IntroductionThe emergency psychiatric care is system is overburdened in the United States. Patients experiencing psychiatric emergencies often require resources not available at the initial treating facility and frequently require transfer to an appropriate psychiatric facility. Boarding of psychiatric patients, defined as a length of stay greater than four hours after medical clearance, is ubiquitous throughout emergency departments (EDs) nationwide. Boarding is recognized as a major cause of ambulance diversions and ED crowding and has a significant adverse impact on healthcare providers, patient satisfaction, and hospital costs. We sought to identify differences between patients who boarded versus patients who did not board, to identify factors amenable to change and identify interventions that could lead to a decrease in overall psychiatric patient length of stay and improve patient care.MethodsThis study is a retrospective multicenter cohort study of all patients assessed to require inpatient psychiatric hospitalization at two community EDs in Illinois from July 1, 2010 through June 30, 2012. We identified 671 patients and collected insurance status, sex, age, time of arrival, time of disposition and time of transfer.ResultsThere was a statistically significant difference in the insurance status between the cohort of patients boarding in the ED compared to non-boarders prior to inpatient psychiatric admission. Our study identified 95.4% of uninsured patients who were boarded in the ED, compared to 71.8% of Medicare/Medicaid patients and 78.3% of patients with private insurance (χ2=50.6, df=2, p<0.001). We found the length of stay to be longer for patients transferred to publicly funded psychiatric facilities compared to those transferred to private facilities, with a mean time spent in the ED of 1,661 minutes and 705 minutes, respectively (p<0.001). Patients with Medicare/Medicaid were nearly twice as likely to return to the ED for psychiatric emergencies than self-pay and privately insured patients, requiring repeat inpatient psychiatric admission (estimate=0.649, p=0.035, OR=1.914).ConclusionThis study found that unfunded patients boarded significantly longer than Medicare/Medicaid and privately insured patients. Patients with private insurance boarded longer than those with Medicare/Medicaid. Patients transferred to publicly funded facilities had significantly longer ED length of stay than patients transferred to private facilities.

In recent years, hookah bars have gained in popularity, especially in urban areas and around college campuses. This was the first case to identify the potential occupational exposure of employees working at hookah bars to CO. Furthermore, the patient's COHb level of 33.8 % was higher than any previously reported in the literature with exposure via hookah pipe. The practitioner should consider CO poisoning in patients who smoke tobacco via a hookah and consider early hyperbaric oxygen therapy in those experiencing significant symptoms.

Celiac artery compression syndrome, also called median arcuate ligament syndrome (MALS), is a rare condition in which the diaphragmatic crura compresses the celiac axis. This results in a constellation of primarily gastrointestinal (GI) symptoms including nausea, vomiting, postprandial abdominal pain, and weight loss. It is typically a diagnosis of exclusion and may be detected via several imaging techniques including ultrasound and computed tomography angiography. We present an atypical case of MALS detected in the emergency department (ED). We review the symptomatology, diagnostic workup, and treatment options here, as well as discuss implications concerning revisits to the ED for recurrent GI symptoms.

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Seeds from the mangrove plant Cerbera (C.) odollam, known as the “suicide tree,” are responsible for a significant number of plant deaths worldwide but are not well recognized in Western medicine. Cerberin is a cardiac glycoside concentrated in the plant’s seeds, which causes disrupted cardiac electrical activity leading to fatal dysrhythmias. We present a fatal case of intentional C. odollam seed ingestion. The patient experienced high-degree heart block and cardiac arrest despite supportive treatment and digoxin immune fab administration. Clinicians should be aware of the potential morbidity and mortality associated with C. odollam poisoning and be prepared for resuscitative interventions.