CONSULTATIONS • Q a t Many patients who present to the ED post trauma

• have microscopic hematuria. When is IVP indicated? level of red blood cells in the urine is significant: five to

20; 20 to 50; 50 to 100? What if the urine clears on subsequent urinalysis?

George Podgorny, MD - - Editor Winston-Salem, North Carolina

A Examination of the urinary sediment is generally the • initial test done to determine injury to the genitouri-

nary tract. A voided specimen is preferable to avoid potential iatrogenic hematuria; however, it is unusual for an injured patient to void spontaneously in a supine position. If a catheter must be inserted to obtain a specimen, it is prudent to perform a plain film of the pelvis first (recommended for most blunt trauma cases) to determine if a pelvic fracture is present. In addition, a careful examination of the perineum and meatus should be performed. If these are negative, a catheter may be passed gently. If not, a retrograde cystoureth- rogram and IVP are indicated.

Generally red blood cells in excess of five/hpf field are suggestive of injury. It must be stressed, however, that injuries can occur without hematuria, Severe, major renal injuries have been noted to present with total lack of red blood cells (up to 25% of cases of renal vascular injury).

In addition, the degree of hematuria (gross or microscopic) is not related to the degree of injury. It is recommended that an WP be obtained in the following situations: significant, blunt abdominal trauma; auto-pedestrian injury; fall from a signifi- cant height; penetrating wounds of the flank or back; fracture of lower ribs, transverse processes of lower thoracic or lumbar vertebrae, or pelvic fracture; or flank mass or cerebrovascular accident tenderness.

An alternative to an IVP (if the patient is allergic to contrast media) is computerized axial tomography' which, in fact, is a superior study but is not recommended presently as the initial screening examination for urologic trauma.

Ann Harwood-Nuss, MD Division of Emergency Medicine Department of Surgery University Hospital of Jacksonville Jacksonville, Florida

q Our physician group covers a 24-hour hospital-based .e emergency department that has no pharmacist after

10:~ P PM. The pharmacy prepackages and prelabels a one- to two-day supply of about 30 of the more commonly prescribed medications, including narcotics. We write the patient's name and date, and amend the standard printed instructions as appropriate. A 24-hour hospital-based pharmacy is ten to 15 minutes driving time away, and we have virtually no "walk- ing" patients.

Would you recommend against such a medication dispens- ing practice? If we should continue as we have, would you have any recommendations concerning both good patient care and avoidance of professional liability?

Kent A Moore, MD Reno, Nevada

A Many hospitals lack 24-hour pharmacy services, yet • dispensing of medications by emergency department

staff is not limited to these hospitals. It seems to be common practice for ED personnel to dispense medications to patients at discharge. Federal and state laws govern such practices. Further recommendations for safe and lawful procedures are as follows: 1) All medications are to be properly labelled in accordance

with law, taking care to provide sufficient auxiliary labels when needed;

2) supplies should be limited to 24 hours whenever possible. A prescription may be written for any supply needed be- yond 24 hours;

3) controlled substances are to be dispensed discriminately in limited supplies. Proper narcotic records are maintained and inventoried; and

4) the formulary for such drugs should be restricted. ED staff members who dispense these medications should be well informed, and should provide adequate patient information and counseling. The institution of 24-hour pharmacy service coverage does

not alleviate the role of ED di'spensing. Federal laws prohibit hospital pharmacies from dispensing medications to outpa- tients unless there is an inventory established for this purpose or extenuating circumstances arise.

Donna Powers, RPh Department of Emergency Medicine Moses H Cone Memorial Hospital Greensboro, North Carolina

148/875 Annals of Emergency Medicine 15:7 July 1986