Original/Research Article

Discharge against Medical Advice in Emergency Department

Payman Asadi, Behzad Zohrevandi, Vahid Monsef Kasmaei, Bahnaz Heidari Bateni

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 110-115

Introduction: Discharge against medical advice (AMA) is the patient voluntarily leaving the hospital against the physician’s advice, which might indicate a problem in the hospital or the quality of care in it. This study aimed to evaluate the frequency and reasons of AMA in the emergency department (ED). Methods: The present cross-sectional study evaluated the reasons of AMA in the ED of Poursina Hospital, Rasht, Iran. The studied population included all the discharged AMA patients from April 2012 to March 2013. Demographic data and data regarding insurance status, insurance provider, number of hospitalization days, admission shift (morning, evening, night), type of disease or reason for referral (multiple trauma, surgery, orthopedics, neurosurgery, neurology), probable readmission in the next 15 days, and reasons for discharge AMA were gathered using a pre-designed checklist. Data were analyzed using SPSS version 20 and chi square test. p < 0.05 was considered significant. Results: 3367 patients were admitted to ED over the course of the study, 1060 (31.4%) of which were discharged AMA (62.92% male). Most discharged AMA patients were married and 20-30 years old. Most had neurological problems and surgery, and were referred in the evening or night shifts. 62.17% of the patients were insured by Ta’min Ejtema’i insurance company. The reasons for discharge AMA was patient related in 1009 (95.19%) cases, medical staff related in 35 cases (3.3%), and hospitalization related in 16 (1.51%) cases. Readmission in the next 15 days was seen in 9.06% of those who were discharged AMA. Conclusion: Based on the results of the present study, most cases of discharge AMA were patient related. Increasing the knowledge of the patients regarding probable consequences, designing outpatient management programs for these patients and improving the quality of medical services can help decrease discharge AMA cases. 

Intranasal Sufentanil versus Intravenous Morphine Sulfate in Pain Management of Patients with Extremity Trauma

Ali Arhami Dolatabadi, Majid Shojaee, Afshin Amini, Hojjat Derakhshanfar, Seyed Mohammad Hosseini, Davood Gallehdar

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 116-121

Introduction: Pain is one of the most common complaints of patients referred to emergency department (ED) and its control is one of the most important responsibilities of the physicians. The present study was designed, aiming to compare the efficiency of intranasal sufentanil and intravenous (IV) morphine sulfate in controlling extremity trauma patients' pain in ED. Methods: In the present clinical trial, extremity trauma cases referred to the ED of Imam Hossein Hospital, Tehran, Iran, from October 2014 to March 2015 were randomly divided into 2 groups treated with intranasal sufentanil (0.3 µg/kg) and IV morphine sulfate (0.1 mg/kg) single-doses. Demographic data and information regarding the quality of pain control such as pain severity before intervention and 15, 30, and 60 minutes after intervention, and probable side effects were gathered using a checklist and compared between the 2 groups. Results: 88 patients with the mean age of 35.5 ± 14.8 years were included in the study (81.8% male). 44 patients received IV morphine sulfate and 44 got intranasal sufentanil. No significant difference was detected between the 2 groups regarding baseline characteristics. In addition, there was no significant difference in the groups regarding pain relief at different studied times (p = 0.12; F = 2.46; df: 1, 86). Success rate of the drugs also did not differ significantly at different studied times (p = 0.52). No significant difference was seen between the groups regarding side effects (p = 0.24). Conclusion: Based on the results of this study, it seems that intranasal sufentanil has a similar effect to IV morphine sulfate in rapid, efficient, and non-invasive pain control in patients with traumatic extremity injuries. 

82 Cases of Medical Lawsuit against Emergency Medicine Specialists; a case study

Masoumeh Pourali, Majid Shojaee, Afshin Amini, Hosein Alimohammadi, Hamidreza Hatamabadi

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 122-126

Introduction: Increase of medical errors is a common concern among health care policy planners. Taking into account the importance of identifying the causes of medical errors and preventing them from persisting, this descriptive study reports 82 cases of medical lawsuit against emergency physicians. Methods: The present case study, describes 82 cases of medical error by emergency medicine specialists, lawsuit outcome, patient outcome, type of malpractice, total investigation procedure time. Data were self-expressed by the participants and gathered using an anonymous questionnaire. Results: Data on 82 lawsuits against emergency physicians were gathered. Mean age of the emergency physicians was 37.3 ± 5.7 years (89.2% male). Finally, in 53 (63.8%) cases malpractice was confirmed. Frequency of medical errors was significantly higher in night shifts compared to evening (p = 0.02) and morning (p = 0.01). Human error was the most frequent cause of malpractice with 27 (50.9%) cases (p < 0.001). Among human errors, diagnostic (48.2%) and treatment (33.3%) errors were the most important causes. Medical errors led to death in 28 (52.8%) cases and severe harm in 6 (11.3%) of the patients (p < 0.001). Conclusion: Frequency of medical errors was calculated to be 63.85% in this study. Most human errors occurred in the night shifts. The major human error was malpractice with 50.9% prevalence. Among human errors, diagnostic and treatment errors were the most frequent. These errors finally led to 52.8% death and 11.3% severe harm among the patients. 

Patient Satisfaction Before and After Executing Health Sector Evolution Plan

Behrouz Hashemi, Alireza Baratloo, Mohammad Mehdi Forouzafar, Maryam Motamedi, Mohammadreza Tarkhorani

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 127-133

Introduction: After long discussions, carrying out health sector evolution (HSE) plan began on May 5, 2014 throughout Iran. Shohadaye Tajrish Hospital, Tehran, was also included in this plan. This study aimed to evaluate the level of emergency department patient satisfaction, before and after running this plan. Methods: This cross-sectional study analyzed the data extracted from a standard questionnaire filled out by the patients presented to the emergency department of Shohadaye Tajrish Hospital over 6-month periods before and after the beginning of HSE. Results: 3665 patients were surveyed. After the execution of the plan, satisfaction decreased significantly regarding pre-discharge training (p = 0.03), hospitalization room condition (p = 0.0002), restroom sanitation (p = 0.007), waiting time to be visited by the physician (p = 0.04), accuracy and duration of physical examination (p = 0.007), feeling confident and desirable outcome (p = 0.03), commitment to religious and moral principles (p = 0.01), and handling financial affairs (p = 0.03). Conclusion: Based on the results of the present study, after execution of HSE plan, patient satisfaction has decreased significantly regarding pre-discharge training, hospitalization room condition, restroom sanitation, timely visit of the physicians, accuracy and duration of physical examination, suggestions for wellbeing of the patient, handling financial affairs, and commitment to religious and moral principles. 

Head Trauma Patients Presented To Emergency Department; an Epidemiologic Study

Arash Forouzan, Kambiz Masoumi, Hassan Motamed, Alireza Teimouri, Hassan Barzegari, Behzad Zohrevandi, Fatemeh Rasouli

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 134-138

Introduction: Traumatic brain injuries are among the most important causes of mortality and disability. Since there is a lot of controversy regarding discharge of head trauma patients, especially those with mild traumatic brain injuries, this study was designed aiming to evaluate traumatic brain injuries from an epidemiologic point of view. Methods: In this retrospective cross-sectional study, patients with isolated head trauma, and all those who underwent computed tomography (CT) were included using convenience sampling. Demographic data and final diagnosis of the patients were extracted from their medical profile, and were analyzed using SPSS 21 and appropriate statistical tests. Results: 786 patients with the mean age of 24 ± 16.8 years (range: 0.5 – 75) were evaluated (67.8% male). 42 patients (5.3%) had abnormal CT scan and were hospitalized. 7 of them (16.7% of hospitalized, 3.3% of low-risk, and 0.9% of all patients) were in the group categorized as low-risk regarding probability of brain injuries. 12 (1.5%) participants needed surgery, 2 of which (0.9%) were initially categorized as low-risk. Vomiting was significantly more in patients with abnormal CT scan (45.2%) compared to those who had normal CT scan (19.6%) (p = 0.0001). No significant difference was detected between the 2 groups in other symptoms. Conclusion: The results of this study indicate that by making decisions based on clinical findings alone, there is a probability of about 3.3% error in management of head trauma patients. In addition, 0.9% of the patients initially categorized as low-risk, needed surgical intervention in the end.


Letter to Editor

Regional emergencies, Bam, Kerman province, Iran Foreign Bodies from the Palm Tree

Setareh Asgarzadeh, Mojtaba Jafari, Masoumeh Moallem

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 108-109

One of the most common causes of emergency department (ED) visits in Pasteur Hospital, Bam, Iran, is a foreign body from palm tree fronds entering different parts of body. This town is located in southeast Iran and has many palm tree orchards. Most of its residents are farmers or orchardists and many children play in these orchards. When palm harvest season approaches (about the end of summer), a considerable number of patients are presented to emergency department of this town with complaint of foreign bodies. These foreign bodies called “date thorns” among the locals (figure1) are wooden and can easily penetrate various body parts due to their needle-like, pointy shape. Some patients manipulate the foreign bodies before going to the ED and cause it to move deeper.

 Another group, delay going to the hospital and only reach ED a few days after the initiation of inflammation, redness, and evidence of infection. History and physical examination aid in finding the place of the foreign body, but sometimes they are not perceptible and diagnostic imaging is needed. Radiolucent objects such as wood cannot be detected in graphy but are visible in sonograms (12). Removal of these bodies is usually performed under sterile conditions, using local anesthesia or regional nerve blockade, by making an incision and searching the region, finding and removing the foreign body, and finally suturing and bandaging. The procedure gets more difficult in children and patients who do not cooperate and occasionally, procedural sedation and analgesia is required, which leads to side effects such as nausea, vomiting, lethargy, agitation, and respiratory depression. Depending on the site of injury, patients are usually unable to use the affected organ for a few days after the procedure and need daily washing and bandage, and sometimes taking antibiotics. If tendon, joint, nerve, or vascular injuries are present, it gets more complicated and need for operation and hospitalization will be added to the afore-mentioned requirements (3-5). This can lead to temporary or permanent disability of the organs during the busiest workdays, in addition to severe pain especially in cases of the foreign body piercing a joint. The presence of these patients in the ED leads to overcrowding and sometimes decreases the time spent on patients in poor condition. This becomes troublesome on occasion as staff and equipment are limited, particularly when sonographic or radiologic guidance is needed for removal of the foreign body (67). In the time between March and October 2014, 240 patients have been presented to the ED with complaint of foreign body, which makes up 10% of total ED visits as 2400 patients visit the ED each month (77.36% male). The patients’ age range was 3 to 70 years. In 190 (79.16%) cases, the foreign body was successfully removed in the ED and the other 50 (20.83%) needed surgery. The foreign body was in the lower extremities in 107 (56.31%) cases, upper extremities in 77 (40.52%) and other body parts in 6 (3.15%). These findings emphasize the importance of prioritizing prevention over treatment. It seems that by taking a few simple measures we can vastly decrease the financial and health burdens of this problem:

1- Avoiding walking barefoot on the grounds beneath palm trees that are full of the dry thorns mentioned. This is especially important in case of children.

2- Education for use and providing personal safety tools such as helmets, long impenetrable gloves, glasses, and proper shoes while working and harvesting dates.

3- Having classes for the farmers and orchardists, held by health centers of the regions affected by this problem.

4- Educating the patients on the importance of rapid referral to ED and not manipulating the foreign body to avoid further complications.

5- Train the medical staff of the ED to increase their skills in removing radiolucent objects using sonographic guidance.

6- Educate the families to take more care of the children especially in harvest season.

7- Mechanization of the harvest process to decrease using hands with the aid of respective organizations 

Case Report

Post-traumatic Acalculous Cholecystitis; a Case Report

Majid Shojaee, Setareh Asgarzadeh, Anita Sabzghabaei

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 139-142

Acalculous cholecystitis, is a rare disease with a high morbidity and mortality, which is developed due to various reasons, including trauma and burn. Its diagnosis is based on clinical suspicion and physical examination. Ultrasonography and computed tomography scan can help in this regard. This report presents a case of post-traumatic acalculous cholecystitis in a 75-year-old patient expressing its method of diagnosis, treatment and outcome. 

Bite; a Rare but Probable Cause for Hemodynamic Instability

Masoumeh Moallem, Vishtasb Nikmanesh, Setareh Asgarzadeh

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 143-146

Scorpion bites are common in south-east Iran, especially in the rural areas. Most scorpion bite cases are benign and cause no systemic side effects. Local erythema and edema, and mild allergic effects are the most common complications of scorpion bites. Yet, rarely dangerous outcomes such as myocarditis, cardiac failure, pulmonary edema, and shock have been reported. The present case report, introduces a case of scorpion bite in a 6 year old child, presented as dyspnea and pulmonary edema. 


Evidence Based Medicine; Positive and negative predictive values of diagnostic tests

Saeed Safari, Alireza Baratloo

Iranian Journal of Emergency Medicine, Vol. 2 No. 3 (2015), 29 July 2015, Page 147-149

در شماره 2، دوره 2، صفحات 105-107 مجله طب اورژانس ایران بعضی از ویژگی های تست های تشخیصی در قالب یک مقاله آموزشی با عنوان "پزشکی مبتنی بر شواهد؛ قسمت اول: تعریف و محاسبه ساده حساسیت، ویژگی و دقت یک تست" تعریف شده و نحوه محاسبه آنها بیان گردید. مقاله حاضر قصد دارد تا دو ویژگی دیگر تست های تشخیصی شامل ارزش اخباری مثبت و منفی را مورد توجه قرار دهد. ارزش اخباری مثبت و منفی به ترتیب عبارتند از موارد مثبت و منفی حقیقی گزارش شده توسط یک تست. به بیانی دیگر این مقادیر بیان کننده این نکته هستند که اگر یک فرد با یک تست مورد آزمایش قرار بگیرد، احتمال مثبت یا منفی بودن حقیقی تشخیص در آنها چقدر است.