Emergency medicine can play a leadership role in enterprise-wide clinical information systems.

At many institutions, the department of emergency medicine is uniquely suited to a leadership role in the deployment of new clinical decision support systems (computer systems that support clinical practice). Many factors favor such a leadership role, including institutional politics, organizational structure, extent of local control, clinician solidarity, openness to change, departmental size and scale, and willingness to take risks. Such a role should be undertaken in partnership with the institution's information services (IS) department, and a clear understanding of goals and responsibilities will facilitate such a partnership. A leadership position with respect to new information systems entails a certain risk, but the potential benefit to an emergency department in today's competitive environment is substantial. The authors' experience with one such collaborative development project is presented.

Computers and connectivity in Illinois emergency departments.

UNLABELLED: Although the Internet has been described as "ubiquitous," little is known about the extent to which physicians have access to the Internet while providing clinical care. OBJECTIVE: To assess the extent of Internet connectivity within the clinical area of every ED within the state of Illinois. METHODS: This was a prospective observational study. Each Illinois ED listed in a published directory was called by telephone, and a responsible party was identified to provide information regarding the type and size of the ED, patient demographics, the types of personal computers (PCs) available in the ED (if any), the types of operating systems used, the availability of access to the World Wide Web (Web), and the highest speed at which an Internet connection could be established. Responses regarding the presence and types of PCs and the types of operating systems used were assessed using one-factor chi-square. Univariate and multivariate predictors of the type of PC used, the presence or absence of Web access, and the highest speed of Internet access were evaluated using optimal discriminant analysis and nonlinear classification tree analysis, respectively. RESULTS: One hundred ninety-eight of the 199 EDs in the state of Illinois (99.5%) completed the survey. Of the responding EDs, 50.5% had PCs, but only 17.6% had Web access. When Web access was available, it was most often available through a high-speed Internet connection that was faster than a dial-up modem. Most departments (68.1%) with PCs used the Windows 95 or Windows 98 operating systems. A majority (62.5%) used the Netscape browser exclusively. Larger EDs (more than six ED beds) in rural or suburban areas were more likely to have a PC compared with smaller EDs (six or fewer beds). Large EDs (more than 12 ED beds) in private tertiary care or academic hospitals were most likely to have Web access. CONCLUSIONS: Although half of Illinois EDs have PCs, only one in six has access to the Internet; thus, most emergency physicians do not have ready access to the Web from the site where they deliver clinical care.

The next-generation emergency department.

The greatest advances in medicine over the next two decades will result from application of the tools and principles of informatics to the problems of clinical medicine. New developments in medical informatics will drive advances in clinical care administration, research, and education. Information flow in the emergency department a decade hence will be characterized by a transformation from a "hunter-gatherer" information model to a "publisher-subscriber" model in which the right information will always be available at the right time. In large part, information will be gathered automatically rather than manually. Computers will be ubiquitous and almost invisible. Invasive and attached monitoring and testing will yield to new remote and noninvasive technologies. Information will be shared and modified as needed, rather than recreated and reentered by each caregiver. Eventually, the use of information technologies in the emergency medicine workplace will enhance our traditional role as hands-on providers of direct patient care.

Venous thrombosis. Lifting the clouds of misunderstanding.

Deep venous thrombosis (DVT) is often occult and difficult to recognize clinically. The diagnostic approach should begin with color-flow (duplex) ultrasound, noninvasive functional tests such as plethysmography, or both. Because these tests are not 100% sensitive, contrast venography or magnetic resonance imaging may be necessary in a patient with unexplained symptoms. A baseline ventilation-perfusion scan should be considered for any patient with DVT, because there is a high incidence of clinically inapparent pulmonary embolism. In the absence of contraindications, systemic or regional thrombolytic therapy should be considered for every patient with acute DVT. Surgical thrombectomy may be indicated for patients with a large, obstructive proximal thrombus. At a minimum, routine treatment should start with heparin and proceed to oral warfarin (Coumadin, Panwarfin, Sofarin), which should be continued for 3 months. Recurrent DVT after cessation of therapy warrants lifetime use of anticoagulants. A filter should be placed in the inferior vena cava whenever a large, poorly adherent thrombus is identified or when there is progression of thrombosis despite an anticoagulant regimen.

Suspected pulmonary embolism. The difficulties of diagnostic evaluation.

It is impossible to prove or disprove a diagnosis of acute pulmonary embolism on clinical grounds. Diagnostic evaluation is best carried out by first attempting to identify a provable alternative diagnosis that can explain a patient's symptoms. Once the diagnosis of pulmonary embolism is seriously considered, a ventilation-perfusion (V/Q) scan is the next step. A positive ("high-probability") or negative ("normal-perfusion") scan is an appropriate diagnostic end point. Unfortunately, most V/Q scans are nondiagnostic, and the workup must be pursued further. Color-flow (duplex) ultrasound, if available, is the next logical step. If a site of deep venous thrombosis cannot be identified, pulmonary angiography is indicated. Newer methods, such as D-dimer measurement and spiral computed tomography, are being studied.

Acute pulmonary embolism. Aggressive therapy with anticoagulants and thrombolytics.

Patients with acute pulmonary embolism are at risk for early death or chronic morbidity. Appropriate therapy can dramatically reduce the incidence of both. Oxygen and heparin therapy should be started as soon as the diagnosis is suspected. The condition of a hypotensive patient with right ventricular overload from acute pulmonary embolism usually is made worse by a fluid challenge; hypotension may be relieved by preload reduction or even by gentle diuresis. Norepinephrine (Levophed), isoproterenol hydrochloride (Isuprel), and epinephrine are the pressor agents of choice. Immediate thrombolysis is the standard of care for any patient with significant hypoxemia or hypotension due to proven pulmonary embolism. Beyond this, the potential benefit of using thrombolytic agents should be considered routinely for every patient with proven pulmonary embolism. Surgical embolectomy is useful for unstable pulmonary embolism when there are absolute contraindications to thrombolysis or when thrombolytic therapy fails. Empirical use of thrombolysis may be considered as a last-ditch effort for a critically ill patient when there is a high clinical suspicion of pulmonary embolism. Standard closed-chest cardiopulmonary resuscitation is ineffective when the pulmonary circulation is obstructed by thrombus. Emergency thoracotomy or femorofemoral cardiopulmonary bypass is appropriately used in patients with full cardiac arrest from pulmonary embolism.

Chronic pulmonary embolism. Often misdiagnosed, difficult to treat.

Chronic thromboembolic pulmonary hypertension with cor pulmonale is an extremely debilitating disease that (1) is more common than generally recognized, (2) is often misdiagnosed, and (3) is difficult to treat. When a patient has persistent exertional dyspnea with no obvious cause, a ventilation-perfusion scan, echocardiography, and (if indicated) pulmonary angiography should be done. Prevention is especially important because by the time a patient is symptomatic, the disease is already far advanced and hemodynamic reserves are greatly reduced. Prevention of recurrence mandates lifetime anticoagulation and placement of a vena cava filter. The only effective treatment is pulmonary endarterectomy, which is being performed at an increasing number of specialty centers across the United States.

Effectiveness of transnasal butorphanol for the treatment of musculoskeletal pain.

A prospective, open-label study of the effectiveness of transnasal butorphanol in the treatment of pain resulting from musculoskeletal injuries. Twenty-eight patients with strains (n = 20), fractures (n = 6), contusions (n = 1), and stab wounds (n = 1) were included. All patients were examined by an attending level emergency medicine physician and deemed to have pain severe enough to warrant parenteral narcotic analgesia. All patients received an initial 1-mg dose of transnasal butorphanol. Subsequent dosing was flexible depending on response to the initial dose. All patients received pain relief from transnasal butorphanol, and only one requested alternative analgesic medication. Fifty-seven percent (n = 16) of patients noticed at least a little relief of pain within 5 minutes of administration and 93% (n = 26) received at least a little relief within 15 minutes. Seventy-one percent of the patients received a 50% reduction of pain within 60 minutes. No serious side effects were noted, but drowsiness occurred in 82% (n = 23) and dizziness in 54% (n = 15) of the patients. One patient discontinued participation in the study because of nausea. In this limited trial transnasal butorphanol proved to be a rapidly effective opioid analgesic. Further controlled studies comparing transnasal butorphanol with standard parenteral narcotics are needed.

Allergic reactions to polidocanol for vein sclerosis. Two case reports.

BACKGROUND: Polidocanol is a sclerosing solution that is highly valued by clinicians and patients for its painlessness, high efficacy, excellent safety profile, low incidence of side effects, and for the rarity of its allergic reactions. Previous estimates of the incidence of allergic reactions have ranged from 0 to 0.06%. OBJECTIVE: Improved recognition of systemic allergy to polidocanol is desirable for both clinicians and for patients. We have attempted to describe two cases recently observed in our population and to provide an improved upper-bounds estimate for the true population incidence of allergy to polidocanol. RESULTS: We report two recent cases of mild systemic allergic reaction to polidocanol in a population of 689 exposed patients, for an observed incidence of 0.3% in our patient population. We have calculated a 95% confidence upper-bound estimate of 0.91% for the incidence of polidocanol allergy in the general population. CONCLUSION: Allergy to polidocanol may be more common than previously recognized. Careful questioning of previously treated patients and more prolonged observation of patients after treatment may yield a larger number of recognized cases.

Deep vein thrombosis: the risks of sclerotherapy in hypercoagulable states.

There have been many case reports of deep vein thrombosis and pulmonary thromboembolism in patients undergoing sclerotherapy for the treatment of varicose veins, but the true incidence of venous thromboembolism in this patient population is unknown. Patients who develop deep vein thrombosis while being treated for varicose veins do so either because of an error in treatment or because the patient suffers from some underlying hypercoagulable state. It is possible to identify prospectively many patients who are at especially high risk for venous thromboembolism by virtue of genetic predisposition, past or recent medical problems, or environmental factors. When sclerotherapy is used in such patients, special efforts must be made to protect against the development of venous thrombosis during treatment.

Functional illiteracy among emergency department patients: a preliminary study.

STUDY OBJECTIVES: To determine the ability of emergency department patients to understand common written discharge instructions and the level of reading difficulty of standard discharge instructions. DESIGN: The study was performed in two parts. In part 1, subjects were asked to read one set of standard written discharge instructions. Then, with the instructions to refer to, subjects were asked to answer five questions about the instructions. A subject's level of success was correlated with age, sex, and highest level of education. In part 2, 47 sets of standard written discharge instructions from six different EDs were computer analyzed using five commonly used readability formulas. Results were reported as grade levels. SETTING: The ED of a large inner-city university hospital. TYPE OF PARTICIPANTS: The subjects for part 1 were 400 adult ED patients who presented on randomly selected days. MEASUREMENTS AND MAIN RESULTS: Part 1: A significant proportion of patients failed to answer correctly at least four of five questions. Patients educated beyond high school demonstrated higher levels of success than did those with less education. A trend was noted for younger subjects to perform better than older subjects. The answers to the three most frequently missed questions were contained within areas of difficult sentence structure or long paragraphs containing large amounts of information. Part 2: The average grade level required to understand instruction sheets ranged from 6.0 to 13.4. More difficult instruction sheets tended to contain numerous multi-syllabic words, long sentences, and difficult sentence structure. CONCLUSION: A significant proportion of ED patients have a demonstrable inability to understand common written instructions. ED instruction sheets are written at a level of difficulty that is out of the readable range for many patients. Health care providers should strive to simplify written materials and to develop new methods for instructing those for whom current written materials have no meaning.

Clostridial myonecrosis resulting from subcutaneous epinephrine suspension injection.

A 32-year-old asthmatic man developed a life-threatening Clostridium perfringens infection after subcutaneous epinephrine suspension injection. Extensive surgical debridement, including forequarter amputation, hyperbaric oxygen therapy, and appropriate antibiotics were used as life-saving measures. The patient made a fair functional recovery. We could find no previously reported cases of gas gangrene following subcutaneous injection in otherwise healthy individuals. The pathogenesis and treatment of this infection are discussed.

Cholesterol screening in the emergency department.

OBJECTIVE: To determine the feasibility of providing cholesterol screening in the emergency department (ED) and to determine compliance with follow-up recommendations. DESIGN: A prospective observational study. SETTING: The Ambulatory Care and Treatment Section of the George Washington University Medical Center ED. PATIENTS/PARTICIPANTS: All patients seen in the Ambulatory Care and Treatment Section of the ED who were 18 years of age or older and who were residents of the metropolitan Washington, D.C., area were eligible to participate. During the six-month study period, 660 patients were asked to participate and 539 (82%) agreed. INTERVENTIONS: Fingerstick cholesterol measurements were performed on all participants. Participants who had elevated cholesterol levels, as determined by the National Cholesterol Education Program guidelines, were scheduled for a six-week follow-up visit in the Lipid Research Clinic, where repeat fingerstick cholesterol measurements were performed. Those participants with elevated cholesterol levels were instructed to follow up with their primary care physicians. Compliance with follow-up was assessed by a telephone contact four months after the initial ED visit. MEASUREMENTS AND MAIN RESULTS: Of the 539 participants, 100 (19%) were found to have elevated cholesterol levels. Fifty-three (53%) returned for the six-week follow-up visit. Of the 53 who returned, 7 (13%) had normal and 46 (87%) had elevated cholesterol levels. Of the 46 participants with elevated cholesterol levels, 15 (33%) reported four months after their ED visit that they had received further follow-up care. CONCLUSIONS: Cholesterol screening in the ED is feasible, but compliance with follow-up is less than desirable.

Diagnostic peritoneal lavage. Questions and answers.

Peritoneal lavage is a useful adjunct to physical examination and to other traditional means of assessing the patient with potential intraabdominal injury. The procedure is safe in experienced hands and may be easily and rapidly performed with a minimum of equipment. The information that lavage provides may spare some patients an exploratory laparotomy and, more important, may identify those patients who appear to be in stable condition but who, in fact, need immediate lifesaving intervention.