Spontaneous Spinal Epidural Hematoma from Rivaroxaban.

Spontaneous spinal epidural hematoma (SSEH) is a rare diagnosis. One known risk factor is anti-coagulation medication. We present a case of SSEH in a 74-year-old male on rivaroxaban therapy who clinically presented with an intermittently resolving and then worsening neurological exam. Due to the extremely high morbidity and mortality associated with this diagnosis, it is important to be aware of the various presentations and adverse effects related to novel anticoagulation.

Using pharmacists to optimize patient outcomes and costs in the ED.

Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.

"Lives there who loves his pain?": empathy, creativity, and the physician's obligation.

Like most EM physicians presented with a wide assortment of patients I've never seen before, will probably never see again, and cannot schedule for a more convenient return visit when there are not three ambulances pulling up to the door, I sometimes get a bit cranky when I interview a patient who has registered for a less-than-valid "emergency." As a resident in Mel Konner's Becoming a Doctor put it, "Low back pain? Low fucking back pain? You're waking me up for low fucking back pain?" Although I ceased a long time ago to ask, "Why now?"-you almost never get an answer that is satisfying-I still think it. Often, I am sad to say. Perhaps it is a result of the obvious forces of callousness born of distance born of training and of stress. Again, Konner captures it well: "It is obvious … that the stress of clinical training alienates the doctor from the patient, that in a real sense the patient becomes the enemy. … At first I believed that this was an inadvertent and unfortunate concomitant of medical training, but I now think that it is intrinsic. Not only stress and sleeplessness but the sense of the patient as the cause of one's distress contributes to the doctor's detachment." Such detachment can blinker our eyes from seeing why patients come to the emergency room and prevent our ears from hearing.

Lidocaine toxicity misinterpreted as a stroke.

For more than 50 years lidocaine has been used to treat ventricular arrhythmias. Neurologic dysfunction, manifested as a stroke, occurred acutely in an 87-year-old woman after she had been administered repeated doses of lidocaine, a lidocaine infusion, then an intravenous amiodarone infusion for ventricular tachycardia. This was ultimately diagnosed as lidocaine toxicity with a serum lidocaine level of 7.9 mg/L (1.5-6.0 mg/L). We discuss lidocaine toxicity and risk factors leading to its development, which include particularly hepatic dysfunction, cardiac dysfunction, advanced age and other drug administration.

Physician reporting of medically impaired drivers.

Emergency physicians frequently encounter patients whose medical conditions represent a risk of loss of control while driving, e.g., epilepsy and diabetes. In certain states, physicians are under a legal obligation to report such drivers to the motor vehicular authorities. To determine the uniformity of legislated reporting requirements for physicians caring for patients whose medical conditions represent an automotive hazard, we conducted a survey of Department of Motor Vehicles (DMV) legal departments of all the states in the United States for the academic year 1999-2000 regarding physician reporting of patients with medical conditions that might predispose them to a motor vehicle crash (MVC) and compared the results to a similar study done in 1986. Six (12%) of the states had mandatory reporting laws, 25 (49%) had permissive reporting laws, and 20 (39%) had no laws regarding physician reporting. There was a significant difference between the distribution of laws by year. There was no uniformity on a national level concerning such legislation.