Patients assault

Fernandez, M. (December 18, 2002). A patient assault on anthrax more than a year spent preparing for fumigation of postal plant in D.C. Washington Post, Section A, p.l. 

Many patients receive lengthy courses of antibiotics that probably should not have been started. More than half of courses of antimicrobial chemotherapy are inappropriate. Influenza pneumonia and viral upper respiratory infections, for example, are impervious to assault by antibiotics, although many patients with these illnesses receive such antibiotics. Of course, influenza may be complicated by postinfluenzal staphylococcal pneumonia, for which antibiotics are indicated. Careful sequential evaluation of seriously ill patients for whom antibiotics are deferred is as important as in patients for whom antibiotics are prescribed. 

Aggressive behavior and assaultiveness in patients with and without histories of major depression (40, 44)... 

The challenge in such cases is to save the eyes... [21]. Beare [22] reported a series of 64 patients with eye injuries from chemical assaults treated in a specialty eye hospital in London with 20,333 Accident and Emergency Department visits and 29,853 outpatient visits during a 12-month period in 1988 [22]. In 17 eyes of 16 patients, there was a total loss of comeal... 

There had been a marked increase in the number of patients presenting to this hospital with chemical eye injuries from assaults over a 6-year period beginning in 1984, when only 1 case was seen [22]. There were 3 cases in 1985, 15 cases in 1986, 37 cases in 1987, and 40 cases in 1988. Of the 64 reported patients, 55 were male and 9 were female. Six patients also had significant facial or eyelid bums, although none became necrotic. Assailants were often gangs of male youths in their teens to twenties, and racial bias was a likely precipitant in certain cases. 

Amongst a series of 38 victims of chemical assault (acids) in Bangladesh, 10 (26%) had injuries of the eyeballs and 18 (47%) had injury of the eyelids [26]. Merle et al. [27] smdied 66 patients with alkali ocular bums (104 eyes) in Martinique (French West Indies) over a 4-year period, of which nearly half (45.5%) were due to deliberate chemical assault (the most frequently involved product was AlkalL 15.3% ammonia, pH 12.8) [27]. 

Branday et al. [28] reported that 562 patients with acute chemical injuries were admitted to 8 regional hospitals in Jamaica during a 10-year period from 1981-1990 [28]. Chemical bums comprised 13.3% of all bum patients admitted during this time period. Nearly half (236 cases 42%) of these chemical bums resulted from deliberate assault, while only 10 of the total chemical bum cases (1.8%) were the result of work-related accidents. In one of the smdy hospitals, 38% of bum admissions were due to chemical bums and 2/3 of these were due to deliberate chemical assaults. Assailants were more likely to be female and victims were either male or other women over disputes involving a relationship with a male partner [28]. 

Of the overall chemical bum patients, the most common sites involved were the face, neck, and upper body (87%), and the eyes or eyelids were involved in 19% of overall cases [28]. In deliberate chemical assault victims, the face and neck were commonly injured, but the genital area was also involved in many victims. Acids, such as sulfuric acid, can be obtained at low cost in Jamaica. These authors note that many of the chemical assault injuries were devastating with facial destruction and blindness. Less than half of the victims decontaminated tliemselves with copious water inigation before presenting to hospital [28]. 

Asaria et al. [29] reported a retrospective review of 125 bum patients admitted to a hospital in Kampala, Uganda over an 18-month period in 2001-2002 [29]. Of these, 15 patients (17%) were victims of deliberate acid assault. The male/female ratio was 1 1. The average total body surface area (TBSA) involved was 14.1% and the most common bum sites were the face (86.7%), head and neck (66.7%), chest (53.5%), and upper limbs (60%). The eyes were commonly involved... 

The circumstances of the acid assault involved attacks by unknown assailants during a robbery in 46.7% (26.7% during a car or motorcycle robbery and 20.0% in a house robbery). A known person was the assailant in 33% of these acid assaults, commonly in a setting of marital discord. Many of these patients ended up living as recluses and dependent on family members for daily support. The acid involved in most cases was sulfuric acid used to restore exhausted automobile batteries, which is readily available at low cost from garages in Uganda [29]. 

Saini and Sharma [30] reported 145 eye injuries amongst 102 Indian patients treated at a major referral center [30]. There were only seven chemical assault victims, but the authors noted that these patients had more severe injuries than patients with accidental injuries with 71.4% of the eyes of chemical assault victims developing phthis bulbi (a deformed eyeball with no light perception). In contrast, phthis bulbi developed in only 3.6% of patients with accidental chemical exposures [30]. 

Amongst 377 patients with chemical bums admitted to a bum center in Guangdong province, China from 1987-2001, 337 (88.5%) were accidental and 40 (10.5%) were from deliberate chemical assault [33]. Of the total number of chemically burned patients, ocular bums occurred in 55 (14.6%) [33]. 

Saini and Sharma [30] reported a series of 145 chemical eye injuries in 102 patients treated at a major referral center in India between 1984 and 1991 [30]. Bilateral injuries were seen in 42.1% of patients. Acids and alkalis accounted for 80% of chemical ocular injuries in this series. Two-thirds of the injuries occurred in young people working in laboratories and factories. Roper-Hall Grade III and IV injuries were seen in 52 eyes (35.9%). In total, 102 eyes (70.3%) recovered with a visual acuity of 6/60 or better. Ten eyes (6.9%) had no light perception. Phthis bulbi (a deformed eyeball with no light perception) occurred in 71.4% of the seven deliberate chemical assault victims but in only 3.6% of the accidental ocular chemical exposures. The final visual acuity was better in the eyes with less severe grades of chemical injuries on presentation [30],... 

FIGURE 7—35. Combination treatments for bipolar disorder (bipolar combos). Combination drug treatment is the rule rather than the exception for patients with bipolar disorder. It is best to attempt monotherapy, however, with first-line lithium or valproic acid, with second-line atypical antipsychotics, or with third-line anticonvulsant mood stabilizers. A very common situation in acute treatment of the manic phase of bipolar disorder is to treat with both a mood stabilizer and an atypical antipsychotic (atypical combo). Agitated patients may require intermittent doses of sedating benzodiazepines (benzo assault weapon), whereas patients out of control may require intermittent doses of tranquil-izing neuroleptics (neuroleptic nuclear weapon). For maintenance treatment, patients often require combinations of two mood stabilizers (mood stabilizer combo) or a mood stabilizer with an atypical antipsychotic (atypical combo). For patients who have depressive episodes despite mood stabilizer or atypical combos, antidepressants may be required (antidepressant combo). However, antidepressants may also decompensate patients into overt mania, rapid cycling states, or mixed states of mania and depression. Thus, antidepressant combos are used cautiously. 

If lithium, valproic acid, or atypical antipsychotic monotherapies are not effective in the acute situation, they can be used together (atypical combo in Fig. 7—35). If this is not effective, a benzodiazepine or a conventional antipsychotic (i.e., a neuroleptic) can be added to first- or second-line monotherapies, especially for the most disturbed patients (Fig. 7—35). That is, sedating benzodiazepines can be used for lesser degrees of agitation (benzo assault weapon in Fig. 7—35), but neuroleptic antipsychotics may be necessary for the most disturbed and out-of-control patients (nuclear weapon in Fig. 7—35). Neuroleptic antipsychotics should be restricted to the acute phase, and administered sparingly. 

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