Faculty Bibliography

OBJECTIVE: To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy. METHODS: We retrospectively reviewed records of all patients in Bellevue's EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated. RESULTS: Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively. CONCLUSIONS: An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.

CONTEXT: Solanum torvum berries, known as susumber or turkey berries, are prepared as part of traditional Jamaican dishes usually served with cod and rice. Poisoning is rare. Although toxic compounds have never been definitively isolated, previous reports suggest toxicity results from inhibition of acetylcholinesterases. We present a case of susumber berry poisoning with detailed electromyographic studies and laboratory analysis. CASE DETAILS: A 54-year-old woman presented to the Emergency Department (ED) complaining of vision, speech, and gait changes; emesis; and diffuse myalgias following consumption of susumber berries. The physical examination demonstrated an intact, lucid mental status, miosis, opsoclonus, severe dysarthria, dysmetria, mild extremity tenderness and weakness, and inability to ambulate. Her symptom constellation was interpreted as a stroke. DISCUSSION: Electromyography demonstrated a pattern of early full recruitment as well as myotonia during the period of acute toxicity. Additionally, solanaceous compounds, in particular solasonine and solanidine, were identified in leftover berries and the patient's serum. Store-bought commercial berries and subsequent serum samples were free of such toxic compounds. EMG studies, together with a laboratory analysis of berries or serum can assist in the differential diagnosis of stroke, and provide both a prognostic screening and confirmation of suspected glycoside toxicity.

OBJECTIVE: To evaluate the acute impact of disasters on diabetic patients, we performed a geospatial analysis of emergency department (ED) use by New York City diabetic adults in the week after Hurricane Sandy. RESEARCH DESIGN AND METHODS: Using an all-payer claims database, we retrospectively analyzed the demographics, insurance status, and medical comorbidities of post-disaster ED patients with diabetes who lived in the most geographically vulnerable areas. We compared the patterns of ED use among diabetic adults in the first week after Hurricane Sandy's landfall to utilization before the disaster in 2012. RESULTS: In the highest level evacuation zone in New York City, postdisaster increases in ED visits for a primary or secondary diagnosis of diabetes were attributable to a significantly higher proportion of Medicare patients. Emergency visits for a primary diagnosis of diabetes had an increased frequency of certain comorbidities, including hypertension, recent procedure, and chronic skin ulcers. Patients with a history of diabetes visited EDs in increased numbers after Hurricane Sandy for a primary diagnosis of myocardial infarction, prescription refills, drug dependence, dialysis, among other conditions. CONCLUSIONS: We found that diabetic adults aged 65 years and older are especially at risk for requiring postdisaster emergency care compared to other vulnerable populations. Our findings also suggest that there is a need to support diabetic adults particularly in the week after a disaster by ensuring access to medications, aftercare for patients who had a recent procedure, and optimize their cardiovascular health to reduce the risk of heart attacks.

Background: Metformin is the most commonly prescribed antiglycemic agent in the USA. Some have suggested that the potential for metabolicacidosis and hyperlactatemia is spurious in patients taking this medication. Hypothesis:We hypothesize thatmetabolic acidosis with hyperlactatemia occurs not infrequently in patients taking metformin.
Method(s): We retrospectively analyzed Toxicology Investigators Consortium (ToxIC) registry data from January 1, 2010 to September 30, 2015. We searched for all patients with metformin toxicity, with emphasis on metabolic acidosis (pH < 7.2) and lactate concentrations. We reviewed demographics, laboratory analyses, co-exposures, treatments, and survival.
Result(s): Seventy-seven cases with metformin listed as 'primary agent, most consequential' were available for analysis. Intent was reported as intentional overdose (n = 65), unintentional (n = 9), adverse drug reaction (n = 2), and drug abuse (n = 1). Of 65 intentional ingestions, all of which were acute, the dose was reported in 12 (range, 4-100 g). Co-exposures were present in 47 (72.3 %). Twelve (18.5 %) cases reported no sequelae. Ten (15 %) experienced a blood glucose <50 mg/dL. Twenty patients (31 %) had a pH <7.2, with an additional six (9.2 %) with an anion gap (AG) >20. Lactate was reported in 17 cases ofmetformin exposure (mean, 3 mmol/L; range 0.17-27.99 mmol/L). In patients coded with metabolic acidosis (n = 7), the mean serum lactate was 4.91 mmol/L (range, 0.44- 27.99mmol/L). Nine patients (13.8%) had acute kidney injury (creatinine >2.0 mg/dL). Four patients were decontaminated with activated charcoal; one received gastric lavage. Interventions included sodium bicarbonate (18.5 %), hemodialysis (12.3 %), and continuous renal replacement therapy (7.7 %). Hypoglycemic patients received glucose >5 %. No fatalities were reported.
Discussion(s): In ToxIC, the majority of metformin exposures were acute, intentional overdoses. Approximately 40 % of the patients with metformin overdoses in ToxIC had metabolic acidosis (pH <7.2 or AG >20). Our analysis of lactate was limited as it was not specifically included in ToxIC until 2015. Renal insufficiency occurred in 13.8 % of patients.
Conclusion(s): Metabolic acidosis was present in a significant number of patients with acute metformin exposures. Providers should be cognizant of this significant toxicity

Study Objectives: Previously, we built machine-learned models to automatically identify Tweets indicating alcohol use from 34,563 labeled Tweets collected over 24 hours during New Year's Day. The models demonstrated an estimated area under the receiver operating curve (AUROC) of 0.94 for identifying alcohol use Tweets. In this study, we validated our alcohol use model in an independently collected dataset - the Electric Zoo music festival on New York City's Randall's Island. This event attracted over 130,000 people in 2013 and resulted in two substance-associated deaths. Methods: The initial dataset contained all Tweets and Instagrams geo-tagged within 5 miles of Randall's Island, covering all event days from August 29-31, 2014. Two authors independently reviewed Tweets for drug- or alcohol-related content. 10% of the Tweets were randomly selected for dual independent review to determine agreement using a weighted Cohen's kappa. Identified Tweets were then jointly reviewed to determine those indicative of alcohol use according to previous definitions. Tweets and Instagrams were considered indicators of alcohol use if they referred to: intention to drink, the act of drinking, location at a bar or liquor store, mention of a specific brand, drinking paraphernalia (eg, flask), consequences from drinking (eg, drunk, wasted, tipsy), or alcohol-related hashtags. Our Bayesian logistic regression machine learned model, which had been derived only from Tweets, was applied to a restricted dataset excluding Instagrams. Results: The complete geo-located collection included 11,071 Tweets and Instagrams. The restricted dataset containing only Tweets consisted of 2,928 elements, of which 82 Tweets were classified as drug- or alcohol-related (weighted kappa = 0.92). Of these, 23 Tweets explicitly referenced alcohol use (eg, "Wine at Zoo is the right play. Instadrunk;" "Wow. I am not sober;" "#clskipfridays #livesummer #Ezoo #were dumb #and drunk"). The model achieved an AUROC of 0.87 when applied to this independent Tweet validation set. Conclusion: Our machine-learned model automatically identified alcohol use at Electric Zoo with high discriminatory power. Differences between the previous estimated AUROC performance and the validated AUROC performance are likely due to language variations between the two groups. An in-depth error analysis may identify approaches to improve model performance. The ability to automate social media geosurveillance of substance behavior at events could be coupled with real-time data feeds. Model automation would allow these real-time data feeds to be analyzed for potential public health interventions (including messaging, Tweet geodensity dependent medical presence, or other measures) to further reduce harm

Introduction: The opening of a new emergency department creates numerous unknowns that can become latent safety threats (LSTs) to patient welfare. Healthcare providers can also experience increased stress working in a novel environment, which has been shown to negatively affect decision making, teamwork, and ultimately patient safety. Methods: In order to identify LSTs and orient staff, multidisciplinary teams participated in 15 in-situ simulations followed by focused debriefing sessions that stressed uncovering LSTs prior to the ED's opening. Participants also received an electronic, de-identified survey requesting feedback and recollection of any additional LSTs not mentioned during the debriefing. Staff members were then sent the NASA-Task Load Index questionnaire during the first week of opening, which focused on the staff members stress level. Results: Over 100 healthcare workers of various disciplines participated in 15 in-situ simulations over the course of one day. Thirty-five LSTs were identified and modified before the opening of the new emergency department. The majority (93%) of participants felt that simulations helped them orient to the new space. While the absolute level of stress was the same between cohorts, irritation and discouragement were 16% less in the group completing the simulation. Discussion: In-situ simulations performed prior to the opening of a new emergency department identified 35 modifiable latent safety threats. Simulations were an effective way to orient staff to the new space and seemed to decrease the level of discouragement and irritation of healthcare workers during the first few weeks of the emergency department's opening. (C) 2015 Elsevier Ltd. All rights reserved.