Pinchas Halpern

Methods: We conducted a prospective, representative-sample nationwide study on morbidity related to 3,4, methylenedioxymethamphetamine (MDMA; ‘ecstasy’) as determined from admissions to 5 geographically representative emergency departments (EDs) and from data from the poison information center (PIC). MDMArelated ED admissions were analyzed over a 7-month period and the records of all PIC calls were reviewed. Results: There were 52 (age 15—44 years, 32 males) ecstasy-related ED admissions during the study period. Most (68%) admissions presented to the ED at night, 52% on weekends and 44% consumed the drug at clubs and parties. Forty-six percent of the patients took between 1/2 to 3 tablets and 29 patients (56%) had taken ecstasy before. Twenty-two subjects (42%) reported poly-drug use. Fifteen subjects (29%) required hospitalization, six of them (11%) to the intensive care unit. The most common manifestations were restlessness, agitation, disorientation, shaking, high blood pressure, headache and loss of consciousness. More serious complications were hyperthermia, hyponatremia, rhabdomyolysis, brain edema and coma. Conclusion: The image of ecstasy as a safe party drug is spurious. The results of this study confirm that the drug bears real danger of physical harm and of behavioral, psychological and psychiatric disturbances.

Introduction: C-reactive protein (CRP) is a real-time and low-cost biomarker to distinguish febrile bacterial infections from non-bacterial febrile illnesses. We hypothesised that measuring the velocity of the biomarker instead of its absolute serum concentration could enhance its ability to differentiate between these two conditions. Methods: We prospectively recruited adult patients (age ≥ 18 years) who presented to the emergency department with fever. We recorded their data regarding the onset of fever and accompanying symptoms. CRP measurements were obtained upon admission. CRP velocity (CRPv) was defined as the ratio between CRP on admission and the number of hours since the onset of fever. Patients were diagnosed by clinical symptoms, blood cultures and imaging studies, and the diagnoses were confirmed by an infectious disease specialist. The efficacy of CRPv as a diagnostic marker was evaluated by using receiver operator curves (ROC). Excluded were patients who did not know the time fever started with certainty, patients with malignancy, patients with HIV infection and patients who had been using antibiotics upon presentation. Results: Of 178 eligible patients, 108 (60.7%) had febrile bacterial infections (mean CRP: 63.77 mg/L, mean CRPv: 3.61 mg/L/hour) and 70 (39.3%) had non-bacterial febrile illnesses (mean CRP: 23.2 mg/L, mean CRPv: 0.41 mg/L/hour). The area under the curve for CRP and CRPv were 0.783 (95% confidence interval (CI) = 0.717 to 0.850) and 0.871 (95% CI = 0.817 to 0.924), respectively. In a 122-patient subgroup with a CRP level of less than 100 mg/L, the area under the curve increased from 0.689 (95% CI = 0.0595 to 0.782) to 0.842 (95% CI = 0.77 to 0.914) by using the CRPv measurements. Conclusions: CRPv improved differentiation between febrile bacterial infections and non-bacterial febrile illnesses compared with CRP alone, and could identify individuals who need prompt therapeutic intervention.

Objective: We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention.Methods: We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol.Results: Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%–68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively).Conclusion: Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.

This prospective, nationally representative, multi-centre study was undertaken to assess non-collision injuries sustained by public bus passengers in Israel. The emergency departments (EDs) of six medical centres, which participated in this eight month study, were chosen to represent both urban and rural catchment areas. All patients diagnosed with injuries sustained on a public bus not involved in a road traffic accident were promptly evaluated for mechanism and nature of injury and demographic parameters. The study cohort consisted of 120 patients (86 were female, 34 were male, age range 3-89 years). Over half were older than 55 years. The most common injuries were to the limbs, vertebral column, and head. The major mechanism of injury was acceleration/deceleration. Most patients were standing when they sustained the injuries. There were no fatalities, and 17 patients were admitted to hospital (9 of 17, 52% older than 55 years). Extrapolation to yearly national statistics suggests a probable total of 729 such injuries. The significant injuries inflicted on passengers of public buses not involved in road traffic accidents warrant decisive preventative measures by transportation authorities.

Objectives: To describe the development of emergency medicine (EM) in Israel and review the specific problems faced by the discipline and describe the solutions that were found. Methods: A comprehensive literature search was conducted for data on development of EM in the UK and in North America, and the personal knowledge of two of the authors (PH and YW) was used in preparing the article. Results: There are differences in development of EM between Israel and the UK/US models. In Israel the specialty developed within the context of established high quality clinical practice and consequently it met resistance from the system, which did not wish to invest in what it felt might be marginal improvements in patient care. The economics of Israeli medicine also dictated that EM be made into a super-specialty rather than a primary specialty. Certified specialists from family medicine, paediatrics, internal medicine, general surgery, anaesthesia, and orthopaedic surgery can access training positions in EM. Currently there are seven active EM programmes of 2.5 years duration and 16 residents. The curriculum is flexible and a national certification examination is being developed. Conclusions: Development of EM can and should take different paths according to the specific local needs and realities. There is no single ideal model suitable for all circumstances. The practice of clinical EM in Israel is comparable with that of any developed country and daily progress is being made in the academic areas of teaching and research. There are worldwide similarities in the process of developing EM as a distinct discipline.

To define the changes in middle cerebral artery flow velocity (Vmca) and the electroencephalogram (EEG) during rapid reduction in arterial carbon dioxide (PCO₂) from acute hypercapnia. Human volunteer study. University-affiliated hospital experimental laboratory. Nine healthy volunteers aged 25–35 years. Subjects rebreathed exhaled gas from a bag pre-filled with 5% carbon dioxide (CO₂) in oxygen, up to an end-tidal CO₂ of 10% or to the limit of discomfort, when they were disconnected. Middle cerebral artery blood flow velocity was continuously measured by transcranial Doppler ultrasound, quantitative EEG was recorded and hemodynamics were monitored non-invasively. Vmca closely correlated with end-tidal CO₂ changes (r=0.65, p2 and in Vmca to baseline within 42±14 s, followed by a rapid further decline in both variables to below baseline. End-tidal CO₂ reached a nadir of 4.4±1.1% at 146±79 s, with Vmca decreasing to 37±10 cm/s at 104±65 s (a 40% reduction and 31% below basal values). Electroencephalogram alpha activity significantly decreased and delta activity increased during hypercapnia. During subsequent hypocapnia, delta activity decreased back to baseline, while alpha activity increased, but remained below baseline. These findings demonstrate the rapid changes occurring in cerebral blood flow during rapid declines in arterial CO₂ and the consequent potential for producing brain ischemia and hemodynamic alterations if inadvertent hyperventilation occurs following institution of mechanical ventilation for acute hypercapnia.

To describe our experience with the implementation of intensive care in the setting of a field hospital, deployed to the site of a major urban disaster. Description of our experience during mission to Turkey; conclusions regarding implementation of intensive care at disaster sites. Military Field Hospital at Adapazari in Turkey. Civilian patients admitted for care at the field hospital. None. On August 17, 1999 a major earthquake occurred in western Turkey, causing approximately 16,000 fatalities and leaving >44,000 injured. Approximately 66,000 buildings were severely damaged or destroyed. A medical unit of the Israeli Defense Forces Medical Corps, consisting of 23 physicians, 13 nurses, nine paramedics, 13 medics, laboratory and roentgen technicians, pharmacists, and associated support personnel, were sent to Adapazari in Turkey. The field hospital treated approximately 1,200 patients over a period of 2 wks, 70 surgical operations were performed, 20 babies were delivered, and a variety of medical, surgical, orthopedic, and pediatric/neonatal care was provided. The 12-bed intensive care unit operated by the unit, was staffed by three physicians and eight nursing/paramedic personnel. Patient mix was: a total of 63 patients, among them five with major trauma, 20 with acute cardiac disease, 15 patients with various acute medical conditions, and 11 surgical and postoperative patients. Three patients were intubated and mechanically ventilated (one cardiogenic pulmonary edema and two major trauma). The intensive care unit provided the following functions to the field hospital: care of the critically ill and injured, preparation for and implementation of transportation of such patients, pre- and postoperative care for major surgical procedures, expertise, and equipment for the care of very ill patients throughout the field hospital. In suitable circumstances, an intensive care capability should be an integral part of medical expeditions to major disasters.