Annals of emergency medicine
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Patients with acute psychiatric emergencies who receive an involuntary hold often spend hours in the emergency department (ED) because of a deficit in inpatient psychiatric beds. One solution to address the lack of prompt psychiatric evaluation in the ED has been to establish regional stand-alone psychiatric emergency services. However, patients receiving involuntary holds still need to be screened and evaluated to ensure that their behavior is not caused by an underlying and life-threatening nonpsychiatric illness. Although traditional regional emergency medical services (EMS) systems depend on the medical ED for this function, a field-screening protocol can allow EMS to directly transport a substantial portion of patients to a stand-alone psychiatric emergency service. The purpose of this investigation is to describe overall EMS use for patients receiving involuntary holds, compare patients receiving involuntary holds with all EMS patients, and evaluate the safety of field medical clearance of an established field-screening protocol in Alameda County, CA. ⋯ Ten percent of all EMS encounters were for involuntary psychiatric holds. With an EMS-directed screening protocol, 41% of all such patient encounters resulted in direct transport of the patient to the psychiatric emergency service, bypassing medical clearance in the ED. Overall, only 0.3% of these patients required retransport to a medical ED within 12 hours of arrival to psychiatric emergency services. We found that 24% of all EMS encounters in Alameda County were attributable to "involuntary hold patients," reinforcing the importance of the effects of mental illness on EMS use.
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It is unknown whether regionalization of postarrest care by interfacility transfer to cardiac arrest receiving centers reduces mortality. We seek to evaluate whether treatment at a cardiac arrest receiving center, whether by direct transport or early interfacility transfer, is independently associated with long-term outcome. ⋯ Both early interfacility transfer to a cardiac arrest receiving center and direct transport to a cardiac arrest receiving center from the scene are independently associated with reduced mortality.
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We describe full neurologic recovery from accidental hypothermia with cardiac arrest despite the longest reported duration of mechanical cardiopulmonary resuscitation (CPR) and extracorporeal life support (8 hours, 42 minutes). Clinical data and blood samples were obtained from emergency medical services (EMS) and the intensive care department. A 31-year-old man experienced a witnessed hypothermic cardiac arrest with a core temperature of 26°C (78.8°F) during a summer thunderstorm; he received mechanical CPR for 3 hours and 42 minutes, followed by 5 hours of extracorporeal life support. ⋯ Three months postaccident, the patient had recovered completely (Cerebral Performance Category score of 1) and resumed normal daily life. Neurologically intact survival from hypothermic cardiac arrest is common, suggesting that aggressive resuscitation measures are warranted. There is a need for the establishment of a clear standard operating procedure and multiteam education and training to further optimize the patient survival chain from on-site triage and treatment to inhospital extracorporeal life support and postresuscitation care.
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Cancer immunotherapy is evolving rapidly and is transforming cancer care. During the last decade, immune checkpoint therapies have been developed to enhance the immune response; however, specific adverse effects related to autoimmunity are increasingly apparent. This study aims to fill the knowledge gap related to the spectrum of immune-related adverse effects among cancer patients visiting emergency departments (EDs). ⋯ Cancer patients treated with ipilimumab, nivolumab, or pembrolizumab may have a spectrum of immune-related adverse effects that require emergency care. Future studies will need to update this profile as further novel immunotherapeutic agents are added.