In an aging society, close cooperation between emergency medicine and home medical care is important. Hospital ambulances manage public functions as a safety net for integrated community care systems. The number of dispatches has continued to increase, reaching 523 cases for the 5 years and 1 month from December 2014 to December 2019, of whom 47% were transferred to the long-term care hospital. Furthermore, our facility (emergency hospital) has worked on providing visiting medical treatment since September 2017. The home medical care provided by an emergency hospital reduces excessive burdens on doctors engaged in homecare, and may promote medical cooperation.

We retrospectively analyzed relationship between department categories and in-hospital cardiac arrest (IHCA). A total of 314 patients who needed rapid response system (RRS) activation in general wards were divided into three groups according to departments that the patients belonged to : medical (n=122), surgical (n=153), cardiovascular (n=39). The probability of IHCA on MET arrival was the highest in cardiovascular group. In multivariate analysis, cardiovascular group was related to the incidence of IHCA. Countermeasures against IHCA should be targeted at this group.

The emergency care system in Japan can be categorized into the following three types : (1)critical care,(2)ER (emergency room), and(3)joint care involving several departments.

Although joint care is the most common approach in Japanese hospitals, it does encompass certain issues that have encouraged hospitals to shift to the ER system as well as take measures to strengthen their structure for emergency care. Our hospital is one example where we have increased EMTs from two to four in addition to three nurses, and exclusively placed one full-time and one part-time doctors for implementing ER system during the daytime. Furthermore, the hospital has established an emergency care committee and also put a focus on managing the availability of hospital beds. In this study, we have evaluated the effectiveness of these measures by examining the response time from receiving a call to providing care.

The result revealed that the response time has effectively reduced, showing a significant improvement in our emergency care service. Rapid responses not only by the emergency department but by doctors from other departments were also a big contributing factor to this result. Meanwhile, the importance and the necessity to further manage the availability of hospital beds were re-emphasized through this evaluation. In order to facilitate the emergency care system, certain measures need to be taken along with implementing the ER system. Raising awareness of emergency care within the hospital, such as by establishing a committee and providing opportunities for issues to be discussed and exchanged, is crucial.

Liposuction is a cosmetic surgery at its own expense. Some patients are transported by ambulance immediately after the surgery. The purpose of this study is to describe the clinical course of such patients and to clarify what is required for treatment including medical fees. We have experienced four cases for two and a half years. All these cases required hospitalization, and half of them required blood transfusion. We have to take some action like to demand payment from facilities where cosmetic surgeries were performed because applying national health insurance to this sort of cases will cause increase on public expenditure.

This study retrospectively examined the characteristics of favorable neurological outcomes in children under the age of 17 years old with cardiac arrest due to endogenous disease. Data was collected from the Japanese Association for Acute Medicine Out-of-Hospital Cardiac Arrest Registry.　Of the 173 subjects, the characteristics (initial cardiac status, witness and age) of the favorable neurological outcome group (N = 13) were compared with those of the unfavorable group (N = 160). The former group demonstrated higher rates of return of spontaneous circulation, lower rates of initial asystole, lower adrenaline dose rates and higher magnesium dose rates.

The current study used objective indices and a short-answer questionnaire to ascertain changes in CPR skills and changes in attitudes towards maintaining those skills 2 and 4 years after a basic life support (BLS) course. A decline in CPR skills was not noted in the 4 years after the BLS course. Respondents were keenly aware of the quality of CPR for up to 2 years after the BLS course. Afterwards, respondents assessed the quality of their own CPR skills and sought to maintain those skills. Learning proper CPR skills affects one's ability to maintain those skills, so the current results underscored the need to periodically assess CPR skills.

The Cincinnati Prehospital Stroke Scale, frequently used by paramedics, is useful for checking focal signs. This Scale is sometimes not useful in subarachnoid hemorrhage (SAH) cases, and there is a lack of objectivity regarding the points of time-to-peak, duration, and headache severity for 'sudden-onset severe headache,' a representative symptom of SAH. We educated paramedics about the diagnostic criteria of thunderclap headache (which is applicable to so-called sudden-onset severe headache) presented in the International Classification of Headache Disorders, 3rd edition. This improved the quality of headache information obtained by paramedics and the rate of appropriate hospital selection for hemorrhagic stroke.

The current case involves an 89-year-old woman. She was 147 cm tall, weighed 43 kg, and had a history of chronic obstructive pulmonary disease (COPD). She became aware of breathing difficulties one month prior. To strengthen respiratory distress in the morning, 2 mg of tulobuterol tape was applied to the chest, and a second piece was additionally affixed to the chest in the evening to improve symptoms. Two hours after the additional application, we noticed palpitations and nausea, and requested emergency care. At the time of arrival to the emergency unit, the awareness level was JCS 1, but the saliva discharge showed a reduced awareness level of JCS 100, which necessitated emergency transport to our hospital. The level of consciousness improved at the time of transportation. When two pieces of tulobuterol tape attached to the chest were removed, the palpitations and nausea resolved. Based on the clinical symptoms, toxic symptoms due to tulobuterol tape were suspected. Patches can be easily adjusted, but care should be taken in the case of the elderly and infants who have problems in management ability or in cases of low weight. In the case of an emergency response, it is necessary to determine a history of oral administration and the presence or absence of a patch by whole-body observation.

We present a case of 86 years old man with dementia who ingested Laundry Detergent Pods (LDP). His family found that he was vomiting and had diarrhea. He was transferred to our hospital. As his family pointed out, we realized he ingested LDP. He had lung injury, acute kidney injury, and dehydration. He was treated with oxygen, antibiotics, and fluid infusion. He was dismissed without sequelae. LDP poisoning may be fatal to an elderly. The risk is not recognized enough. Anyone who cares for elderly with dementia should be educated on the risk of LDP ingestion.

Background : Massive pulmonary embolism is a life threating condition, which requires early intensive care.　Case : Previously healthy 58 years old woman. She was transported to our department for struggling for breathing. We suspected obstructive shock due to pulmonary embolism by examination. While we prepared for induction of extracorporeal membrane oxygenation (ECMO), she was resuscitated and diagnosed as massive pulmonary embolism. After 21 days hospitalization, she was discharged from hospital without a neurological deficit.　Conclusion : Rapid detection and intervention including ECMO play key role to resuscitate a patient with pulmonary embolism.

A 77-year-old man receiving anticoagulant therapy was admitted to our hospital for right upper abdominal pain. Enhanced computed tomography showed rectus sheath hematoma (RSH) in the upper abdomen and extravasation of contrast agent into the hematoma. We performed conservative therapy, and his symptoms resolved without worsening. He was discharged on the sixth day. RSH is likely to occur in patients with sudden abdominal pain receiving anticoagulant therapy or in individuals with frequent cough. RSH occurring on the cranial side of the navel may therefore be treatable by conservative therapy, even if the contrast agent leaks.

It is difficult to diagnose pregnant females because of radiological examination which is harmful for their fetus. A 35-year-old pregnant female came to our emergency room because of an intermittent moderate abdominal pain for almost one month. At beginning, we have diagnosed her as enterocolitis, however her pain had gotten severe during our physical examination. We then, performed Ultrasound examination and MRI without CT scan. Thus we were able to diagnose that, Mucinous Cystadenoma of Appendix was the reason for Intussusception. She was later transferred to the central hospital of our university to receive a higher-level treatment.

We report a case of 28-year-old male who was transported to our emergency department due to persistent perineal pain for two days. He got an inflamed golf-ball-sized perineum with normal vital signs. Computed tomography (CT) showed right superior cavity-forming lung lesion and perineal abscess. He was diagnosed as active pulmonary tuberculosis by acid-fast bacilli smear and polymerase chain reaction (PCR) assay. Bacteria and mycobacterium tuberculosis were identified from perineal abscess. In this case, we presumed that bacterial infection was complicated with existing subcutaneous tuberculous abscess. Tuberculosis always should be considered because patients with tuberculosis have a variety of symptoms.

A 69-year-old man with severe pneumonia was hospitalized in intensive care unit. Ultrasonography on the 12th day showed fibrin clots and fibers, but no drainage was performed due to negative culture results. CT on the 29th day revealed empyema but drainage and urokinase administration were unsuccessful. Surgery was attempted on the 35th day, but it was already organized and could not be removed. When ultrasonography confirmed findings that suspected fibrin, it was possible to decide whether to intervene and avoid surgery. Repeated ultrasound examination could be useful in determining timing of drainage without frequent chest CT scans.

We report an 80-year-old man who presented with exertional dyspnea, pleural effusion, and anasarca. Pacemaker implantation for complete atrioventricular block did not improve his symptoms. CT revealed multiple lymphadenopathies in the cervical and axillary lymph nodes. His respiratory status worsened on day 6, and he was transferred to the ICU and received mechanical ventilation. Following steroid therapy, pleural effusion decreased, and his respiratory status improved. Mechanical ventilation was stopped on day 20, and the patient left the ICU on day 24. In patients with the aforementioned signs, we must consider TAFRO syndrome and start steroid pulse therapy.

We encountered 2 cases of lateral thoracic artery injury after thoracic drainage. In our cases, transarterial embolization using a gelatin sponge and n-butyl-2-cyanoacrylate effectively treated the injury. This complication is rare. Due to the presence of the artery, it is unsafe to insert a thoracic catheter or tube in the ‘safety triangle’ area defined by the British Thoracic Society guideline. An angiography, but not enhanced computed tomography can reveal the injury, and transarterial embolization is an effective treatment strategy.

Nafamostat mesilate (NM) has often been used as an anticoagulant for extracorporeal circulation in hemodialysis patients who have a high risk of bleeding. Reports of cardiac arrest caused by an allergic reaction to NM are rare. We report the case of a 70-year-old man who experienced NM-induced anaphylactic shock during hemodialysis, which resulted in cardiac arrest ; he did not have a rash. In patients receiving NM who experience cardiac arrest during hemodialysis, anaphylactic shock should be considered, regardless of the presence or absence of anaphylaxis-associated dermatological signs or a history of uneventful hemodialysis-related NM treatments.

We present the case of a 56-year-old man with super-refractory status epilepticus, a disorder characterized by status epilepticus for 24 hours or more after the onset of anesthetic therapy. The patient needed multiple anticonvulsants for epilepsy control and intensive care for multi-organ failure. Treatment required 123 days of hospital care with good recovery. Management was successful in this case despite poor prognostic predictions owing to the high mortality rate associated with this disorder. Cooperation between neurologists and acute care physicians might play a key role in the successful management of such cases.

The commonalities of our cases are followings : latter stage elderly, minor fall trauma, patients with diffuse idiopathic skeletal hyperostosis (DISH), and chance fracture with neurological deficits. DISH fractures predispose to late onset neurological deficits because diagnosis is likely to be inaccurate and leading to pseudoarthrosis. In elderly traumatized patients with lower back pain, it is necessary to consider the possibility of burst and chance fracture even if minor trauma. Delayed diagnosis and prolonged waiting for surgery would be associated with late onset neurological deficits. The careful management is required for emergency physicians because similar cases will be increased in Japan.

We report a case of severe multiple trauma treated at a hybrid operating room (hybrid OR). A 54-year-old man was brought to the emergency department with a history of a hit by a light pickup. He presented with hypotension, after resuscitative endovascular balloon occlusion of the aorta, trauma pan-scan CT revealed traumatic hemopneumothorax, splenic injury, and pelvic fracture. We performed damage control surgery and damage control interventional radiography for splenic injury in the hybrid OR. On day 52 he was discharged by walking. The hybrid OR could be a very effective tool for the treatment of fatal multiple trauma.

An 87-year-old man presented with sudden dyspnea. Computed tomography showed pneumothorax. Thus, we performed emergency thoracic drainage ; eruption of stinking pus was noted. Following this, the patient's blood pressure increased, but it fell again soon after. He was hospitalized and received meropenem and clindamycin. Bacteroides and Peptostreptococcus were detected from pleural effusion culture. He was discharged on the 115th day of hospitalization. In our case, subacute obstructive shock was complicated with septic shock due to gas production from anaerobic bacteria.Early treatment with appropriate antibiotics against anaerobic bacteria is recommended in such situations.

A 25-year-old man had an injury involving approximately 10% of his back, caused by contact with a rotating body while working in a metalworking factory. Preservation treatment with washing and ointment application was continued. Pockets and exposed bones were found. When combined with local negative pressure wound therapy for wound bed preparation before stratified skin grafting, the treatment attained good granulation and closure of the pockets. Stratified skin grafting was performed, and the engraftment of the skin graft was good. Engraftment was effective probably because the wound bed preparation was performed with negative pressure wound therapy.

A 44-year-old man presented with a headache. He had mild altered mental status, renal insufficiency, thrombocytopenia, and severe hypertension. He was diagnosed with hypertensive emergency, especially malignant hypertension with TMA and PRES. The case was difficult to differentiate from TTP at the presentation and plasma exchange was empirically started. In several days of clinical course, lab result of ADAMTS13 activity returned no decrease, which indicated TTP is not likely. This is an educational case to show the importance of slow blood pressure management and the differential diagnosis of TMA in malignant hypertension.

A 4-year-old boy was admitted to the emergency department because of weakness and numbness of the right limbs. A head MRI showed an acute ischemic lesion in the left posterior limb of the internal capsule and MR angiography showed a constriction of the left middle cerebral artery. He had a history of varicella 5 weeks before hospitalization and varicella zoster virus DNA were detected in his examination of cerebrospinal fluid at the admission. He had a diagnosis of stroke secondary to varicella zoster virus vasculopathy. Aciclovir, prednisolone and low molecular weight heparin were started. With significant improvement, he was discharged on day 18 with no symptoms.

A 79 year-old woman was admitted to our hospital with a diagnosis of severe acute pancreatitis. Although antibiotics and critical organ support were continued, she went into septic shock by infected pancreatic necrosis thus percutaneous drainage was added. The lavage was performed daily and bigger catheter replaced. However she died with progressive multiple organ failure because of poor drainage and catheter related blood stream infection. Although Step-up approach has been proposed as a treatment strategy, there are many unclear points such as the specific method of intervention and the timing of transition to necrosectomy, and further case accumulation is needed.

A male of sixties took examination of gastrography with barium. Next day, he had abdominal pain and he consulted an emergency department of nearby hospital. His pain was worse after he was given an enema. CT image showed perforation of gastrointestinal. He was introduced to our hospital. On admission, he had a peritoneum stimulation sign. A Hartmann's procedure was performed. After operation he had abdominal abscess and was needed aspiration and given antibiotics. Barium peritonitis after examination of gastrography is rare, but when it occurs, it became severe. Easy enema should not be used for constipation after barium examination.

Cholesteatoma is known to cause hearing loss and vertigo when it extends inner ear. Fifteen days prior to this admission, a 65-year-old man visited our department of otolaryngology with a complaint of vertigo. As a result, he was diagnosed with Cholesteatoma and was undergoing treatment. Presented to our ED complaining with shivering and his temperature was 39.6℃ on arrival. Contrast enhanced head CT revealed right cholesteatoma extends to inner ear with bone destruction and pneumocephalus. He was transferred to ENT and tympanoplasty was performed. Cholesteatoma can be a rare cause of vertigo and may become severe condition with meningitis.

A 56-year-old woman who had a history of ulcerative colitis and depression visited a hospital for epigastralgia and was diagnosed with functional dyspepsia. Two days later, her symptoms were getting worse, so she was taken to the previous hospital and was diagnosed with appendicitis, then she was transferred to our hospital. Although CT scan showed no evidence of perforation, her systolic blood pressure dropped to 70 mmHg after CT scan, and an emergency appendectomy was performed. No perforation was found in the appendix, and the pathological diagnosis was gangrenous appendicitis. She was discharged on the postoperative 10th day.

Sodium valproate is frequently used for treatment of epilepsy, and it includes many kinds of side effect. We report a case of severe acute pancreatitis due to sodium valproate, complained of stomachache and high fever. Pancreatitis as a side effect of sodium valproate has no high frequency, but there are also reports of deaths. It is necessary to know that pancreatitis can occur among the patients treated with sodium valproate.

An 81-year-old man was hospitalized with a diagnosis of pelvic fracture due to traffic accident. A denture defect was found on the 6th day of hospitalization, and a chest X-ray revealed a swallowed piece of the denture. Computed tomography revealed gas in the wall of the stomach and portal vein. Upper gastrointestinal endoscopy showed inflammatory changes in the stomach, and the piece of denture was found. Klebsiella pneumoniae and Escherichia coli were detected in the gastric mucosal culture, and the patient was diagnosed with acute gastric cellulitis caused by the accidental ingestion of a piece of denture.

36Weeks gestation, parous woman in 30's, child born with a caul at the emergency site, to broke up egg membrane by emergency medical technician. However, in Japan, there is not permitted to break egg membrane for emergency life-saving treatment of obstetrics and gynecology by emergency medical technician. Therefore, in the current legal system that does not allow for break membrane by the emergency medical technician, there is a possibility that the life of a new born babies at pre-hospital may be threatened. So, it is necessary to break egg membrane the emergency medical technician can carry out.