Re: ‘Toxicology Answer: An Illustrated Case of Ethylene Glycol, Direct and Indirect’

On behalf of my colleagues (Dr. Shenoi and Dr. Filip), I offer our letter to the editor responding to misconception in Dr. Hack’s recent case report of ethylene glycol poisoning. In his case report, Dr. Hack strongly recommended using UV light from Wood’s lamp to examine the urine for fluorescence. Dr. Hack included the published evidence against this approach and then again recommended this. We believe that this “test” is useless and misleading. We disagree with his endorsement of this approach. We also take the opportunity to point out one of the indirect clues (apparent lactate elevation), which we assert is more useful. We hope for your favorable consideration to publish our comments on Dr. Hack’s case report. We welcome his reply, if he so chooses.

—Michael Mullins, MD, FACEP, FAACT

Re: ‘A Seven-Step Approach to Massive Hemoptysis’

I enjoyed the article by Dr. Helman on Massive Hemoptysis and would like to add some suggestions. If a focal source of bleeding can be determined (by CXR or bronchoscopy) then specific interventions can be done to isolate the bleeding segment/lobe/lung while still safely ventilating the uninvolved lung. A left mainstem intubation with a standard ETT (but possibly requiring broncoscopic guidance for correct placement) isolates a right-lung source of bleeding but while a right mainstem intubation is easy to achieve blindly and isolates a left-lung bleed, it unfortunately is difficult to position the ETT without also blocking the right upper-lobe bronchus. A better strategy for left-lung bleeding is to position a balloon-tipped catheter, such as a Fogarty, into the left mainstem bronchus (or further into either LUL or LLL bronchi if the specific source of bleeding is confined to one lobe) and keep the ETT in the standard tracheal position. Double-lumen ETT are not recommended for lung isolation during pulmonary hemorrhage as they can be challenging to position optimally (and keep in place) and do not offer lumens large enough for bronchosopy or even appropriate sectioning.

—Joseph Shiber, MD, FACEP, FACP, FCCM

Re: ‘Tackling Emergency Department Crowding’

Until we solve the post-acute care shortage, we’re doomed.

—Chuck Pilcher, MD

Re: ‘VACEP Legal Victory Illustrates Why the Prudent Layperson Standard Still Matters’

Great article that showcases the vigilance and tenacity needed to protect patient access and to ensure reimbursement for PLP services. A victory of patients, families, hospitals and ED physicians.

—Susan Nedza, MD, MBA, FACEP

Re: ‘Your Employer Should be an Open Book’

When I look for a job, I am concerned about adequate staffing and an accurate volume. Many recruiters are given a volume and you start and the volume is 50 percent higher. Also, there should be an orientation, but sometimes to a new department there is little or none. Is it a toxic environment? Many things like, “what if the ICU is full,” [we] are not oriented to. Can you get a stat consult for a specialist? What if the hospitalist refuses to admit? An attending emergency physician needs to know [these things]. Our patients always come first and [for us] to deliver the best care. You get the feeling that what the recruiter only wants is the commission. They should want us to be satisfied with the job.

—Steven M. Winograd, MD, FACEP

Re: ‘How To Identify and Work With Neglected Children in the ED’

As a retired PEM physician, I want to thank the authors for this excellent reminder that child abuse and neglect includes medical neglect. With today’s fractured and fragmented care, the ED is often the only common point of care for these children. Keep alert to physical signs of abuse and neglect. But also take a few minutes too review the EMR when dealing with frequent flyers with chronic medical conditions.

—Edward Walkley, MD, FACEP, FAAP