The American journal of emergency medicine
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Case Reports
Ventricular fibrillation in a 21-year-old after inhalation of an isobutyl nitrite "popper" product.
Alkyl nitrite analogs known as "poppers" have been inhaled recreationally for decades. They are available to be purchased from gas stations marketed as "nail polish remover not for human consumption". These rapid-onset, short-acting, vasodilators cause the user to experience euphoria, dizziness, tachycardia and flushing. While chronic use may lead to problems such as methemoglobinemia or neuropathy, nitrites rarely lead to acute life-threatening side effects such as ventricular dysrhythmias. ⋯ Alkyl nitrite "popper" users and clinicians should be aware that products labeled to contain nitrites may contain volatile hydrocarbons along with nitrites and have the potential to cause arrhythmia.
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Following initial stabilization, critically ill children often require transfer to a specialized pediatric hospital. While the use of specialized pediatric transport teams has been associated with improved outcomes for these patients, the additional influence of transfer mode (helicopter or ground ambulance) on clinical outcomes remains unknown. ⋯ Among critically ill pediatric patients without traumatic injuries transported by a specialty team, those patients who would have been transferred by helicopter if available but were instead transferred by ground ambulance reached their site of definitive care approximately 2.5 h later. Helicopter transport for these patients was not associated with in-hospital mortality, but was potentially associated with reduced hospital length of stay.
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Urinary tract infections (UTIs) seen in the emergency department are commonly treated as an outpatient with oral antibiotics. Given that antibiotics are available for over-the-counter purchase in Mexico, there is speculation that potential misuse and overuse of antibiotics in United States-Mexico border areas could lead to antibiotic resistance patterns that would render some empiric treatments for UTIs less effective. The purpose of this study was to examine the effectiveness of Infectious Disease Society of America (IDSA) guideline-recommended antibiotics for treatment of outpatient UTI diagnosed in the emergency department. Data were collected from a county hospital on the U.S.-Mexico border with a metropolitan area of over 2 million people. Secondary analysis included frequency of urine culture isolated, resistance rates of urine pathogens, and prescriber habits. ⋯ Our findings suggest that, while part of standard IDSA guidelines, fluoroquinolones and TMP-SMX are not ideal empiric antibiotics for treatment of outpatient UTI in the U.S.-Mexico border region studied due to high resistance rates. Although not listed as first line agents per current IDSA recommendations, 2nd and 3rd generation cephalosporins, and amoxicillin/clavulanate would be acceptable options given resistance patterns demonstrated in accordance with IDSA allowance for tailoring selection to local resistance. Nitrofurantoin appears to be consistent with recommendations and demonstrates a favorable resistance profile for treatment of outpatient UTI within this region.
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'Surprise billing', or the phenomenon of unexpected coverage gaps in which patients receiving out-of-network medical bills after what they thought was in-network care, has been a major focus of policymakers and advocacy groups recently, particularly in the Emergency Department (ED) setting, where patients' ability to choose a provider is exceedingly limited. The No Surprises Act is the legislative culmination to address "surprise bills," with the aim of promoting price transparency as a solution for billing irregularities. However, the knowledge and perceptions of patients regarding emergency care price transparency, particularly the degree to which ED patients are cost conscious is unknown. Accordingly, we sought to quantify that perception by measuring patients' direct predictions for the cost of their care. ⋯ This study is the first to our knowledge that sought to quantify how patients perceive the cost of acute, unscheduled care in the ED. We found that ED patients generally do not consider the price before going to the ED, and subsequently overestimate the negotiated total costs of acute, unscheduled emergency care as well as their out-of-pocket responsibility for care. Certain demographics are less predictive of this association. Notably, patients with Medicare/Medicaid and those with high school education or below were of the furthest off in predicting the actual cost of care. This lends credence to the established trend of patients' limited knowledge of the total cost of healthcare; moreover, that they overestimate the cost of their care could serve as a barrier to accessing that care particularly in more vulnerable groups. We hope that this finding adds useful information to policymakers in sculpting future legislation around surprise billing.