Decontamination is crucial but is a very difficult art, as the mustard gas lingers on skin and clothing and easily passes through regular Surgical gloves. Specialized gloves with charcoal filters designed by the military should be used, if available, or health care workers are likely to get contaminated.

At a default, a hot shower is dangerous; this can promote mustard gas formation and cause further topical absorption. Many methods of decontamination have been tried. Use of 0.5% regular household bleach can be used. Some have used powdered milk, talcum power, flour, and activated charcoal slurry. Mustard is fairly insoluble in water alone. The military have specialized kits with compounds that either absorb mustard or inactivate it; involved as they have been in war in the Middle East, they consider mustard gas poisoning a risk of major potential and have worked accordingly. The author would suggest that, if you are without military gear and aids and feel that you might genuinely need them, you consider calling an excellent civilian offshoot of the military, the Chemical and Biological Defense Information Analysis Center in Maryland.

7. Conclusion

In summary, terrorist chemical attack is not implausible, and the range of toxic agents is rather intimidating. Decontamination appears key to helping all victims. From the start, the nurse and physician first seeing the patient must also play both verbal and clinical detective: What happened? When did it happen? Where were you when it happened? Was there a smell or taste you could identify? What seems most affected? Is there difficulty breathing, skin blistering, or Neurological examination abnormalities? Pay careful atten- tion to the eyes, the lids, and the pupils. Be ready to call and ask other EDs if they are seeing similar cases and be careful always that you yourself do not become contaminated and end by merely adding to the line of patients needing treatment. Frankly, with due respect to both state and federal authorities, television channels such as CNN and MSNBC love disasters because they sell well and seem to get personnel to the scene faster than official spokespeople. One may get clues from other patients shown on television. Finally, it should be noted that not only civilian but also military data strongly suggest remembering that one is dealing with a terrified group [16] and that every effort to make victims feel properly attended to, respected, and treated with care is critically important. Friendly, organized care takes the teeth out of terror.

Acknowledgment

The author would like to acknowledge Heyward Isham, former director, Intelligence and Research (INR), USDOS, for teaching how to think like the adversary.

Thomas E. Goffman MD Cancer Intelligence and Research (C-INR) Virginia Beach, VA 23455, USA

E-mail address: [email protected] doi:10.1016/j.ajem.2009.04.001

References

1. http://en.wikipedia.org/wiki/Bhopal_disaster as accessed 3/11/09.
2. http://www.wdtv.com/home/ticker/11142756.html as accessed 3/4/09.
3. McGregor A. Unmasking terror IV. Washington (DC): Jamestown Foundation; 2008. p. 13.
4. Ohbu A, Yamashina A, Takasu N, et al. Sarin poisoning on Tokyo subway. South Med J 1997;90:587-93.
5. http://frwebgate.access.gpo.gov/cgi-bin/get-cfr.cgi?TITLE=40&- PART=355&SECTION=50&YEAR=2001&TYPE=TEXT as

accessed 2/25/09.

1. http://www.atsdr.cdc.gov/cercla/07list.html as accessed 2/25/09.
2. Roy MJ. Physician’s guide to terrorist attack. New Jersey: Humana; 2004. p. 253-336.
3. “Iraq gas attack makes hundreds ill” as accessed 3/15/09.
4. Sidell FR, Takafuji ET, Franz DR, editors. Textbook of military medicine: medical aspects of chemical and biologic warfare. Washington DC: Borden; 1997.
5. Central Intelligence Agency Unclassified Semi-Annual Report to Congress on the acquisition of technology relating to weapons of mass destruction and advanced conventional weapons. 1 January-30 to June, 2001. GPO, Washington DC; 2001.
6. http://www.cyanidepoisoning.org/pages/identify_poison.asp as accessed 3/5/09.
7. http://ccc.apgea.army.mil/products/handbooks/mmccthird edition- jul2000.pdf as accessed 3/5/09.
8. www.cbrniac.apgea.army.mil as accessed 3/5/09.
9. http://emergency.cdc.gov/agent/riotcontrol/; http://www.wikihow. com/Deal-With-Riot-Control-Agents; http://www.fas.org/nuke/guide/ usa/doctrine/dod/fm8-9/3ch7.htm all accessed 3/5/09.
10. Borak J, Diller WF. Phosgene exposure: mechanisms of injury and treatment strategies. J Occup Environ Med 2001;143:110-9.
11. http://www.ecbc.army.mil./hld. and http://cbiac.apgea.army.mil/. Accessed 3/5/09.

Building an effective ED Influenza vaccine program

To the Editor,

Influenza virus infections are responsible for approxi- mately 36,000 deaths and 200,000 hospitalizations in the United States yearly [1-3]. The burden for this preventable disease is staggering, especially if consideration for loss of work and quality of life are added to the health care cost [4-6]. For more than 20 years, the emergency department (ED) has been discussed as a site for the development of vaccination programs [7]. Studies have been done that discuss many parameters, including feasibility, barriers to success, staff attitudes, patient willingness to receive the vaccine in this environment, and cost-benefit ratios [8-13]. Less commonly found in the literature are examples of successfully implemented ED influenza vaccine initiatives

Table 1 Planning and yearly influenza program modifications with outcomes

Time period Planning and changes implemented Outcome measures Preparation Self-select nurse and physician champion.

Define population to be served.

Educate nurses and physicians. Meeting attendance records

Develop alliance with health department for patient (pt) educational materials and vaccines.

First year Centers for Disease Control and Prevention guidelines followed for pts with exceptions:

If the pt had a primary care physician, the pt was referred to him/her.

Minors were referred to pediatrics. Residents of skilled nursing facilities (SNFs) were not screened.

Women who were pregnant were referred to their obstetrician.

Pts given screening form (Fig. 1) in triage Screening form reviewed by bedside nurse Bedside nurse gave immunization and information sheet (Fig. 2).

Public recognition of participating staff via e-mail and at meetings

No negative feedback for nonparticipating staff

Second year CDC guidelines followed with same exceptions as those in the first year

Vaccines given by standing order Family members could be included.

Negotiated vaccine supply for 2 y 283 pt vaccines administered

Total of 633 vaccines given: 282 pt vaccines, 351 to EMS/pt/families

EMS providers were offered service. Unanticipated positive response from

Two screening forms used (one for pts, one for other categories)

Staff incentives expanded to include nominal gift cards and rewards

Staff allowed to include their families in vaccination program

Third year CDC guidelines with exceptions of SNF and pregnant pts

Minors >=12 y were included

Pts with primary care physicians were vaccinated

Subsequent years

Minors >=9 y were included in the program. Nurses prepare vaccines at the beginning of shifts to anticipate need.

Vaccines given to walk-in community members Network begins non-ED-based “drive thru” vaccine program

To be consistent in documentation with “Drive Thru Program,” the current screening form

(Fig. 1) used for all vaccines was given, and the cost of ED-administered vaccines was absorbed by the network.

Total staff incentives ($10 increments) were $200.

EMS providers

Yearly trend of expanding eligibility increases vaccination

Year 5: First year that N1000 vaccines were given

12,000 vaccines given in 2008

Total program existence No pt, family, or community complaints

No complaints from other providers

No quality improvement cases generated No malpractice claims initiated

No staff complaints to nursing supervisor No additional staff hired for these tasks No length-of-stay issues identified

[14,15]. Seemingly, the move from conceptualization to actualization has been slow, and rates of influenza vaccina- tions in the ED are too small to permit estimation of a national total [16]. Reasons for this disconnect between burden of disease and ED preventive practices can be overcome. We set out to show how an effective vaccine campaign can be developed and use our own hospital’s 7-year history as a model of success.

This project was initiated in 2002 at an urban teaching ED with an annual census of 23,500. Payor mix then was 20% self- pay, 40% medical assistance (MA), 9% medicare, 11% managed care, and 20% private insurance. No other preventive health initiatives were in existence. For a prior study [17], staff had been surveyed about attitudes, and most (81%) agreed that they should facilitate prevention of disease. See Table 1 for program preparation and yearly modifications. For 7 years, we have interfaced with our community and provided a service that has not been accepted as standard of care for emergency medicine. One of the unanticipated benefits has been the positive response from emergency medical service (EMS). It was unrecognized that in our community, no effective mechanism for immunizing this vulnerable group existed. In addition to EMS participation, successes seem to be dependent on accessible vaccine supply, allowing staff participation to be optional and treating the family as a unit (not just immunizing the patient). This report is a summation of a public health initiative.

The subsequent limitations are noted. Participation in the program from a patient, nurse, or physician perspective was voluntary. There are few data measurements. It is not possible for us to generate the percentage of patients who presented who were not screened, those eligible patients who were screened, or those who were screened appropriately but did not receive a vaccine. The demographics of the patients who received the vaccine are not known. We cannot illustrate the demographics of the recipients who were not patients who received a vaccine. With these gaps in measurements not withstanding, we feel the successes of each patient that was vaccinated without sequelae warrants this commentary. As a nonprofit hospital, we use the total vaccines delivered as a part of the annual community benefit to maintain our nonprofit status. What works for us may not be applicable for others where payor mix, severity of illness, staff attitudes, or medical staff responsiveness might not be similar. The authors would encourage EDs implementing a vaccine initiative to contact the health bureau to see what arrangement for vaccine contributions could be made. Even if this option is not available, the vaccine cost pales in comparison with the cost of an admission that could have been prevented or ED resources that could have been spared during high-volume season. This is especially true in the dynamically changing ED. For example, at this site, in the 7-year time period discussed, the volume of patients increased by 32% with a payor mix shift, which revealed an increase in self-pay patients and in the percentage of

patients covered by public assistance.

Length of stay in the same 7-year period has been scrutinized. It is unclear why there have not been changes in length of stay, but we believe that it is a combination of the following: Staff are more likely to be attentive to screening results in low-volume times, parallel processing design of the program allows for this phenomena, and actual administra- tion of vaccine requires only a minute of nursing time.

Influenza increases ED visits and exacerbates overcrowd- ing during winter months. When staff were educated about the program, one of the key components reinforced was that each patient immunized on their current visit would be one less seen in their busiest months. It was hoped that that this program would help diminish the demand for ED services for at-risk people and frequent ED visitors. Most importantly, whatever barriers to performance that were or were perceived to be in existence have, at least partially, been overcome.

The authors hope that with reports like these, which demonstrate even modest successes, the profession can move forth from conceptualizing the possibility of influenza programs in the ED to engaging in these initiatives routinely.

Marna Rayl Greenberg DO Gavin C. Barr, Jr. MD Richard S. Mackenzie MD Alex M. Rosenau DO Kevin R. Weaver DO Michele Ortiz RN

Department of Emergency Medicine Lehigh Valley Hospital and Health Network

Allentown, PA 18103, USA E-mail address: [email protected]

doi:10.1016/j.ajem.2009.04.003

References

1. Keren R, Zaoutis TE, Saddlemire S, Luan XQ, Coffin SE. Direct Medical cost of influenza-related hospitalizations in children. Pedia- trics 2006;118(5):e1321-7.
2. Thompson WW, Shay DK, Weintraub E. Influenza-associated hospitalizations in the US. JAMA 2004;292:1333-40.
3. Thompson WW, Shay DK, Weintraub E. Mortality associated with influenza And respiratory syncytial virus in the United States. JAMA 2003;289:179-86.
4. Mc McBean AM, Babish JD, Warren JL. The impact and cost of influenza in the elderly. Arch Intern Med 1993;153(18):2105-11.
5. Me Menec VH, Black C, MacWilliam L, Acki FY. The impact of influenza-associated respiratory illnesses on hospitalizations, physi- cian visits, emergency room visits, and mortality. Can J Public Health 2003;94(1):59-63.
6. Modlin JF, Snider DE, Brooks DA, Clover RD, Fleming DW, Guerra FA, et al. Use of standing orders programs to increase adult vaccination rates. MMWR 2000;49(RR01):15-26 Accessed 11/21/2008:http:// www.cdc.gov/mmwr/preview/mmwrhtml/rr4901a2.htm.
7. Polis MA, Davey VJ, Collins ED, Smith JP, Rosenthal RE, Kaslow RA. The emergency department as part of a successful strategy for increasing adult immunization. Ann Emerg Med 1988;17(10):1016-8.
8. Rodriguez RM, Baraff LJ. Emergency department immunization of the elderly with pneumococcal and influenza vaccines. Ann Emerg Med 1993;22(11):1729-32.
9. Wrenn K, Zeldin M, Miller G. Influenza and pneumococcal vaccination in the emergency department: is it feasible? J Gen Intern Med 1994;9(8):425-9.
10. Kapur AK, Tenenbein M. Vaccination of emergency department patients at high risk for influenza. Acad Emerg Med 2000;7(4):354-8.
11. Rimple D, Weiss SJ, Brett M, Ernst AA. An emergency department- based vaccination program: overcoming the barriers for adults at high risk for vaccine-preventable disease. Acad Emerg Med 2006;13(9): 922-30.
12. Chiasson AM, Rowe P. Administering influenza vaccine in a Canadian emergency department: is there a role? CJEM 2000;2(2):90-4.
13. Fernandez WG, Oyama L, Mitchell P, Edwards EM, St George J, Donnovan J, et al. Attitudes and practices regarding influenza vaccination among emergency department personnel. J Emerg Med 2008 [Electronic publication ahead of print].
14. Slobodkin D, Kitias J, Ziefske P. Opportunities not missed- systematic influenza and pneumococcal immunization in a public inner-city emergency department. Vaccine 1998;16(19):1795-802.
15. Pearon E, Lang E, Colacone A, Farooki N, Afilalo M. Successful implementation of a combined pneumococcal and influenza vaccina- tion program in a Canadian emergency department. CJEM 2005;7(6): 371-7.
16. Pailin DJ, Muenning PA, Emond JA, Kim S, Camargo CA. Vaccination practices in U.S. emergency departments. Vaccine 2005; 23(8):1048-52.
17. Greenberg MR, Weinstock M, Gaston Fenimore D, Sierzega GM. Emergency department tobacco cessation program: staff participation and intervention success among patients. J Am Osteopath Assoc 2008; 108(8):391-6.

The diagnosis of renal lesion from acute uncomplicated pyelonephritis in the ED

To the Editor,

Uncomplicated infections of the high urinary tract with Renal damage may cause permanent impairment of the renal function. In the emergency department (ED), assessing whether an infection of the upper urinary tract has involved the renal parenchyma is problematic. Undesired conse- quences are either an underestimate of the extension of the infection or the submission of too many patients with a limited infection to useless and expensive Diagnostic and therapeutic procedures [1]. The missing diagnosis causes concern, given that even small parenchymal scars can lead to renal failure, particularly in the presence of analgesic abuse or congenital anomalies [2]. Radiological evidence of an extension of the infection to the kidney dramatically changes both the therapeutic approach and follow-up. The upper urinary tract infection (UUTI) without renal damage consists of a superficial infection at a site where it is relatively easy to reach high concentrations of antibiotics [3]. On the contrary, infection extended to the renal parenchyma (pyelonephritis [PN]) affects tissues located in depth, where natural defenses are less efficacious because of a hostile physicochemical milieu, and many antibiotics have limited possibility to spread around [3]. Thus, antimicrobic therapy to eradicate the infection should be quite different for UUTI and PN.

The main purpose of our work is to assess the accuracies of clinical symptoms, physical findings, history, and

History criteria Signs

Pain or burning at micturition Evoked lumbar pain Superpubic pain Abdominal pain Flank pain Hematuria (stick) Lumbar pain or feeling of heaviness Pyuria Fever Bacteriuria (stick) Nausea and vomit Fever

“Classical” symptoms include fever, renal pain, and symptoms mimicking cystitis.

diagnostic tests in the identification of acute PN in the ED. Secondarily, we intend to assess the accuracy of contrast- enhanced ultrasound (CEUS) compared with magnetic resonance for the recognition of the acute renal lesion. The present letter reports preliminary findings of our study.

Table 1 Anamnestic criteria and signs used to screen patients with suspicious infection of the upper urinary tract in the ED

Prospective evaluation of all patients attending the ED of San Luigi Gonzaga University Hospital in Torino, Italy, between May 2005 and June 2006, allowed identification of 54 patients exhibiting symptoms of UUTI. The diagnostic suspicion was based on the presence of at least one of the “classical” items, in addition to at least one of the other items listed in Table 1. After recording of history data and clinical findings, each patient underwent routine blood and urine analyses, Conventional ultrasound (US) of the kidney and bladder (Siemens Sonoline G50, convex 3.5-5 MHz probe). Patients exhibiting factors that might predispose to acute secondary PN were excluded (Table 2). In 23 patients, the suspicion of primary upper urinary infection was confirmed through criteria listed in Table 3. Within 24 hours, these patients were submitted to renal MR. Within 12 hours, 8 patients underwent CEUS: They had been selected randomly, according to the availability of the staff of the ED radiology unit (contrast SonoVue, Bracco, Italy; Sonoline Elegra,

Table 2 Factors predisposing to acute complicated or secundary pyelonehrytis

Predisposing factors

Urinary tract obstruction Neurogenic bladder renal stones

Congenital morphological malformations Analgesic abuse

Diabetes Pregnancy

Immunosuppression Bladder-Ureter reflux Polycystic kidney Renal transplant

Invasive diagnostic measures Surgery

Tumors of the kidney or urinary tract

Fig. 1 Screening and consent for influenza vaccination.

Fig. 1 (continued)

Fig. 2 English and Spanish immunization information sheets.

Fig. 2 (continued)

Fig. 2 (continued)

Fig. 2 (continued)