Faculty Bibliography

Sudden hospital closures displace patients from usual sources of care and force them to access facilities that lack their prior medical records. For patients with complex needs and for nearby hospitals already strained by high volume, disaster-related hospital closures induce a public health emergency. Our objective was to analyze responses of patients from public versus private emergency departments after closure of their usual hospital after Hurricane Sandy. Using a statewide database of emergency visits, we followed patients with an established pattern of accessing 1 of 2 hospitals that closed after Hurricane Sandy: Bellevue Hospital Center and NYU Langone Medical Center. We determined how these patients redistributed for emergency care after the storm. We found that proximity strongly predicted patient redistribution to nearby open hospitals. However, for patients from the closed public hospital, this redistribution was also influenced by hospital ownership, because patients redistributed to other public hospitals at rates higher than expected by proximity alone. This differential response to hospital closures demonstrates significant differences in how public and private patients respond to changes in health care access during disasters. Public health response must consider these differences to meet the needs of all patients affected by disasters and other public health emergencies. (Disaster Med Public Health Preparedness. 2015;00:1-9).

Medical and medication errors remain definite threats to patients in US health care. Medical toxicologists frequently encounter patients either harmed by or at risk for harm from adverse drug events, including medication errors and inadvertent exposures. An historical perspective, as viewed through the lens of specific disciplines, can be useful to trace systemic responses to safety threats. Early efforts to address anesthesia perioperative risks and recent actions in medicine, surgery, and obstetrics to introduce checklists, communication tools, and systems approaches are reviewed. Patient safety concepts can be utilized and disseminated by toxicologists to improve medication safety and drive innovative approaches to confront patient harm. Various approaches include simulation of high-risk scenarios which might predispose to medication error, assembling multidisciplinary groups of health care providers to review events and implement mitigation strategies, and proactive patient safety rounds in clinical areas to allow frontline staff to voice concerns and introduce solutions for administration, evaluation, and implementation. We review selected lessons from the past and current innovations to achieve safe medication practice.

Background: Airway management skills are an essential part of EM resident training. They are recognized as a key ACGME competency milestone. All EM trainees must achieve mastery in performing basic support of oxygenation and ventilation until a definitive airway can be secured. Junior residents frequently overlook these important fundamental skills. In our residency, no formalized program was in place to assess first year residents' airway skill retention or identify potential skill improvement and remediation. Objectives: The goal of our study is to demonstrate improvements in PGY1 residents' comfort with basic airway management skills using an immersive simulation-based curriculum. Methods: Residents participated in three high fidelity simulations. The scenarios required identification of risk factors for a difficult airway, demonstration of effective BVM skills, patient repositioning, and use of nasal trumpets, oral airways and PEEP valve if necessary. The cases included a patient with methadone overdose where naloxone was not yet available, a patient with pulmonary edema requiring ventilatory support, and a MVC patient requiring maintenance of C-spine immobilization during airway management. We utilized a survey-based design with pre- and post-session distribution assessing trainees' comfort with basic airway skills. The survey consisted of 5-point Likertscale questions, and we employed the paired Student t-test for data analysis. Results: A total of 13 PGY1 residents completed the one-on-one didactic session. All residents universally chose "strongly agree" when asked if the simulations were helpful. Instructors responded that the residents' airway techniques improved at the completion of the scenarios. The trainees reported significantly higher confidence in basic airway skills after training (mean score +1.13, p<0.005). During subsequent feedback, residents identified how cognitive stress impaired information retrieval, decision-making, and in some, fine motor skills. Adherence to an airway checklist mitigated these potential safety threats. Conclusion: An immersive simulation-based curriculum significantly improved PGY1 residents in their comfort level toward basic airway skills. As a secondary objective, program leadership was also able to assess and complete the level 1 ACGME milestones for airway skills for all PGY1 session attendees

CONTEXT: Nearly pure caffeine is sold as a "dietary supplement," with instructions to ingest 1/64th to 1/16th of one teaspoon (50-200 mg). We report a patient with refractory cardiac dysrhythmias treated with defibrillation, beta-adrenergic blockade, and hemodialysis to highlight concentrated caffeine's dangers. CASE DETAILS: A 20-year-old woman presented with severe agitation, tremor, and vomiting approximately 1-2 h after suicidal ingestion of concentrated caffeine (powder and tablets). Within minutes, ventricular fibrillation commenced. Defibrillation, intubation, and amiodarone administration achieved return of spontaneous circulation (ROSC). Shortly thereafter, she developed pulseless ventricular tachycardia (VTach), with ROSC after defibrillation and lidocaine. She subsequently experienced 23 episodes of pulseless VTach, each responsive to defibrillation. Activated charcoal was administered via orogastric tube. An esmolol infusion was started. Hemodialysis was initiated once she was hemodynamically stable. She was extubated the following day, continued on oral metoprolol, and transferred to psychiatry on hospital day seven, achieving full neurological recovery. Serum caffeine concentrations performed approximately six and 18 h post-ingestion (pre/post-dialysis) were 240.8 mcg/mL and 150.7 mcg/mL. DISCUSSION: Severe caffeine toxicity can produce difficult to treat, life-threatening dysrhythmias. Concentrated caffeine, marketed for dietary supplementation, presents a substantial public health risk that demands action to limit consumer availability.