Severe Hypochloremic Metabolic Alkalosis

Chloride is the most abundant negative charge ion in extracellular fluid. In plasma it combines with sodium as sodium chloride and with potassium as potassium chloride. Chloride also is found with hydrogen as hydrochloric acid in the stomach. Although chloride was the first electrolyte to be easily measured, it has been considered often the least important of the major electrolytes because of its attachment to both sodium and potassium. There were lot of research and report about electrolyte imbalance, however it was difficult to find the clinical report about hypochloremia. We recently managed a patient with pyloric stenosis who was admitted to ICU with severe hypochloremic metabolic alkalosis. He was treated with hydration of normal saline and conservative management. Metabolic alkalosis and severe hypochloremia were improved and the patient was discharged on ICU 3 days.ope

A Diagnostic Utility of Fitz-Hugh-Curtis Syndrome by Using contrast Enhanced Abdominopelvic Computerized Tomography

Purpose: Fitz-Hugh-Curtis (FHC) syndrome is characterized by right upper quadrant pain due to perihepatitis with pelvic inflammatory disease (PID). It is diagnosed by using its typical symptoms, but final diagnosis is made by confirmation of the presence of laparoscopically visualized perihepatic violin string like adhesions. However, laparoscopy is difficult to perform in the emergency department. Recently, on computerized tomography (CT) a linear enhancement of the liver capsule was detected in a patient with FHC syndrome. We present a review of a series of 11 cases in female of FHC syndrome diagnosed by CT. Methods: We reviewed the medical records and the CT findings of 11 cases of FHC syndrome diagnosed during 7 months in the emergency department. The clinico radiologic criteria of our hospital is as follows: First, right upper quadrant pain. Second, linear enhancement of the liver capsule in the contrast enhancement phase of CT. Third, no pathologic findings for the liver, the gallbladder and the biliary tract in CT. Results: Eleven patients were diagnosed during 7 months by using criteria. The mean age was 30.2 (range: 16~46) years. Seven patients had a history of PID within 6 months. Seven of the 9 patients who take a pelvic examination were positive in C. trachomatis PCR (polymerase chain reaction), and another patient had a positive N. gonorrhoeae cervix culture. One patient who showed negative in both the C. trachomatis PCR and the N. gonorrhoeae cervix culture had cultured E. coli in urine and blood culture. Conclusion: CT makes easy the previously difficult diagnosis of FHC syndrome in female patients capable of pregnancy with right upper quadrant abdominal pain.ope

How many emergency physicians does Korea need?

Purpose: This research used mathematical modeling to project the supply and demand of emergency physicians over the next decade in Korea. Methods: A model was used to project the annual emergency physicians (EP) workforce supply and demand through the year 2015. The mathematical equations used were as follows: Supply = number of emergency physicians at the beginning of the year plus annual residency graduates minus annual attrition; Demand formula I = 5.29 fulltime equivalent positions/emergency department (ED) x the number of hospital EDs, Demand formula II = annual ED visits/(4,700visits/EP/year), Demand formula III = (11 to 16 EP per major referral ED) + (6 to 8 EP per urban district/ regional hospital ED). Results: While the most conservative demand projection was 1,505 EPs in the year 2015, the most aggressive supply estimate with a yearly supply of 120 new EPs and a 1% attrition rate was 1,362 EPs in that year. Conclusion: In Korea, emergency physicians will remain in short supply for the next ten years, even at the present levels of EM residency output.ope

Analysis on the out-of-pocket money of a university inpatients compensated by workers' compensation insurance

산업보건학과/석사[한글]본 연구는 산재보험 환자를 대상으로 의료 이용 시 발생하는 비급여 진료비의 크기를 분석하고 본인부담 진료비에 영향을 주는 요인을 분석하였다. 조사 연구 대상은 모 대학 부속병원에서 2005년 1월 1일부터 2006년 2월 28일까지 입원하여 퇴원한 환자 16,252명을 대상으로 보험종별, 진료 분야별, 다빈도 주요 3개 상병별에 대한 비급여 부분의 본인부담 진료비를 항목별로 타 보험과 비교 분석하였다.조사 연구 결과를 요약하면 다음과 같다.첫째, 요양급여 비용 중 본인부담금은 산재보험 환자가 26.0%, 건강보험 환자 50.1%(법정본인부담 포함), 자동차보험 환자 22.1%로 나타났다. 산재보험 환자의 본인부담금 중 상급병실료 차액이 36.1%로 가장 높게 나타났으며, 다음은 선택진료비 34.1%, 마취수술료 16.3%, 주사약제료 7.0% 순으로 나타났다.둘째, 선택진료비는 산재보험 환자의 경우 전체 본인부담금 중 34.1%를 차지하였고, 자동차보험 환자 25.1%, 건강보험 환자 19.4% 순으로 산재보험 환자가 가장 높게 나타났다.셋째, 상급병실료 차액은 자동차보험 환자가 41.2%로 가장 높게 나타났으며, 다음으로 산재보험 환자가 36.1%, 건강보험 환자 17.2% 순으로 나타났다.넷째, 다빈도 3개 상병의 중증도와 관련된 임상적 특성을 보험종별로 비교하였다. 수술 소요시간이 180분 초과의 경우 산재보험 환자는 25.1%이고, 자동차보험 환자는 14.9%, 건강보험 환자는 10.7%로 산재보험 환자의 경우 수술시간이 3시간을 초과하는 경우가 타 보험 환자에 비해 의미 있게 높았다. 상병 개수의 경우 3개 이상인 경우가 산재보험 환자는 41.1%로 가장 많았고, 이는 자동차보험 환자 27.7%, 건강보험 환자 4.8%보다 통계학적으로 유의하게 높았다.다섯째, 산재보험 환자 중 정형외과 환자 175명을 대상으로 본인부담 진료비의 실제 부담자를 조사한 결과 146명 중 71.9%(105명)가 환자 본인이 지불하였고, 사업주 부담은 23.3%(34명), 환자와 사업주가 공동으로 부담한 경우는 4.8%(7명)로 나타났다.이러한 연구 결과로 볼 때 산재보험 환자의 본인부담금이 높으며, 재해자에 대한 완전 요양 서비스를 지향하고 있는 산재보험의 원칙에서 볼 때 본인부담금 제도에 대한 개선이 시급한 과제라 생각된다. [영문]This study was performed to analysis out-of-pocket money of patient compensated by Workers' Compensation (Industrial Accident Compensation Insurance; IACI) and to be compared with other insurance types; Automobile Insurance (AI) or National Health Insurance (NHI). The study subjects were 16,252 in-patients in a university hospital from 2005.1.1 ~ 2006.2.28. , Out-of-pocket money of three different insurance types were compare in some different aspects; types of insurance, major diagnosis groups, clinical differences in three high frequent diagnoses.The results were as follows;1. IACI patients paid 26.0% total medical fee as out-of-pocket money while AI and NHI patients paid 22.1% and 50.1% respectively as out-of-pocket money.2. The out-of-pocket money of IACI patients consisted of the ward balance (36.1%), special doctors' fee (34.1%), anesthesia and operation surcharge(16.3%), and injection medication fee(7.0%).3. Clinical characteristics related to severity were compared for the most frequent diseases. The cases with more than 180 minutes operational time was 25.1% in IACI, 14.9% in AI, and 10.7% in NHI, so IACI had more long operation time cases. The number of associated diagnosis more than three was 41.1% in IACI cases, and it was , significantly higher than 27.7% in AI cases or 4.8% in NHI cases. These meant IACI cases was more severe than others.4. The out-of-pocket money was paid by injured workers themselves in most cases (71.9%), by employer (23.3%) or by both injured workers and employer (4.8%).According to the above results, IACI system should be considered to lower the out-of-pocket money.ope

Comparison of ringer's lactate soultion and normal saline in the treatment of rhabdomyolysis induced by doxylamine

의학과/석사[한글]횡문근융해증은 독시라민 중독 환자의 5∼57% 정도에서 발생한다고 알려져 있으며 조기에 적절히 치료되지 않으면 급성신부전으로 진행되기에 조기 발견 및 치료가 중요하다. 횡문근융해증의 치료는 수액요법 및 요의 알카리화인데 수액요법에 있어서 생리식염수 또는 링거액을 투여할 것을 권장하고 있으며 현재까지 두 수액은 큰 차이가 없는 것으로 알려져 있다. 연구자는 많은 양의 생리식염수 투여가 과염소성대사산증을 유발할 수 있음에 착안하여 독시라민에 의해 발생한 횡문근융해증 치료를 위한 수액제로서 생리식염수와 링거액의 차이를 비교해 보고자 하였다.연구는 독시라민 중독으로 내원한 97명의 환자 중 다른 약물을 같이 복용한 8명을 제외한 89명 중 횡문근융해증이 발생한 28명(31%)을 대상으로 단일 맹검 무작위 전향 연구로 수행하였다. 횡문근융해증이 발생한 28명은 무작위로 링거액군에 15명, 생리식염수군에 13명을 배정하였다.수액치료를 시작한지 12시간 째의 urine/serum pH는 링거액군에서, serum Na+ 및 Cl-는 생리식염수군에서 유의하게 높았다. 수액치료를 시작한지 12시간 째의 serum K+, creatine kinase(CK)가 정상수치로 회복될 때까지의 시간은 두 군 간에 유의한 차이가 없었다. 중탄산나트륨 투여량 및 이뇨제의 사용횟수는 생리식염수군에서 유의하게 많았다.연구자는 독시라민 중독으로 발생한 횡문근융해증의 수액요법에 사용되는 생리식염수와 링거액을 비교하였다. 생리식염수에 비해 링거액은 중탄산나트륨 투여가 거의 없이도 요를 알칼리화 할 수 있었고 횡문근융해증의 치료기간에도 차이가 없었다. 또한, 다량의 투여에도 불구하고 다량의 생리식염수 투여 시에 나타나는 과염소성대사산증을 보이지 않았다. 이상의 결과에서 독시라민 중독으로 발생한 횡문근융해증 치료에서 링거액은 생리식염수보다 안전하고 유용함을 알 수 있었다. [영문]The incidence of rhabdomyolysis induced by doxylamine intoxication is reported from 5% to 57%. Early detection and treatment of rhabdomyolysis is necessary to minimize kidney damage. Aggressive intravenous hydration with crystalloid fluids such as normal saline or Ringer's lactate solution and urine alkalization is a recommended treatment. But, large amount of normal saline infusion may induce hyperchloremic metabolic acidosis. The purpose of this study was to compare the effectiveness and side effect of Ringer's lactate solution and normal saline in the treatment of rhabdomyolysis induced by doxylamine intoxication.In this 15-months long prospective randomized single-blind study, after excluding 8 patients among 97 doxylamine-intoxicated patients, 28 patients(31%) developed rhabdomyolysis and were randomly allocated to normal saline group(15 patients) and Ringer's lactate group(13 patients) respectively. After 12 hours' aggressive hydration(300 ml/h), urine/serum pH were significantly higher in Ringer's lactate group, serum Na+/Cl- were significantly higher in normal saline group. There were no significant differences in serum K+ level and the time to CK normalization. The amount of sodium bicarbonate administered and the frequency of diuretics administration were significantly higher in normal saline group.Unlike normal saline group, Ringer's lactate group needed little supplemental sodium bicarbonate and did not develop metabolic acidosis. In conclusion, Ringer's lactate is more useful than normal saline in the treatment of rhabdomyolysis induced by doxylamine intoxication.ope

Reactive Airways Dysfunction Syndrome (RADS) from Chlorine Gas Releasing Cleaning Agents

A previously healthy 57-year-old woman with dyspnea and wheezing presented to the emergency department a few minutes after exposure to unknown gas from mixing bleach (sodium hypochlorite) and cleaning agent (hydrochloric acid) at work place. Initial physical examination revealed severe wheezing on both whole lung fields, but the chest radiograph was normal. Arterial blood gas analysis showed only moderate hypoxemia. The patient was treated with oxygen, βadrenergic bronchodilators, antihistamines and corticosteroids, after then symptoms were improved. And the patient discharged against medical advice. We report a rare case of reactive airways dysfuntion syndrome from chlorine gas exposure.ope

The Local Ensemble Transform Kalman Filter (LETKF) with a Global NWP Model on the Cubed Sphere

We develop an ensemble data assimilation system using the 4-dimensional Local Ensemble Transform Kalman Filter (LEKTF) for a global hydrostatic Numerical Weather Prediction (NWP) model formulated on the cubed-sphere. Forecast-analysis cycles run stably and thus provide newly updated initial states for the model to produce ensemble forecasts every 6 hours. Performance of LETKF implemented to the global NWP model is verified using the ECMWF reanalysis data and conventional observations. Global mean values of bias and root mean square difference are significantly reduced by the data assimilation. Besides, statistics of forecast and analysis converge well as the forecast-analysis cycles are repeated. These results suggest that the combined system of LETKF and the global NWP formulated on the cubed-sphere shows a promising performance for operational uses

Consent for Emergency Patients: How Far Must We Go?

PURPOSE: The number of medical malpractice suits on violation of informed consent is on the rise. While the medical community can encourage its members on informing their patients, the legal community has a considerable amount of studies on the subject. However, there has not been any systematic debate on the subject for emergency medical situations. The exemption of informed consent in emergency medical situations seems to be the common notion. Nevertheless, the recently enacted Emergency Medical Services Law mandates the provision of informed consent in emergency medical situations by the emergency medical personnel. Therefore, a systematic research focusing on the informed consent in emergency medical service was necessary. METHOD: This was a qualitative study by survey. The results of the opinions of emergency physicians surveyed was compared to previous studies by the legal community on informed consent. RESULTS: The legal community view informed consent as a legal duty. But the emergency physicians view it as a part of much professionalized medical act, so the professional ethics should guide the acquisition of informed consent. The legal community and the judicial precedents exempted informed consent in an emergency. But the emergency physicians see informed consent in emergency medical service equal to that of any other medical situation, only that it can be delayed. The emergency physicians have to provide an explanation for each step of the process, but the method varies and the unified form of informed consent provided by the law is not suitable. Informed consent should be acquired even in an emergency like cardiopulmonary resuscitation (CPR), but it can be delayed until the end. Professional ethics should guide the initiation of CPR, but the termination of CPR should be under the informed consent. Non-urgent patients should be informed even in an overcrowded emergency room. The duty is not released or relieved solely on the reason that it is the emergency room. CONCLUSION: There is a difference in opinion between the legal and the medical community, but for the benefit of the emergency patients a compromise should reached.ope

A Case of Streptococcal Toxic Shock Syndrome with Myonecrosis due toGroup A β-hemolytic Streptococcus

Streptococcal toxic shock syndrome with myonecrosis is a rapidly progressive process that kills 80% of patients in 72-96 h. Various bullae, hypotension, fever, and evidence of organ failure are late clinical manifestations. The symptoms and signs of myonecrosis can be nonspecific and misleading, not clearly revealing the involvement of deep skeletal muscle. Thus, the challenge to clinicians is to make an early diagnosis and to intervene with aggressive fluid replacement, emergent surgical debridement, and general supportive measures. We describe an presentation of myonecrosis of the lower extremities secondary to group A beta-hemolytic streptococcus infection in a 21-years-old woman. In addition, the patient had no history or evidence of trauma to the affected area.ope