Physician Workflow in Two Distinctive Emergency Departments: An Observational Study

OBJECTIVES

We characterize physician workflow in two distinctive emergency departments (ED). Physician practices mediated by electronic health records (EHR) are explored within the context of organizational complexity for the delivery of care.

METHODS

Two urban clinical sites, including an academic teaching ED, were selected. Fourteen physicians were recruited. Overall, 62 hours of direct clinical observations were conducted characterizing clinical activities (EHR use, team communication, and patient care). Data were analyzed using qualitative open-coding techniques and descriptive statistics. Timeline belts were used to represent temporal events.

RESULTS

At site 1, physicians, engaged in more team communication, followed by direct patient care. Although physicians spent 61% of their clinical time at workstations, only 25% was spent on the EHR, primarily for clinical documentation and review. Site 2 physicians engaged primarily in direct patient care spending 52% of their time at a workstation, and 31% dedicated to EHRs, focused on chart review. At site 1, physicians showed nonlinear complex workflow patterns with a greater frequency of multitasking and interruptions, resulting in workflow fragmentation. In comparison, at site 2, a less complex environment with a unique patient assignment system, resulting in a more linear workflow pattern.

CONCLUSION

The nature of the clinical practice and EHR-mediated workflow reflects the ED work practices. Physicians in more complex organizations may be less efficient because of the fragmented workflow. However, these effects can be mitigated by effort distribution through team communication, which affords inherent safety checks.

“Rainbow Draws” in the Emergency Department: Clinical Utility and Staff Perceptions

Background

Collecting a predefined set of blood tubes (the “rainbow draw”) is a common but controversial practice in many emergency departments (EDs), with limited data to support it. We determined the actual utilization of rainbow draw tubes at a single facility and evaluated the perceptions of ED staff regarding the utility of rainbow draws.

Methods

We analyzed 2 weeks of ED visits (1326 visits by 1240 unique patients) to determine blood tube utilization for initial and add-on testing, as well as the incidence of additional venipunctures. We also surveyed ED staff regarding aspects of ED phlebotomy and test ordering. Utilization data analysis was structured to satisfy specific concerns addressed in the ED staff survey.

Results

Observed tube utilization data showed that fluoride/oxalate, citrate, and serum separator tubes were frequently discarded unused, and that the actual utility of the rainbow draw for add-on testing and avoiding additional venipunctures was low. ED staff perceived that the rainbow draw was highly valuable, both to expedite add-on testing and to avoid additional venipunctures. Contrasting the objective (utilization data) and subjective (survey results) to drive changes in the standard ED blood collection reduced the estimated waste blood by 175 L/year.

Conclusions

Comparison of perceptions and objective utilization data drove process changes that were mutually agreeable to ED and laboratory staff. Although specifics of ED and laboratory work flows vary between institutions, the principles and strategy of this study are widely applicable.

Association of Vital Signs and Process Outcomes in Emergency Department Patients

Introduction

We sought to determine the association of abnormal vital signs with emergency department (ED) process outcomes in both discharged and admitted patients.

Methods

We performed a retrospective review of five years of operational data at a single site. We identified all visits for patients 18 and older who were discharged home without ancillary services, and separately identified all visits for patients admitted to a floor (ward) bed. We assessed two process outcomes for discharged visits (returns to the ED within 72 hours and returns to the ED within 72 hours resulting in admission) and two process outcomes for admitted patients (transfer to a higher level of care [intermediate care or intensive care] within either six hours or 24 hours of arrival to floor). Last-recorded ED vital signs were obtained for all patients. We report rates of abnormal vital signs in each group, as well as the relative risk of meeting a process outcome for each individual vital sign abnormality.

Results

Patients with tachycardia, tachypnea, or fever more commonly experienced all measured process outcomes compared to patients without these abnormal vitals; admitted hypotensive patients more frequently required transfer to a higher level of care within 24 hours.

Conclusion

In a single facility, patients with abnormal last-recorded ED vital signs experienced more undesirable process outcomes than patients with normal vitals. Vital sign abnormalities may serve as a useful signal in outcome forecasting.

Emergency Physicians' Perceived Influence of EHR Use on Clinical Workflow and Performance Metrics

OBJECTIVE

Over the last decade, electronic health records (EHRs) have shaped clinical practice. In this article, we investigated the perceived effects of EHR use on clinical workflow and meaningful use (MU) performance metrics.

MATERIALS AND METHODS

Semistructured interviews were conducted with 20 (n = 20) physicians at two urban emergency departments. Interview questions focused on time spent on EHR use, changes in clinical practices with EHR use, and the effect of MU performance metrics on clinical workflow. Qualitative coding using grounded theory and descriptive analyses were performed to provide descriptive insights.

RESULTS

Physicians reported that EHRs improved their clinical workflow, especially on MU-related activities including door-to-doctor time and admit decision time. EHR use also affected physicians work efficiency, quality of care provided, and overall patient safety.

CONCLUSION

Physicians' perception of EHRs is likely to influence their practices. With negative perceptions of EHR usability problems, positive aspects of EHR use, including the influence on MU performance metrics, may be overridden.

Serum Lactate and Mortality in Emergency Department Patients with Cancer

Introduction

Patients with malignancy represent a particular challenge for the emergency department (ED) given their higher acuity, longer ED length of stay, and higher admission rate. It is unknown if patients with malignancies and hyperlactatemia are at increased risk of mortality. If serum lactic acid could improve detection of at-risk patients with cancer, it would be useful in risk stratification. There is also little evidence that “alarm” values of serum lactate (such as >/=4 mmol/L) are appropriate for the population of patients with cancer.

Methods

This was a continuous retrospective cohort study of approximately two years (2012–2014) at a single, tertiary hospital ED; 5,440 patients had serum lactic acid measurements performed in the ED. Of the 5,440 patients in whom lactate was drawn, 1,837 were cancer patients, and 3,603 were non-cancer patients. Cumulative unadjusted mortality (determined by hospital records and an external death tracking system) was recorded at one day, three days, seven days, and 30 days. We used logistic regression to examine the risk of mortality 30 days after the ED visit after adjusting for confounders.

Results

In an unadjusted analysis, we found no statistically significant difference in the mortality of cancer vs. non-cancer patients at one day and three days. Significant differences in mortality were found at seven days (at lactate levels of <2 and 4+) and at 30 days (at all lactate levels) based on cancer status. After adjusting for age, gender, and acuity level, 30-day mortality rates were significantly higher at all levels of lactic acid (<2, 2–4, 4+) for patients with malignancy.

Conclusion

When compared with non-cancer patients, cancer patients with elevated ED lactic acid levels had an increased risk of mortality at virtually all levels and time intervals we measured, although these differences only reached statistical significance in later time intervals (Day 7 and Day 30). Our results suggest that previous work in which lactate “cutoffs” are used to risk-stratify patients with respect to outcomes may be insufficiently sensitive for patients with cancer. Relatively low serum lactate levels may serve as a marker for serious illness in oncologic patients who present to the ED.

Are testers also admitters? Comparing emergency physician resource utilization and admitting practices

OBJECTIVE

To describe the relationship between emergency department resource utilization and admission rate at the level of the individual physician.

METHODS

Retrospective observational study of physician resource utilization and admitting data at two emergency departments. We calculated observed to expected (O/E) ratios for four measures of resource utilization (intravenous medications and fluids, laboratory testing, plain radiographs, and advanced imaging studies) as well as for admission rate. Expected values reflect adjustment for patient- and time-based variables. We compared O/E ratios for each type of resource utilization to the O/E ratio for admission for each provider. We report degree of correlation (slope of the trendline) and strength of correlation (adjusted R² value) for each association, as well as categorical results after clustering physicians based on the relationship of resource utilization to admission rate.

RESULTS

There were statistically significant positive correlations between resource utilization and physician admission rate. Physicians with lower resource utilization rates were more likely to have lower admission rates, and those with higher resource utilization rates were more likely to have higher admission rates.

CONCLUSIONS

In a two-facility study, emergency physician resource utilization and admission rate were positively correlated: those who used more ED resources also tended to admit more patients. These results add to a growing understanding of emergency physician variability.

Modelling attending physician productivity in the emergency department: a multicentre study

Objectives

Emergency physician productivity, often defined as new patients evaluated per hour, is essential to planning clinical operations. Prior research in this area considered this a static quantity; however, our group’s study of resident physicians demonstrated significant decreases in hourly productivity throughout shifts. We now examine attending physicians’ productivity to determine if it is also dynamic.

Methods

This is a retrospective cohort study, conducted from 2014 to 2016 across three community hospitals in the north-eastern USA, with different schedules and coverage. Timestamps of all patient encounters were automatically logged by the sites’ electronic health record. Generalised estimating equations were constructed to predict productivity in terms of new patients per shift hour.

Results

207 169 patients were seen by 64 physicians over 2 years, comprising 9822 physician shifts. Physicians saw an average of 15.0 (SD 4.7), 20.9 (SD 6.4) and 13.2 (SD 3.8) patients per shift at the three sites, with 2.97 (SD 0.22), 2.95 (SD 0.24) and 2.17 (SD 0.09) in the first hour. Across all sites, physicians saw significantly fewer new patients after the first hour, with more gradual decreases subsequently. Additional patient arrivals were associated with greater productivity; however, this attenuates substantially late in the shift. The presence of other physicians was also associated with slightly decreased productivity.

Conclusions

Physician productivity over a single shift follows a predictable pattern that decreases significantly on an hourly basis, even if there are new patients to be seen. Estimating productivity as a simple average substantially underestimates physicians’ capacity early in a shift and overestimates it later. This pattern of productivity should be factored into hospitals’ staffing plans, with shifts aligned to start with the greatest volumes of patient arrivals.

Interphysician Differences in Emergency Department Length of Stay

BACKGROUND

Emergency physicians differ in many ways with respect to practice. One area in which interphysician practice differences are not well characterized is emergency department (ED) length of stay (LOS).

OBJECTIVE

To describe how ED LOS differs among physicians.

METHODS

We performed a 3-year, five-ED retrospective study of non-fast-track visits evaluated primarily by physicians. We report each provider's observed LOS, as well as each provider's ratio of observed LOS/expected LOS (LOS_O/E); we determined expected LOS based on site average adjusted for the patient characteristics of age, gender, acuity, and disposition status, as well as the time characteristics of shift, day of week, season, and calendar year.

RESULTS

Three hundred twenty-seven thousand, seven hundred fifty-three visits seen by 92 physicians were eligible for analysis. For the five sites, the average shortest observed LOS was 151 min (range 106-184 min), and the average longest observed LOS was 232 min (range 196-270 min); the average difference was 81 min (range 69-90 min). For LOS_O/E, the average lowest LOS_O/E was 0.801 (range 0.702-0.887), and the average highest LOS_O/E was 1.210 (range 1.186-1.275); the average difference between the lowest LOS_O/E and the highest LOS_O/E was 0.409 (range 0.305-0.493).

CONCLUSION

There are significant differences in ED LOS at the level of the individual physician, even after accounting for multiple confounders. We found that the LOS_O/E for physicians with the lowest LOS_O/E at each site averaged approximately 20% less than predicted, and that the LOS_O/E for physicians with the highest LOS_O/E at each site averaged approximately 20% more than predicted.

The durability of operational improvements with rotational patient assignment

INTRODUCTION

Previous work has suggested that Emergency Department rotational patient assignment (a system in which patients are algorithmically assigned to physicians) is associated with immediate (first-year) improvements in operational metrics. We sought to determine if these improvements persisted over a longer follow-up period.

METHODS

Single-site, retrospective analysis focused on years 2-4 post-implementation (follow-up) of a rotational patient assignment system. We compared operational data for these years with previously published data from the last year of physician self-assignment and the first year of rotational patient assignment. We report data for patient characteristics, departmental characteristics and facility characteristics, as well as outcomes of length of stay (LOS), arrival to provider time (APT), and rate of patients who left before being seen (LBBS).

RESULTS

There were 140,673 patient visits during the five year period; 138,501 (98.7%) were eligible for analysis. LOS, APT, and LBBS during follow-up remained improved vs. physician self-assignment, with improvements similar to those noted in the first year of implementation. Compared with the last year of physician self-assignment, approximate yearly average improvements during follow-up were a decrease in median LOS of 18min (8% improvement), a decrease in median APT of 21min (54% improvement), and a decrease in LBBS of 0.69% (72% improvement).

CONCLUSION

In a single facility study, rotational patient assignment was associated with sustained operational improvements several years after implementation. These findings provide further evidence that rotational patient assignment is a viable strategy in front-end process redesign.

Emergency Department Holding Orders

BACKGROUND

Holding orders help transition admitted emergency department (ED) patients to hospital beds.

OBJECTIVE

To describe the effect of ED holding orders.

METHODS

We conducted a single-site retrospective study of ward admissions from the ED to the hospital internal medicine (HIM) service over 2 years. Patients were classified based on whether the ED did (group 1) or did not (group 2) write holding orders; group 1 was subdivided into patients sent to the floor with only ED holding orders (group 1A) vs. with subsequent HIM admission orders (group 1B). Outcomes were ED length of stay (LOS), time from decision to admit to ED departure (D→D), transfer to a higher level of care within 6 h (potential undertriage), and discharge from admission ward within 12 h (potential overtriage).

RESULTS

There were 9501 admissions: 6642 in group 1 (2369 in group 1A and 4273 in group 1B) and 2859 in group 2. Reductions in mean LOS between groups (with 95% confidence intervals [CIs] of the differences) were as follows: group 1 vs. 2: 44 min (39-49 min); group 1A vs. 1B, 48 min (43-53 min); group 1B vs. 2: 27 min (22-32 min); group 1A vs. 2: 75 min (69-81 min). Mean D→D was shorter in group 1A than 1B by 43 min (40-45 min). Holding orders were not associated with increases in potential undertriage or overtriage.

CONCLUSIONS

ED holding orders were associated with improved ED throughput, without evidence of undertriage or overtriage. This work supports the use of holding orders as a safe and effective means to improve ED patient flow.

Physician in Triage Versus Rotational Patient Assignment

BACKGROUND

Physician in triage and rotational patient assignment are different front-end processes that are designed to improve patient flow, but there are little or no data comparing them.

OBJECTIVE

To compare physician in triage with rotational patient assignment with respect to multiple emergency department (ED) operational metrics.

METHODS

Design-Retrospective cohort review. Patients-Patients seen on 23 days on which we utilized a physician in triage with those patients seen on 23 matched days when we utilized rotational patient assignment.

RESULTS

There were 1,869 visits during physician in triage and 1,906 visits during rotational patient assignment. In a simple comparison, rotational patient assignment was associated with a lower median length of stay (LOS) than physician in triage (219 min vs. 233 min; difference of 14 min; 95% confidence interval [CI] 5-27 min). In a multivariate linear regression incorporating multiple confounders, there was a nonsignificant reduction in the geometric mean LOS in rotational patient assignment vs. physician in triage (204 min vs. 217 min; reduction of 6.25%; 95% CI -3.6% to 15.2%). There were no significant differences between groups for left before being seen, left subsequent to being seen, early (within 72 h) returns, early returns with admission, or complaint ratio.

CONCLUSIONS

In a single-site study, there were no statistically significant differences in important ED operational metrics between a physician in triage model and a rotational patient assignment model after adjusting for confounders.

Emergency Department Rotational Patient Assignment

STUDY OBJECTIVE

We compare emergency department (ED) operational metrics obtained in the first year of a rotational patient assignment system (in which patients are assigned to physicians automatically according to an algorithm) with those obtained in the last year of a traditional physician self-assignment system (in which physicians assigned themselves to patients at physician discretion).

METHODS

This was a pre-post retrospective study of patients at a single ED with no financial incentives for physician productivity. Metrics of interest were length of stay; arrival-to-provider time; rates of left before being seen, left subsequent to being seen, early returns (within 72 hours), and early returns with admission; and complaint ratio.

RESULTS

We analyzed 23,514 visits in the last year of physician self-assignment and 24,112 visits in the first year of rotational patient assignment. Rotational patient assignment was associated with the following improvements (percentage change): median length of stay 232 to 207 minutes (11%), median arrival to provider time 39 to 22 minutes (44%), left before being seen 0.73% to 0.36% (51%), and complaint ratio 9.0/1,000 to 5.4/1,000 (40%). There were no changes in left subsequent to being seen, early returns, or early returns with admission.

CONCLUSION

In a single facility, the transition from physician self-assignment to rotational patient assignment was associated with improvement in a broad array of ED operational metrics. Rotational patient assignment may be a useful strategy in ED front-end process redesign.

Diagnosis of reversible causes of coma

Because coma has many causes, physicians must develop a structured, algorithmic approach to diagnose and treat reversible causes rapidly. The three main mechanisms of coma are structural brain lesions, diffuse neuronal dysfunction, and, rarely, psychiatric causes. The first priority is to stabilise the patient by treatment of life-threatening conditions, then to use the history, physical examination, and laboratory findings to identify structural causes and diagnose treatable disorders. Some patients have a clear diagnosis. In those who do not, the first decision is whether brain imaging is needed. Imaging should be done in post-traumatic coma or when structural brain lesions are probable or possible causes. Patients who do not undergo imaging should be reassessed regularly. If CT is non-diagnostic, a checklist should be used use to indicate whether advanced imaging is needed or evidence is present of a treatable poisoning or infection, seizures including non-convulsive status epilepticus, endocrinopathy, or thiamine deficiency.

Flashback phenomenon and residual neurological deficits after the use of "bath salt" 3, 4- methylenedioxypyrovalerone

BACKGROUND

The use and abuse of designer drugs has been recognized for decades; however there are many derivatives of compounds that make their way into the community. Abuse of compound(s) known on the street as "bath salt" is on the rise.

METHODS

We report the case of a 33-year-old man who complained of "flashbacks" and right arm shaking that followed a night of "bath salt" snorting. The active compound methylenedioxypyrovalerone methamphetamine (MDPV) was confirmed; however, analysis of three different "bath salt" products showed difference in their active components.

RESULTS

The patient's symptoms remained stable and he was discharged home after observation in the emergency department with instructions to return for any symptom progression.

CONCLUSION

Practitioners should be aware of the abuse of the compounds and that not all "bath salt" products contain MDPV.

Safety of epinephrine for anaphylaxis in the emergency setting

BACKGROUND

While epinephrine is the recommended first-line therapy for the reversal of anaphylaxis symptoms, inappropriate use persists because of misunderstandings about proper dosing and administration or misconceptions about its safety. The objective of this review was to evaluate the safety of epinephrine for patients with anaphylaxis, including other emergent conditions, treated in emergency care settings.

METHODS

A MEDLINE search using PubMed was conducted to identify articles that discuss the dosing, administration, and safety of epinephrine in the emergency setting for anaphylaxis and other conditions.

RESULTS

Epinephrine is safe for anaphylaxis when given at the correct dose by intramuscular injection. The majority of dosing errors and cardiovascular adverse reactions occur when epinephrine is given intravenously or incorrectly dosed.

CONCLUSION

Epinephrine by intramuscular injection is a safe therapy for anaphylaxis but training may still be necessary in emergency care settings to minimize drug dosing and administration errors and to allay concerns about its safety.

N-acetylcysteine plus intravenous fluids versus intravenous fluids alone to prevent contrast-induced nephropathy in emergency computed tomography

STUDY OBJECTIVE

We test the hypothesis that N-acetylcysteine plus normal saline solution is more effective than normal saline solution alone in the prevention of contrast-induced nephropathy.

METHODS

The design was a randomized, double blind, 2-center, placebo-controlled interventional trial. Inclusion criteria were patients undergoing chest, abdominal, or pelvic computed tomography (CT) scan with intravenous contrast, older than 18 years, and at least one contrast-induced nephropathy risk factor. Exclusion criteria were end-stage renal disease, pregnancy, N-acetylcysteine allergy, or clinical instability. Intervention for the treatment group was N-acetylcysteine 3 g in 500 mL normal saline solution as an intravenous bolus and then 200 mg/hour (67 mL/hour) for up to 24 hours; and for the placebo group was 500 mL normal saline solution and then 67 mL/hour for up to 24 hours. The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.

RESULTS

The data safety and monitoring board terminated the study early for futility. Of 399 patients enrolled, 357 (89%) completed follow-up and were included. The N-acetylcysteine plus saline solution group contrast-induced nephropathy rate was 14 of 185 (7.6%) versus 12 of 172 (7.0%) in the normal saline solution only group (absolute risk difference 0.6%; 95% confidence interval -4.8% to 6.0%). The contrast-induced nephropathy rate in patients receiving less than 1 L intravenous fluids in the emergency department (ED) was 19 of 147 (12.9%) versus 7 of 210 (3.3%) for greater than 1 L intravenous fluids (difference 9.6%; 95% confidence interval 3.7% to 15.5%), a 69% risk reduction (odds ratio 0.41; 95% confidence interval 0.21 to 0.80) per liter of intravenous fluids.

CONCLUSION

We did not find evidence of a benefit for N-acetylcysteine administration to our ED patients undergoing contrast-enhanced CT. However, we did find a significant association between volume of intravenous fluids administered and reduction in contrast-induced nephropathy.

Risk factors for radiocontrast nephropathy after emergency department contrast-enhanced computerized tomography

OBJECTIVES

Radiocontrast nephropathy (RCN) is a known complication of procedures in which intravascular iodinated contrast material is used. The authors sought to determine the risk factors for RCN after emergency department (ED) contrast-enhanced computerized tomography (CECT).

METHODS

This was a retrospective case-control study of patients presenting to a tertiary care ED between January 1, 2004, and December 31, 2006. Inclusion criteria were CECT performed in the ED, serum creatinine measured prior to CECT, and serum creatinine measured 48 to 96 hours after CECT. Exclusion criterion was dialysis-dependent renal failure prior to CECT. The outcome of RCN was defined as an absolute creatinine increase of greater than or equal to 0.5 mg/dL, or a 25% increase above baseline. The charts of all RCN patients and a random sample of non-RCN patients were reviewed to document the presence or absence of potential risk factors. Univariate analysis was performed using chi-square and multiple logistic regression applying a weighted technique to account for sampling of non-RCN patients.

RESULTS

Among the 5,006 patients meeting inclusion criteria, 349 (7%) developed RCN. Multiple regression analysis demonstrated that serum creatinine > 2 mg/dL, liver disease, heart failure, hematocrit < 30%, hypertension, and diabetes were risk factors for RCN, whereas age > 75 years, vascular disease, and serum creatinine > 1.5 mg/dL were not. The area under the curve (AUC) for the model was 0.65. Although the risk of RCN increased with the number of risk factors present, we could not develop a model with sufficient diagnostic accuracy to guide clinical decision-making.

CONCLUSIONS

The authors report risk factors for RCN in a large case-control study, but could not develop an accurate decision tool to identify patients at increased risk for RCN after ED CECT.

Acute topiramate toxicity

Topiramate (Topamax) is an anti-epileptic medication for which acute toxicity is infrequently reported. A 5-yr-old girl, not previously taking topiramate, developed neurological symptoms after acute ingestion of this medication. She was intermittently agitated, complained of "not being able to feel anything," demonstrated arching movements of the back, and perseverated upon questioning. Computerized tomography of the head and electroencephalography were both normal, and urine toxicology testing for drugs of abuse was negative. A serum topiramate level was 10.5 mcg/mL, confirming the ingestion. The patient was observed for 24 h, over which time her symptoms completely resolved.

Ephedrine‐Induced Cardiac Ischemia: Exposure Confirmed with a Serum Level

The temporal association of symptoms consistent with ephedrine toxicity after ingestion of ephedrine-containing dietary supplements is heavily relied upon to confirm exposure. Few reports in the literature attempt to associate toxicity with serum levels of these drugs. We report a case of ephedrine-induced cardiac ischemia confirmed by a plasma level. A 22-year-old woman ingesting an ephedrine- and caffeine-containing product for 2 days presented with multiple symptoms, including palpitations, nausea, tremulousness, abdominal pain, and vomiting. The initial electrocardiogram (ECG) revealed a normal sinus rhythm with 1 mm of ST segment depression in leads V3 and V4, along with inverted T waves in leads V1-V4. Her symptoms and ST segment depression resolved over several hours with medical management. The amplitude of her T wave inversions notably diminished with therapy; however, they did not completely resolve. Troponins at presentation and the following morning were negative, and an echocardiogram showed only trace tricuspid regurgitation. A serum ephedrine level, drawn approximately 6 to 7 hr after ingestion, was 150 ng/mL. She was discharged from the hospital after being instructed to avoid ephedrine-containing products.

Pediatric "body packing"

BACKGROUND

Recent events in the United States have led to increased security at national borders, resulting in an unexpected increase in drug seizures. In response, drug smugglers may begin using children as couriers, including using them as "body packers."

OBJECTIVE

To look at the occurrence of body packing, the concealing of contraband within the human body, which is well documented in adults, in the pediatric literature.

PATIENT REPORTS

Two cases of pediatric body packing, in boys aged 16 years and 12 years. Patient 1, a 16-year-old boy, presented with findings consistent with opioid intoxication after arriving in the United States on a transcontinental flight. His mental status improved after he received naloxone hydrochloride, and he subsequently confessed to body packing heroin. He was treated with a naloxone infusion and aggressive gastrointestinal decontamination. He ultimately passed 53 packets of heroin, one of which had ruptured. He recovered uneventfully. Patient 2, a 12-year-old boy, presented to the emergency department with rectal bleeding. He had recently arrived in the United States from Europe, and he confessed to body packing heroin. He was treated with whole-bowel irrigation and activated charcoal, and he subsequently passed 84 packets. He also recovered uneventfully.

CONCLUSIONS

We report the first 2 cases of body packing in the pediatric literature and review the diagnosis and management of this clinical entity. Pediatricians should be aware that body packing, regrettably, is not confined to the adult population.

Physostigmine as a treatment for gamma-hydroxybutyrate toxicity: a review

INTRODUCTION

Gamma-hydroxybutyrate is a potent sedative-hypnotic agent and a popular drug of abuse. In the United States, gamma-hydroxybutyrate is a Schedule I controlled substance (sodium oxybate) with orphan drug status for the treatment of narcolepsy within approved clinical studies. Physostigmine is a carbamate inhibitor of acetylcholinesterase that is reported to attenuate the sedative effects of a number of drugs, including gamma-hydroxybutyrate. We reviewed the literature that pertains to the use of physostigmine to treat gamma-hydroxybutyrate-induced sedation.

METHODS

A structured literature search was performed to identify articles in which physostigmine and gamma-hydroxybutyrate were mentioned. Keywords were used to identify relevant articles in the Medline database, and the reference sections of articles identified by this method were hand-checked to identify additional articles. Those articles that presented original evidence pertaining to the use of physostigmine to treat gamma-hydroxybutyrate-induced sedation were included in this review; those that did not were rejected.

RESULTS

The literature search identified 22 articles, six of which did not pertain to the subject matter. Of the 16 articles which remained, 12 were rejected because they offered opinions without presenting original evidence. Of the four articles that presented original evidence, there were no in vitro studies and no animal studies. There were two small case series in which physostigmine was given to treat acute gamma-hydroxybutyrate toxicity in an emergency department setting, and two larger series in which physostigmine was given to attenuate the sedation induced by gamma-hydroxybutyrate in a more structured anesthesia setting. Although these references report that physostigmine attenuates gamma-hydroxybutyrate-induced sedation, there are methodological flaws and confounding factors that limit the scope of the conclusions that can be drawn from them.

CONCLUSIONS

There is currently insufficient scientific evidence to support the routine use of physostigmine in the treatment of gamma-hydroxybutyrate toxicity. Further studies are needed to determine the role, if any, for physostigmine in this setting.

The "ecstasy" hangover: hyponatremia due to 3,4-methylenedioxymethamphetamine

3,4-Methylenedioxymethamphetamine (MDMA, or "ecstasy") has gained an undeserved reputation as a "safe" drug among its users. However, hyperthermia, rhabdomyolysis, hepatotoxicity, disseminated intravascular coagulation, long-term serotonergic neurotoxicity, and death are all associated with MDMA use. Hyponatremia is also reported, and its manifestations are frequently delayed several hours after the drug is ingested. The etiology of this hyponatremia is unclear; both the syndrome of inappropriate antidiuretic hormone release (SIADH) and free-water intoxication are advanced as explanations. We describe a 19-year-old female who presented to the emergency department with altered mental status 1 day after using MDMA. Her initial serum sodium was 121 mmol/L, and computerized tomography (CT) of her head demonstrated cerebral edema. She was treated with hypertonic saline and fluid restriction, and her serum sodium increased to 132 mmol/L over the next 24 hours. She regained consciousness completely within 48 hours of presentation and recovered uneventfully. MDMA toxicity, particularly the pathophysiology and treatment of MDMA-induced hyponatremia, are discussed.

Case report and literature review of chlorine gas toxicity

Chlorine gas exposure is uncommon in children and when it occurs usually results in mild ocular, oropharyngeal, or respiratory symptoms. Occasionally, however, chlorine gas poisoning may cause severe pulmonay toxicity. We report the case of a 14-y-old boy with a history of asthma who was exposed to chlorine gas as a result of an ill-advised science experiment. His clinical condition deteriorated over the course of several hours, and he required intubation and ventilatory support. During his hospitalization, he developed the acute respiratory distress syndrome. He was treated with positive pressure ventilation, beta-adrenergic agonists, and corticosteroids. After 19 d, he was extubated and subsequently made an excellent recovery. We discuss his case and review the etiology, pathophysiology, clinical presentation, laboratory findings, treatment and possible long-term sequelae of chlorine gas toxicity.