The resilience of the human body

Correspondence black, and 8.5% Hispanic. The median age was 22; 94.9% were single/never married; and 26.6% had children. Of the respondents, 58.2% were employed full time, 12.9% were working part time, and 28.9% were not employed. Of the respondents, 38.5% were in school: of these, 5.5% in high school or completing a General Equivalency Diploma (GED), 85.6% in college or graduate school, and 8.9% in vocational school. Although 51.1% of respondents had private/commercial insurance, 44% had Medicaid, Medicare, DC Alliance (a system designed to cover the “gap” in coverage when people do not meet eligibility requirements for Medicaid), or no insurance at all. Of the respondents, 74.1% were in the ED for medical reasons; 4.1% for an intentional injury; and 21.8% for an unintentional injury. Of the patients, 27.7% were smokers, 58.7% drank at least 1 drink in an average week, and 12.6% drank more than 7 drinks per week. Of the patients, 49.3% had “ever” used drugs; and 29.1% had used in the previous 30 days: most reported marijuana but a handful had recently used each of cocaine, ketamine (special K), heroin, or ecstasy. Of these patients, 51.4% had tattoos but none had a gang-related tattoo. Of the patients, 19.0% had been arrested at least once. Of these, 43.9% had been arrested more than once; 21.4% of those arrested had been charged with a felony at least one time, and 26 respondents had done time in juvenile hall or prison. Of the patients, 5.5% had “easy access” or owned a gun. (Note that the District of Columbia had a strong gun control law during the period of this study.) Among our respondents, 3.6% were gang members and 9.0% had friends in gangs. All but 1 of the 8 gang members had already “gotten out” of the gang. All gang members wrote down their gang's name, and these were verified by the internet as gangs/crews active in the District of Columbia. One hundred percent of the gang members were black (P = .026 compared with nongang members), and 62.5% were female. Members had entered the gang between the ages of 12 and 16 years, and all were in local “crews” ranging in size from 40 to 1000 members, rather than nationally recognized gangs. Patients reported that they had held/did hold a variety of leadership levels within their gangs: 2 were leaders, 4 were full members, and 1 was an associate member. Of the gangsters, 62.5% were “very comfortable” with discussing gangs with providers; only 1 was “uncomfortable.” Gang members were more likely to have children (62.5% vs 24.9%; P b .001) and to have ever used drugs (100% of gang members; P = .003). They were significantly more likely to have been arrested than nongang members (P = .007) but not more likely to report easy access to a firearm. Gang members were more likely to be in the ED as the result of an injury than nongang members (P = .024), and tended to be less likely to have commercial insurance (25.0% vs 52.8%; P = .59). In our institution, ED staff beliefs about patients and gang membership were inaccurate. Even if all patients arriving in this age range with penetrating trauma during our study were 835 gang members, the prevalence would only have risen about 0.7%; nowhere near the 23% that the staff estimated. Traditionally, gang members are thought to be male adolescents and young adults. However, a 2008 report found that, in high-risk, high-crime neighborhoods, up to 29.4% of girls identified themselves as gang members [6]. Our results parallel their assertions that many of these young women were found to be involved in high-risk behaviors such as unprotected sex, young motherhood, and criminal activities leading to arrests. As a result, they may be more likely than their male counterparts to visit the ED for health issues unrelated to violence or injuries; we believe that this deserves further investigation. Overall, few of our young urban adult patients were gang members; but those who identified themselves as such were very forthcoming about their gang involvement and associated risky behaviors. We believe that further research including verifying similar results in other institutions including EDs serving younger adolescents is warranted. Mandeep Grewal MD Mary Pat McKay MD, MPH Alison Shaffer Teitlebaum MS, MPH The George Washington University Washington DC 20037, USA E-mail address: [email protected] doi:10.1016/j.ajem.2011.04.017 References [1] Lyon JM, Henggeler S, Hall JA. The family relationship, peer relations, and criminal activities of Caucasion and Hispanic-American gang members. J Abnorm Child Psychol 1992;20:439-49. [2] MacKenzie K, Hunt G, Joe-Laidler K. Youth gangs and drugs: the case of marijuana. J Ethn Subst Abuse 2005;4:99-134. [3] Zun LS, Downey L, Rosen J. Who are the young victims of violence? Pediatr Emerg Care 2005;21(9):568-73. [4] Saabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care 2008;46: 678-85. [5] Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med 2007;22: 1231-8. [6] National Youth Gang Center. National Youth Gang Survey Analysis. Available at: http://www.iir.com/nygc/nygsa/. Accessed February 27, 2009. The resilience of the human body To the Editor, The human race has evolved over millions of years. This evolution has allowed our bodies to adapt to critical situations, which are otherwise lethal in other species. One example of such adaptation is the human blood pH. This 836 Table 1 Correspondence Laboratory data Electrolytes Sodium (mmol/L) Potassium (mmol/L) Chloride (mmol/L) Bicarbonate (mmol/L) BUN (mg/dL) Creatinine (mg/dL) Blood glucose (mg/dL) Anion gap Lactate (mmol/L) ABG pH pCO2 (mm Hg) pO2 (mm Hg) Bicarbonate Base excess CBC WBC (103/μL) Hemoglobin (mg/dL) Hematocrit (%) Platelet (103/μL) ED visit 1 ED visit 2 (presentation) Postdemodialysis After 12 h (after second hemodialysis) 129 7.7 90 13 108 14.3 105 26 135 7.6 90 3 130 17.5 160 42 13.7 135 6 85 9 93 11.5 235 41 135 4.4 92 19 56 7.2 151 24 3.8 6.62 11.1 161 1.1 −36.6 7.05 33.4 416 9.1 −20.6 7.49 24.6 153 18.4 −3.5 24 14.2 44.3 344 25.1 11.8 34.9 213 9.4 10.2 28.4 103 13.1 14.3 40.1 209 ABG indicates arterial blood gases; BUN, blood urea nitrogen; CBC, complete blood count; WBC, white blood cell count. characteristic measurement, by virtue of its compensatory mechanisms, keeps the pH in a range of 7.35 to 7.45 even under adverse circumstances. As clinicians, we have encountered patients with severe hypoxemia and hypercarbia in our emergency departments (EDs), medical and surgical wards, and the intensive care units. Moreover, many clinicians care, on a regular basis, for noncompliant patients with end-stage renal disease (ESRD) who have not undergone hemodialysis for several days at a time and that present to ED with life-threatening hyperkalemia. In these patients with ESRD, severe sepsis and septic shock lead to a severe metabolic acidosis [1-3]. We recently were confronted with a patient with ESRD that made us rethink the resilience of the human body. A 55-year-old gentleman with history of diabetes, hypertension, hyperlipidemia, and hepatitis C, on oral metformin, presented to our ED with intractable nausea and vomiting. He complained of having “gastroenteritis” and was not able to keep any thing down for 2 days before his presentation to the ED. On physical examination, he was tachycardic and tachypneic with dry mucosa. His initial laboratory test results are depicted in Table 1. As the ED physician was about to initiate treatment, the patient left the ED against medical advice. Several attempts at contacting the patient after he left were unsuccessful, including sending the police to his home address. Approximately18 hours later, the patient presented to the ED ambulatory complaining of nausea and intractable vomiting. He was found to have serum bicarbonate of 3 mmol/L and potassium of 7.6 mmol/L on blood chemistry analysis. Arterial blood gases revealed a pH of 6.62, pCO2 of 11.1 torr, PaO2 161 torr, and bicarbonate of 1.1 with a base excess of −36.6 L and a serum lactate of 13.7 mmol/L . Blood cultures and urine drug screen were negative as well as acetaminophen and salicylates levels. The patient underwent aggressive intravenous fluid resuscitation and was initiated on emergent hemodialysis. He responded well with a dramatic improvement in his severe metabolic acidosis. He was discharged home after 3 days of hospital stay with a referral to social work for assistance. What is amazing on this case presentation is the fact that severe acidosis is commonly fatal. Lactic acidosis is also known to be a fatal, and complication of metformin use is rare. Indeed, this complication carries a mortality rate of more than 50% [4-6]. We remain amazed as to how some individuals can defy the physiological rules while presenting ambulatory to the ED with life-threatening hyperkalemia and severe acidosis with pH of 6.62. Salim Surani MD, MPH Texas A&M University Corpus Christi, TX 78404, USA E-mail addresses: [email protected] [email protected] Marlene Morales MD Christus Spohn Hospital Corpus Christi, TX 78405, USA Mauricio Rodriguez PharmD Texas A&M University, TX, USA Correspondence Joseph Varon MD The University of Texas Health Science Center at Houston, TX, USA The University of Texas Medical Branch at Galveston, TX, USA University General Hospital, Houston, TX, USA doi:10.1016/j.ajem.2011.04.020 References [1] Stang M, Wysowski DK, Butler-Jones D. Incidence of lactic acidosis in metformin users. Diabetic Care 1999;22:925-7. [2] Mecher C, Rackow EC, Astiz ME, et al. Unaccounted for anion in metabolic acidosis in severe sepsis in humans. Crit Care Med 1991;19: 705-11. [3] Park M, Azevedo LC, Maciel AT, et al. Evolutive standard base excess and serum lactate level in severe sepsis and septic shock patients resuscitated with early goal directed therapy: still outcome markers? Clinics 2006;61:47-52. [4] Scale T, Harvey JN. Diabetes, metformin and lactic acidosis. Clin Endocrinol 2011;74(2):191-6. [5] Bailey CJ, Turner RC. Metformin. N Engl J Med 1996;334:574-9. [6] Misbin RI, Green L, Studel BV, et al. Lactic acidosis in patient with diabetes treated with metformin. NEJM 1998;338:265-6. An alternative approach to community consultation for emergency research without informed consent To the Editor, Critically ill or injured patients often cannot give informed consent to be enrolled in clinical trials. In 1996, the US government passed a rule (21 CRF 50.24) [1] to allow research without informed consent in emergency situations. One of the requirements of the rule is “community consultation” (CC), that is, advance disclosure of the research plan with the community where the study will be conducted and solicitation of opinions regarding the acceptability of the research. However, there are no clear definitions or guidance that helps investigators and institutional review boards decide how to perform CC properly. In the past, CC has been done with advertisements in print or electronic media, random dialing surveys [2], and/or town hall meetings [3]. These methodologies may be costly, time consuming, and may be ineffective (for 1 study in a catchment area of 1.5 million only 25 people attended the town hall meeting [4]). Because of these barriers, in recent years, few studies have been done using the rule [3]; and most of this type of research on critically ill patients has been conducted outside the United States. We propose using the emergency department (ED) as the site for CC. This is appropriate because most critically ill and injured patients come to the ED. In addition, the number of annual ED visits in the United States is about one third of the population, so a large number of people are available in EDs for CC, especially if you include friends and family members who come with patients. 837 To explore the feasibility of performing CC in the ED, we distributed pamphlets describing research without informed consent to patients, family members, and staff in the ED of a suburban level I trauma center. To check whether the pamphlets were read and solicit opinions about the acceptability of this type of research, we asked the participants to fill out anonymously a questionnaire in the pamphlet regarding their support for research without informed consent. We used a 5-point Likert scale to analyze the responses and dichotomized the results (strongly agree and agree categories indicate “support”). We compared results among groups (patients, family members, and staff) using the χ2 test (α = .05). Of the 400 questionnaires, 389 (97%) were completed. Of these 29%, 19% and 52% were from patients, family members, and staff, respectively. Women comprised 53%, and 79% were whites. The average age was 46 ± 16 years. Of the responders, 95% supported research without informed consent, 54% would volunteer themselves for such research, and 79% would volunteer a family member. Differences among the 3 groups were not statistically significant (P = .36). Printing the pamphlets costs $250. We found a high level of support for research without informed consent and suggest a method for doing CC efficiently in the ED. We believe that this should satisfy the CC requirement under rule 21 CRF 50.24 and will allow more studies on critically ill patients to be done in the United States. George Perdrizet MD, PhD Department of Surgery Morristown Medical Center Morristown, NJ 07962, USA Barnet Eskin MD, PhD John Allegra MD, PhD Department of Emergency Medicine Morristown Medical Center Emergency Medical Associates Research Foundation Morristown, NJ 07962, USA E-mail address: [email protected] Melissa Kraynak Department of Emergency Medicine Morristown Medical Center Morristown, NJ 07962, USA Scott Shapiro BS Catherine Pocoroba MS, PA-C Francis Simons BS, MS Department of Surgery Morristown Medical Center Morristown, NJ 07962, USA doi:10.1016/j.ajem.2011.04.022