Purpose: To describe the experience of homeless patients arriving at a tertiary care center in Japan, from arrival in the ER to hospital discharge.
Methods: We retrospectively reviewed the clinical course of homeless compared to non-homeless patients presenting to our ER, using six complementary databases to identify all patients. Subsequently, we described and analyzed the characteristics of homeless patients compared with non-homeless patients. We performed a χ² test for categorical comparisons, and considered p<0.01 to indicate statistical significance.
Results: Compared to non-homeless patients, homeless patients were more likely to arrive to the ER by ambulance (54.5% vs. 19.6%, p<0.001); yet, had significantly lower rates of hospital admission (23.5% vs. 30.2%, p<0.001). A greater proportion of homeless patients arrived to the ER during the day (8am to 6pm) versus after hours (6pm to 8am). Compared to those patients who disclosed their homeless status at the time of their presentation to the ER, those patients who did not disclose their homeless status at the time of their presentation to the ER were more likely to be admitted to the hospital (13.9% vs. 63.7%, p<0.001), and tended to have longer hospital lengths of stay. The common presenting diagnoses of homeless patients were gastrointestinal disorders (23.3%), central nervous system diseases (21.3%) and respiratory diseases (15.5%). Homeless patients who present to the ER with a decreased level of consciousness tend to have longer hospital stays.
Conclusion: Among all patients present to the ER, homeless persons those who disclose their homeless status are less likely to be admitted to hospital in comparison to those who do not disclose, and in comparison to those who are not homeless. These findings indicate that homeless patients in Japan may receive differential treatment from the acute healthcare system.

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Introduction: Preventable trauma death (PTD) sometimes occurs in the Japanese emergency medical service (EMS). Evaluating the quality of treatment given to trauma victims is important for elucidating the problems and determining means of improvement.
Objective: To evaluate the time passage of emergency medical activity and its quality, to show the proportion of PTD cases, and to clearly reveal problems inherent in the latest emergency system.
Methods: We conducted a questionnaire-based survey of police departments, fire departments, and hospitals in Chiba prefecture to investigate emergency activities involving 196 fatalities caused by traffic accidents. We then selected 87 victims who still had vital signs at first contact with emergency medical teams, and investigated the emergency medical activities and the time passage of the victims. Following a peer review conference to elucidate problems, victims were classified as PTD, ‘suspected PTD’, or ‘impossible to save’.
Results: Average time from the accident to first contact with a doctor was 44 min 18 s. Four cases (4.6%) were classified as PTD and 12 (13.8%) as suspected PTD. Cause of death for 9 cases (4 PTD, 12 suspected PTD) was bleeding from the trunk, 6 of which were transported to an emergency critical care center (ECCC). The problems identified were delays of blood transfusion, surgery, and transcatheter arterial embolization and overly invasive surgery. Of the 9 cases of bleeding from the trunk, 3 cases deemed severe by EMS personnel were not transported to an ECCC and subsequently died. Six of the 16 cases of PTD or suspected PTD had stable vital signs and normal consciousness in the prehospital setting and were transported to facilities other than an ECCC and subsequently died.
Discussion: The main problems identified were too lengthy delay between the accident and treatment, under-triage in the prehospital setting, and PTD occurring even in an ECCC. An integrated approach to handling traffic accident victims is required, and should consist of a doctor delivery system in the early response phase, selection of an ECCC by EMS personnel in cases of severe trauma, assignment of a higher triage category for victims with injuries to the trunk, and a trauma care center system employing specialized medical personnel to receive severely injured patients.
Conclusion: The EMS should be revised to provide a doctor delivery system for early-phase response, assignment of a higher triage category for victims with injuries to the trunk, and the establishment of a trauma care center system.

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A 23-year-old male who had his chest and abdomen hit by falling heavy steel was brought by ambulance. At the emergency room he had tracheal intubation for respiratory distress, rapid infusion and bilateral tube thoracostomy for right pneumothorax and left pneumohemothorax. CT scans showed splenic rupture, hemoperitoneum, bilateral pulmonary contusions, left subclavian artery occlusion and other conditions. Emergency laparotomy for splenectomy and postoperative intensive care with mechanical ventilation for pulmonary contusion were performed. On day 3 the left thoracic drainage changed to a milky color during enteral feeding. Laboratory analysis of the drainage demonstrated fat droplets and an increase in the number of cells of which lymphocytes were dominant, which led us to confirm the diagnosis of chylothorax. Despite fasting and total parenteral nutrition, on day 5 the drainage increased to 4.4 liters up from 2.4 liters on day 3 (onset) and 1.8 liters on day 4. Massive edema and poor oxygenation developed as a result of protein loss. Video-assisted thoracoscopic surgery was performed on day 6 (day 4 after onset). A chyle leak arose from the injured thoracic duct close to the left subclavian artery injury. After ligation the chyle leak was completely stopped. On day 104 the patient was transferred to a rehabilitation hospital. Traumatic chylothorax without iatrogenic etiology is extremely rare. If the chyle leak affects the general or respiratory condition, or if the leakage is more than a liter per day on day 2 after onset, an operation is required as soon as possible. Video-assisted thoracoscopic thoracic duct ligation has been found to be an effective method for treating chylous leaks.

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We report a case of disturbance of consciousness due to hyperammonemia stemming from urinary tract infection with urease-producing bacteria and complicated with hypothyroidism. An 84-year-old woman visited her family doctor with a history of excessive fatigue and was prescribed ciprofloxacin hydrochloride for cystitis and sulpiride for depression. The following day, she was brought to our hospital in an ambulance because of disturbance of consciousness. Sulpiride poisoning was suspected, and she was admitted to our emergency department. Because blood tests suggested hyperammonemia (197 μg/dl) and hypothyroidism, she was administered Lactulose, branched-chain amino acids, and thyroid hormones. Neither liver disease nor portosystemic shunting was observed in the blood or the imaging tests. The consciousness level initially improved along with the ammonia levels, however it later deteriorated again as the ammonia levels increased. Because urinary tract infection was complicated, we started administering antimicrobials. As a result, the level of ammonia normalized, and the level of consciousness improved. Arthrobacter cumminsii was detected by urine culture. Thus, we made a diagnosis as hyperammonemia due to urinary tract infection with urease-producing bacteria. In addition, hypothyroidisim in the patient aggravated hyperammonemia. In cases of hyperammonemia unaccompanied by liver disease, urease-producing bacterial infection and/or hypothyroidism should be considered.

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This is the first case report of a Japanese boy who suffered from reentry high altitude pulmonary edema (reentry HAPE). A 10 year-old Japanese boy moved from Japan to 3,400 meters (La Paz, Bolivia). He had lived in La Paz without symptoms for 10 months. Pulmonary edema occurred 17 hours after returning home from a short stay at low altitude. He was initially diagnosed with a common cold, but later diagnosed with reentry HAPE and treated with oxygen, intravenous dexamethasone, and oral acetazolamide. Therapeutic descent by flight was cancelled, as he improved and returned to school five days after the onset of symptoms. Reentry HAPE occurs when residents at high altitude return home after traveling to low altitude locations. Rate of reentry HAPE is higher in children than in adults. In this case, reentry HAPE occurred for the first time after the patient had traveled to low altitude locations three previous times. Contributing factors might be viral respiratory infection, insomnia, and excessive exercise. Misdiagnosis of reentry HAPE may result in death. Even if residents at high altitude are accustomed to traveling to low altitude, they and their medical providers should be aware of the symptoms and treatment of reentry HAPE.

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The prognosis of traumatic cardiac arrest (TCA) is poor, and survival without significant neurological deficit is rare. We report a survival case of TCA in a 5 year-old boy injured by collapsing material. The patient was in shock en route to the hospital, and went into cardiopulmonary arrest (CPA) just before arrival. Cardiopulmonary resuscitation (CPR) was begun immediately, which resulted in a return of spontaneous circulation (ROSC). Type IIIb liver injury was identified on abdominal CT, and damage control surgery was performed. In the OR the patient had two episodes of CPA, for a total arrest duration of 31 minutes. Right hepatic lobectomy was performed 27 hours after the accident once the patient was hemodynamically stable, and he was transferred to another hospital without neurological deficit on post-operative day 44. The survival rate of TCA in children is 4.8-8.0%. In our case, CPA occurred just prior to arrival at the hospital, the duration of cardiac arrest was brief, and there was no craniocervical injury, which may have contributed to the patient's favorable outcome. Our case suggests that neurologically intact survival in a child with TCA is possible with continuous CPR and damage control surgery performed immediately following ROSC.

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Head injuries produced by static loading mechanisms have been called low-velocity, crushing head injuries (CHI). If the injury is not fatal, there is usually no severe disturbance of consciousness, but CHI are characterized by damage to the cranial nerves caused by traction, stretching, and fractures of the cranial base due to the distortion of the skull. In this paper, we report on six cases of low-velocity CHI. There were four adults and two pediatric cases (less than five years of age). Cranial nerve palsy was observed in five cases. Skull base fractures traversing the clivus were recognized in four cases, optic canal fractures in two cases, and carotid canal fractures in two cases. The final neurological outcomes were as follows: full recovery (three cases), and minor (two cases) and severe (one case) morbidity. CHI is a rare condition with a unique injury mechanism and clinical symptoms. CHI patients present with a variety of cranial nerve injuries caused by distortion of the cranial base and the distribution of basilar skull fractures. In occupational accidents in adults and traffic accidents in children, CHI caused by static loading forces should be considered, and proper imaging studies are necessary to make an accurate diagnosis.

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A 77-year-old male presented at a local hospital with abdominal discomfort of 1-month duration. Three days earlier, he had undergone lower gastrointestinal endoscopy, a day after which, he developed fever and chills. A left internal iliac artery aneurysm of 11 cm in diameter and internal air were observed on an abdominal computed tomographic scan performed at the same hospital. Moderate melena was also confirmed. Based on these findings, infection of the left internal iliac artery aneurysm and rectal rupture was diagnosed, and emergency surgery was performed. The surgery, which involved a F-F (femoro-femoral) bypass followed by laparotomy and Hartmann's operation with excision of the aneurysm, saved the patient's life. In Japan, only few studies have reported cases of ilioenteric fistula in the lower gastrointestinal tract, and the onset of sepsis seen in this case was also rare. Thus, this case should be considered as a part of the differential diagnosis of sepsis and melena.

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