency department 4 h after an intentional overdose of 10 tablets of ALA 600 mg each (6 g, 92.3 mg/kg). She developed refractory seizures, metabolic acidosis, thrombocytopenia, rhabdomyolysis, depressed cardiac contractility, kidney injury, and supraventricular tachycardia. Her condition deteriorated and she developed multi-organ failure. The patient was started on dual pressors, anti-epileptic medications, high-dose insulin and euglycemia protocol, and methylene blue (1 mg/kg). Despite aggressive resuscitation, she required intubation and died. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This was the ninth case and the first reported adult mortality from ALA toxicity with multi-organ failure. Our case shared some similar findings with previously reported cases, including refractory seizures, metabolic acidosis, thrombocytopenia, and rhabdomyolysis. Refractory supraventricular tachycardia and severe agitation have not been reported with ALA toxicity previously. The range of toxicity of ALA is not well established. A reported dose of 6 g caused death in a pediatric patient as well as our patient, but others survived doses of 6 g and 18 g. Toxicologists and emergency physicians should be prepared for clinical deterioration and consider aggressive resuscitation in severe ALA toxicity.