The most notable acute effects of CS are lacrimation, ocular pain, and blepharospasm.Skin discomfort is also common, and skin erythema and blistering have been seen in rare instances of prolonged exposure.CS also produces irritant effects on other mucosal surfaces and can produce pulmonary symptoms of subjective dyspnea, coughing, and rarely bronchospasm.A number of topical decontamination agents have been proposed for use after OC and/or CS exposure, including proprietary mixtures sold commercially for decontamination purposes. Despite advertising claims of efficacy, none of these products to the authors’ knowledge have been demonstrated to be effective in the published literature to date. The results of this study indicate that the use of baby shampoo as a decontamination agent after OC and CS exposure provides no better or faster relief from acute symptoms than water irrigation alone. These findings are consistent with a previous study of several potential decontamination agents for OC exposure, including Maalox®, 2% lidocaine gel, milk, and baby shampoo, compared to water irrigation alone.That small but well-done, prospective, randomized study included 10 subjects in each group and did not suggest efficacy for any of the agents studied. The present study confirms and expands on that work by adding a larger group of 40 OC-exposed subjects with serial post-exposure symptom assessments and by extending the evaluation to 18 subjects exposed to CS as well.Those researchers found that a Maalox®-impregnated, topical dressing provided a small amount of pain relief compared to a saline impregnated dressing.
As acknowledged by the authors, their small study has limited clinical application,grow rack as it did not include ocular or mucosal exposure to OC, as typically occurs in law enforcement or self-defense uses. Both pepper spray and tear gas are known to be generally safe and effective in modifying the behavior of criminal suspects and crowds.Their use will likely remain common for the foreseeable future in law enforcement and self-defense settings, and for crowd control. Although these agents rarely produce significant injuries, illness, or fatalities, they are profoundly uncomfortable. Medical and public safety personnel must remain diligent in screening and identifying the minority of exposed subjects who do suffer medical complications, and they should be familiar with the effects of these agents and with appropriate post-exposure decontamination and treatment procedures. There are several limitations to this investigation. The amount, frequency, and specific method of shampoo application could not be fully standardized in the participants. While a practical and realistic approximation of real-world utilization, it is possible that this intuitive application method did not optimally deliver the shampoo to the eyes or elsewhere and that another method of application could provide additional relief. We assessed only two parameters of discomfort for each type of exposure. These parameters were chosen based on prior experience and reports, and this was an intentional decision based on concern that assessment of numerous parameters would result in global rather than specific discomfort ratings in subjects experiencing marked acute discomfort. Subjects were permitted to leave the decontamination area at their own discretion when they felt ready to continue with their training per traditional training practices; most left prior to the 10- or 15-minute assessment point, leaving few data points and wide confidence intervals at this time point. Future iterations of this study should include mandatory participation throughout the assessment period to counter this.
In addition, future studies with similar methods may use the standard deviations in discomfort ratings that we observed among participants in calculating needed sample sizes. Small sample sizes in this study limited the ability to assess small differences in discomfort ratings. It was not possible to blind the investigators or participants to the agent they received, as an inert lathering agent was not available and may have confounded results if used. It was felt that the prospective, randomized, controlled trial design was the best counter to this limitation. Lastly, the possibility of a placebo effect should not be discounted; individuals who use a “special” decontamination agent to address their discomfort may have an expectation that their symptoms, no matter how severe, are less than what they might experience had they not used the decontamination agent. This expectation may result in belief that the agent is effective based on personal experience.Disparities in health outcomes between insured and uninsured patients have been demonstrated throughout medicine1 and in various surgical settings including trauma and emergency surgery.Insurance-related disparities in trauma outcomes are unique, given that the Emergency Medical Treatment and Active Labor Act “ensures public access to emergency services regardless of ability to pay.”Recent studies have shown insurance-related disparities in outcomes after both blunt and penetrating trauma,with consistently increased mortality for uninsured patients.Despite a growing body of literature demonstrating disparities in trauma outcomes on the basis of race and socioeconomic status, causal mechanisms are poorly understood.While the causal mechanisms of worsened outcomes for uninsured patients after trauma remain unclear, we saw Affordable Care Act -related healthcare expansion as a natural experiment. The ACA was designed in part to provide access to care for many of the nation’s uninsured; given increased mortality for the uninsured following trauma, we expected a concomitant decrease in mortality. Patients may have experienced improved outcomes after enactment of the ACA due to greater access to higher quality hospitals, improved inpatient care, or improved rehabilitation care in the hospital or beyond.
While the ACA provides a potential opportunity to reduce disparities in care and outcomes, results have thus far been mixed.A recent study surprisingly suggested an increase in trauma mortality after Massachusetts healthcare reform.It is unclear if this effect will be seen nationwide, especially in light of the bulk of previous literature showing poorer outcomes for uninsured trauma patients when compared to their insured counterparts.In Illinois,microgreens shelving the ACA led to a 24% decrease in the uninsured population, though its impact on insurance-related trauma disparities has yet to be determined.The primary aim of this study was to determine the impact of ACA-related insurance expansion on trauma mortality in Illinois. The secondary aim was to determine the remaining insurance-level effects of the ACA on trauma mortality in Illinois. Our results demonstrate that the patients who remained uninsured after ACA implementation in Illinois had a disproportionately high mortality after trauma. While the ACA related insurance expansion significantly decreased the number of uninsured adults in Illinois, we did not find a significant decrease in overall trauma mortality after the expansion. Our data support prior studies that have shown that being uninsured is an independent predictor of mortality after trauma.It might be hypothesized that these differences in mortality are due to mechanisms of injury, which can lead to differential mortality. Penetrating trauma is associated with high mortality rates;however, recent studies have shown that even among patients with blunt injuries alone, uninsured patients die at a higher rate.Many additional factors have been shown to affect mortality of patients presenting with trauma. The ACA has provided increased coverage for the uninsured in the form of Medicaid expansion for adults up to 138% of the federal poverty level and the Health Insurance Marketplace, which provides access to insurance plans for those who do not qualify for Medicaid.Our study demonstrates that this program effectively reduced the number of uninsured patients in Illinois, confirming findings from prior studies.We hypothesized that if insurance is truly an independent predictor of trauma mortality, then mortality rates should fall after ACA-related insurance expansion, bearing in mind that many of the individual improvements in health status associated with insurance coverage may not be fully realized until years after the initial intervention. However, if hospital and provider factors were the major drivers of insurance-related disparities in outcomes, then we would expect a decrease in trauma mortality after ACA. Osler et al. found that healthcare reform in Massachusetts paradoxically increased overall trauma mortality.While there was no significant change in overall trauma mortality after ACA insurance expansion in our study, we found that those patients who remain uninsured appear to suffer significantly higher mortality after ACA implementation. We are not suggesting that the ACA is causing a rise in mortality among the remaining uninsured patients as might be inferred from Figure 4, but rather we believe the group that remains uninsured after ACA healthcare expansion is suffering an unusually high burden of trauma-related mortality. Scott et al. suggested that since young people who benefit from the dependent healthcare expansion are mostly children of insured adults there would be increased disparities between the newly insured and the uninsured.At least a proportion of the increased mortality in our remaining uninsured population may be attributable to this phenomenon.
Unmeasured factors are likely contributing to this increased burden of mortality as well. The insurance-related disparities observed in this study may reflect patient factors, hospital or provider factors, or unknown or unmeasured confounders.Unmeasured host-level cofounders in this study that could contribute to the undue burden of mortality in this group include obesity,homelessness,and immigration status.Volume quartiles indicate average yearly inpatient hospital trauma volume over the study period. Reference groups are provided in parentheses. Table 2. Regression model evaluating effects of post-ACA* period and covariates on inpatient trauma mortality in Illinois. remaining uninsured. Better understanding of the underlying reasons for this increased mortality may lead policymakers to enact policies to reduce the disparity between patients who are insured and those who remain uninsured. The guidelines published by the National Health Lung, Blood Institute , and endorsed by the American Academy of Emergency Medicine, detail an acute pain algorithm.When possible, the NHLBI guidelines recommend treating pain associated with VOC using patient-specific protocols, as well as patient-controlled analgesia, aggressively treating pain plus reassessing the patient’s pain and level of sedation every 15-30 minutes. The NHLBI acute pain algorithm recommends treating acute pain in a day hospital or another short-term stay hospital setting such as an observation unit first, before considering hospital admission for uncomplicated VOC.The need for frequent hospital admission for patients with SCD and its association with premature death has been cited as a major concern for these patients.Readmission for patients with SCD within 30 days of the index visit has been cited as a concern.The U.S. 30-day readmission rate for Medicare patients with an index admission averaged 18.4% in 2012, down from 19% in the five years prior.The Centers for Medicare and Medicaid are beginning to monitor and will ultimately penalize hospitals for excess re-admissions within 30 days for the same diagnosis. In 2010, sickle cell anemia ranked number one, at 31.9%, for the percentage of patients readmitted within 30 days of an index visit.7 Opportunities to decrease admissions for patients with VOC have been demonstrated by use of a DH model.In this model, a hospital will dedicate space and staffing to provide care for patients experiencing a VOC, outside of the emergency department or an inpatient bed. While a feasible model, there are logistical issues to implementing this model on a national level, especially for small hospitals. Alternatively, 36% of hospitals in the U.S. have implemented an ED observation unit ,which may prove an alternative to hospital admission and treatment in a DH. The use of an EDOU for the treatment of VOC has been recommended for patients with continued pain, but without another indication for hospital admission.Transferring patients from an ED to the EDOU allows for more time to resolve the VOC and possibly avoid hospital admission. In the context of a two-center quality improvement project designed to implement best practices for the ED management of patients with complications of sickle cell disease,we had a unique opportunity to prospectively examine the impact of different utilization rates of DH care, and/or EDOU care on rates of hospital admission for patients with sickle cell anemia experiencing VOC. We also had the opportunity to assess ED encounters and hospitalizations for our two cohorts of patients at outside centers within a 20-mile radius of each study site, an aspect of care rarely reported on. The objectives of this prospective study were to 1) estimate and contrast the acute healthcare utilization of two patient cohorts with sickle cell anemia presenting to one of two academic medical centers, and 2) assess acute care utilization of these cohorts seeking care at outside hospitals, within 20 miles of the home specialty centers.