Abstract
Objective: This study is unique as it examines biological materials brought to the emergency department. The purpose of this study was to investigate the reasons behind the presence of nonhuman biological material in the emergency department.
Methods: The materials brought were photographed and a pre-prepared survey form was filled in following examination.
Results: A total of 46 biological materials were brought to the emergency department within a 12-month period. Ticks were the most frequently brought material, and the most common reason for bringing them was to get the creature removed from the body. Situations in which the physician did not have knowledge about the material were more frequent among those that were neutral about being satisfied with the attitude of the physician towards the material brought, and satisfaction was higher in cases when the physician was knowledgeable, although this was not statistically significant.
Conclusion: Physicians should not condemn biological materials brought into the department after exposure. If possible, they should try to gain more knowledge about them. If the material is not to be stored, once it is made sure that it is not dangerous, it should be disposed of in a medical waste bin. Physicians should be knowledgeable toward the frequency and the types of such agents in their region.
Keywords: emergency department, biological materials, tick
Introduction
We live with constant positive and negative interactions with the creatures we share the world with. Although negative interactions are decreasing with increasing urbanization, the harm done to humans by other creatures is still a serious social and medical problem1). Vertebrates such as dogs, cats, snakes and mice, along arthropods including scorpions, ticks, bees, spiders and lice, and plants or herbal products are often responsible for medical problems2,3,4). Conversely, there are examples of interactions between humans and other creatures that are medically positive. For example, in studies conducted in hospitals and emergency departments with the help of dogs, positive contributions to the physiological and psychological conditions of patients are reported5, 6). As a result of negative interactions with creatures, individuals sometimes visit the emergency department due to toxicological exposure, infestation, and trauma (e.g. scratches, bites, blunt or penetrating trauma).
Studies examining injuries in patients that visit the emergency department after negative interactions with other creatures are common in the literature. Unlike these studies in the literature, our study is unique as it examined nonhuman creatures brought to the emergency department. The purpose of this study was to investigate the reasons behind bringing biological material to the emergency department.
Methods
Ethical board approval for this study was obtained from the Hasan Kalyoncu University (Date 06/11/18, Number: 2018-08). Authors declare that human rights were respected according to the Declaration of Helsinki. The biological materials brought to the emergency department in one of the hospitals in Gaziantep between December 2018 and October 2019, and the individuals (patients and patient’s relatives) who brought the material are included in the study. Consent was obtained after informing individuals about the study. Materials brought into the emergency department were photographed and a pre-prepared survey form was filled in after examinations. The participants’ age, gender, educational level, the characteristics of the material, and reasons for bringing the material are addressed in the survey form. For reasons behind bringing the material options included: having the creature analyzed, having it treated, removing it from the body, being curious about what it is, contributing to the treatment plan and other (i.e., a reason not included in the options). Finally, participants answered whether they were satisfied with the physician’s attitude toward the biological material that they brought. They answered this question using the following options: definitely yes, yes, neutral, no, and definitely not. Following these questions, physicians recorded “whether they were knowledgeable about the biological material brought” on the survey form, followed by informing the participants about the subject.
Statistical method
The relationships between two independent variables at the categorical measurement level were tested with the Exact Chi-square test. Numbers and percentage values were given for categorical variables as descriptive statistics. The SPSS Windows version 24.0 package program was used for the statistical analysis and a P value of <0.05 was considered statistically significant.
Results
Forty-six biological materials were brought to the emergency department within a 12-month period. One of these (a plant seed) was excluded from the study, because its photograph is lost. Therefore, a total of 45 biological materials are included in the study. Participant’s average age was 40.04 (17–70); 60.0% (n=27). Most participants had a low educational level (primary school and below), and 51.1% (n=23) were female. Ticks were the most frequently brought material due to tick bites. The most common reason for bringing them in was to get the creature removed from the body. Physicians were knowledgeable about 71.1% (n=32) of the materials brought, and 82.2% (n=37) of the participants reported satisfaction with the physician’s attitude toward them. Generally, we found that materials were brought in after a toxic or traumatic exposure, but some unusual demands were also made. These include a horse with an injured hoof, a cat with four extremities amputated, a pigeon that could not fly, and a sparrow with an injured leg (Table 1 and Figure 1).
Table 1. Descriptive statistics.
| Age [mean (min-max)] | 40.04 (17–70) | ||
|---|---|---|---|
| n | % | ||
| Educational level | Low (Primary school and below) | 27 | 60.0 |
| Moderate (High school) | 10 | 22.2 | |
| High (University and higher) | 8 | 17.8 | |
| Gender | Male | 22 | 48.9 |
| Female | 23 | 51.1 | |
| Material brought | Scorpion | 6 | 13.3 |
| Bee | 2 | 4.4 | |
| Plant parts (seed, leaf, fruit) | 5 | 11.1 | |
| Tick (stuck to the body) | 15 | 33.4 | |
| Tick (removed from the body) | 4 | 8.9 | |
| Spider | 3 | 6.7 | |
| Horse (Alive) | 1 | 2.2 | |
| Centipede | 1 | 2.2 | |
| Rat | 1 | 2.2 | |
| Moth | 1 | 2.2 | |
| Cat (Alive) | 1 | 2.2 | |
| Pigeon (Alive) | 1 | 2.2 | |
| Sparrow (Alive) | 1 | 2.2 | |
| Chicken meat | 1 | 2.2 | |
| Body lice | 1 | 2.2 | |
| Carabidae | 1 | 2.2 | |
| Why it was brought | To have the creature analyzed | 11 | 24.4 |
| To have the creature treated | 4 | 8.9 | |
| To have the creature removed from the body | 16 | 35.6 | |
| Being curious about what it is | 5 | 11.1 | |
| Contributing to the treatment plan | 9 | 20.0 | |
| The physician’s knowledge | Yes | 32 | 71.1 |
| No | 13 | 28.9 | |
| Satisfaction from the physician’s attitude | Definitely not | 1 | 2.2 |
| Neutral | 7 | 15.6 | |
| Yes | 23 | 51.1 | |
| Definitely yes | 14 | 31.1 | |
Figure 1.
Photos of some of the biological materials.
A high proportion of males (36.4%) brought material to have the creature analyzed, while a high rate of females (47.8%) came to have the creature removed from the body, although no statistically significant relationships were observed between gender and reasons for bringing the material.
A high rate (36.0%) of individuals with low educational backgrounds came to have the creature removed from the body; participants with moderate educational levels reported coming to have the creature analyzed and to have the creature removed from the body (30.0%). Additionally, participants with high educational levels came to have the creature removed from the body and reported curiosity about what it was (37.5%). According to analyses, no statistically significant differences between educational levels and why the material was brought were identified.
When evaluating physician attitudes towards the materials brought, those who presented to remove the creature from the body stated definitely yes (57.1%) and yes (34.8%). This evaluation was higher than that of the other options in different categories. While those who selected neutral had brought the material to have the creature analyzed, to have it treated and to contribute to the treatment plan, all individuals who were unsatisfied reported bringing the material to have the creature treated (Table 2).
Table 2. Examination of the relationship between why it was brought and the variables.
| Why it was brought | ||||||||||||
| To have the creature analyzed | To have the creature treated | To have the creature removed from the body | Being curious about what it is | Contributing to the treatment plan | P | |||||||
| n | % | n | % | n | % | n | % | n | % | |||
| Gender | ||||||||||||
| Male | 8 | 36.4 | 3 | 13.6 | 5 | 22.7 | 2 | 9.1 | 4 | 18.2 | 0.229 | |
| Female | 3 | 13.0 | 1 | 4.3 | 11 | 47.8 | 3 | 13.0 | 5 | 21.7 | ||
| Education level | ||||||||||||
| Low (Primary school and below) | 7 | 28.0 | 1 | 4.0 | 9 | 36.0 | 1 | 4.0 | 7 | 28.0 | 0.152 | |
| Moderate (High school) | 3 | 30.0 | 1 | 10.0 | 3 | 30.0 | 1 | 10.0 | 2 | 20.0 | ||
| High (University and higher) | 0 | 0.0 | 2 | 25.0 | 3 | 37.5 | 3 | 37.5 | 0 | 0.0 | ||
| Was the person who brought it satisfied with the physician’s attitude | ||||||||||||
| Definitely not | 0 | 0.0 | 1 | 100.0 | 0 | 0.0 | 0 | 0.0 | 0 | 0.0 | 0.027 | |
| Neutral | 2 | 28.6 | 2 | 28.6 | 0 | 0.0 | 1 | 14.3 | 2 | 28.6 | ||
| Yes | 7 | 30.4 | 0 | 0.0 | 8 | 34.8 | 2 | 8.7 | 6 | 26.1 | ||
| Definitely yes | 2 | 14.3 | 1 | 7.1 | 8 | 57.1 | 2 | 14.3 | 1 | 7.1 | ||
The P value was obtained from the Exact χ2 test.
Situations in which the physician had no knowledge about the material were more frequent among those reporting neutral satisfaction with the attitude of the physician towards the material brought and satisfaction was higher in cases where the physician was knowledgeable (yes 78.3% and definitely yes 78.6%); however, this was not statistically significant (Table 3).
Table 3. The relationship between the physician’s knowledge about the material and satisfaction.
| The physician’s knowledge | ||||||
|---|---|---|---|---|---|---|
| Yes | No | P | ||||
| n | % | n | % | |||
| Was the person who brought it satisfied with the physician’s attitude | ||||||
| Definitely not | 0 | 0.0 | 1 | 100.0 | 0.104 | |
| Neutral | 3 | 42.9 | 4 | 57.1 | ||
| Yes | 18 | 78.3 | 5 | 21.7 | ||
| Definitely yes | 11 | 78.6 | 3 | 21.4 | ||
The P value was obtained from the Exact χ2 test.
Discussion
Emergency department visits because of negative interactions with creatures is a health problem frequently encountered in developed countries7, 8). Annually, more than 1 million emergency department visits are due to bites and stings (by animals other than dogs), and 300,000–350,000 dog bites have been reported9). Medical publications contain possible effects of negative interactions with creatures and their treatment measures. In relevant publications, images of the affected patient, parts of the body involved, and treatment delivery are often included. While the characteristics of the inflicting species are also included, their photographs rarely are. Although there are no problems defining injuries caused by mammals, it can be said that there is a serious identification problem in injuries caused by arthropods9). Well, as emergency department physicians, are we required to see the inflicting creature in such injuries, or is it correct to bring the creature to the emergency department? Alternatively, should we be knowledgeable of every creature brought to the emergency department?
In this study, we saw that 35.6% of the creatures brought to the emergency department had been brought for removal from the body (87% of them were ticks). Tick bites cause many serious diseases including allergic reactions, Lyme disease, and Crimean-Congo hemorrhagic fever10, 11). Therefore, requests to remove creatures stuck to any part of the body are natural. This group reports the most satisfaction with the physician’s attitude towards bringing the material. However, 44.4% of the creatures were brought to the emergency department to have it analyzed and to contribute to the treatment plan. In such cases, participants were unsatisfied with the attitude of the physician towards the material they may have brought to make the physician’s job easier. In our study, physicians were knowledgeable in about 71.1% of the materials brought, no relationships between the physician’s knowledge and satisfaction levels were reported. In light of this information, we think that the dissatisfaction in 44.4% of the aforementioned participants could be due to the physician not showing the attitude they expected. A good treatment response and doctor-patient communication are critical for patient satisfaction12,13,14). We think that satisfaction was absent due to communication failures between the doctors and patients. The distinctive characteristics of these creatures have been explained in many medical publications and books. The purpose of this is to help physician recognize the agent, plan treatment, and foresee possible risks. Therefore, we believe that bringing these biological materials to emergency departments should not be condemned.
So, what should physicians do in such situations? How many emergency departments has this situation been defined in and where algorithms have been created? Well, can these biological materials lead to medico-legal problems related to treatment in the future? Should we store these materials? What kind of waste should they be considered to be, if we do not store them? Medical wastes by these materials may cause infectious pathogen spread and threaten community and environmental health15). Health care providers are required to know medical waste management protocols to protect their health, and environmental health16). Mostly, in such cases, physicians do not know what to do and no algorithms for emergency departments concerning these situations have been identified. On the other hand, despite biological materials potentially causing medico-legal problems relating to treatment, whether or not these materials should be stored, and in which conditions they should be stored under, is largely unknown for emergency department providers. When these biological materials are brought to the emergency department after an interaction, the emergency department physician should first check whether it poses a threat. If it is to be stored, it can be stored in alcohol within a sealable container suitable for the size of the material. Following this, it can be sent to the local health ministry laboratory. If it is not stored, it should be disposed of in a medical waste bin.
Extraordinarily, four creatures had been brought to the emergency department for treatment. In terms of their design and employee training, emergency departments aim to provide services to human beings. Hence, is there a legal barrier for treating animals? Does a physician have the right to deny medical assistance to a creature in need? Although legislations vary from country to country, in our country, only veterinarians can perform medical and surgical interventions on animals in accordance with the “Animal Protection Law” (number 5199)17). The individuals who had brought the four living animals for treatment provided the study with the necessary information were referred to centers where they could be treated.
Conclusion
Bringing biological materials to the emergency department after exposure should not be condemned by physicians. If possible, they should try to be more knowledgeable about them. If the material is not to be stored, after making sure it is not dangerous, it should be disposed of in a medical waste bin. Physicians should be knowledgeable about the frequency and type of such agents within their region.
Authorship
M.B. contributed to conception; M.B. and M.S. contributed to design; M.M.O. contributed to supervision; M.B., H.G. and T.T. contributed to data collection and processing; T.A. contributed to analysis and interpretation; M.B. and M.S. contributed to literature review; M.B. and T.A. contributed to writing; and M.S., and M.M.O. contributed to critical review.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Conflict of interest
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
References
- 1.Nogalski A, Jankiewicz L, Cwik G. Animal related injuries treated at the Department of Trauma and Emergency Medicine, Medical University of Lublin. Ann Agric Environ Med 2007; 14: 57–61. [PubMed] [Google Scholar]
- 2.Steele MT, Ma OJ, Nakase J. EMERGEncy ID NET Study GroupEpidemiology of animal exposures presenting to emergency departments. Acad Emerg Med 2007; 14: 398–403. doi: 10.1197/j.aem.2006.12.012 [DOI] [PubMed] [Google Scholar]
- 3.Rangan C. (Emergency Department evaluation and treatment for children with arthropod envenomations: immunologic and toxicologic considerations. Clin Pediatr Emerg Med 2007; 8: 104–109. doi: 10.1016/j.cpem.2007.04.004 [DOI] [Google Scholar]
- 4.Hung OL, Shih RD, Chiang WK. Herbal preparation use among urban emergency department patients. Acad Emerg Med 1997; 4: 209–213. doi: 10.1111/j.1553-2712.1997.tb03743.x [DOI] [PubMed] [Google Scholar]
- 5.Cole KM, Gawlinski A, Steers N. Animal-assisted therapy in patients hospitalized with heart failure. Am J Crit Care 2007; 16: 575–585, quiz 586, discussion 587–588. doi: 10.4037/ajcc2007.16.6.575 [DOI] [PubMed] [Google Scholar]
- 6.Nahm N, Lubin J, Lubin J. Therapy dogs in the emergency department. West J Emerg Med 2012; 13: 363–365. doi: 10.5811/westjem.2011.5.6574 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Gudmannsson P, Berge J. The forensic pathology of fatal attacks by the large mammals inhabiting the Nordic wilderness—a literature review. J Forensic Sci 2019; 64: 976–981. doi: 10.1111/1556-4029.13994 [DOI] [PubMed] [Google Scholar]
- 8.Ruda A, Kolejka J, Silwal AT. Spatial concentrations of wildlife attacks on humans in Chitwan national park, Nepal. Animals (Basel) 2020; 10: 153. doi: 10.3390/ani10010153 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Langley R, Mack K, Haileyesus T. National estimates of noncanine bite and sting injuries treated in US hospital emergency departments, 2001–2010. Wilderness Environ Med 2014; 25: 14–23. doi: 10.1016/j.wem.2013.08.007 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Pisazka V, Duscher G, Hodžić A. Alpha-gal allergy after a tick bite in Austria. Wien Klin Wochenschr 2019; 131: 385–388. doi: 10.1007/s00508-019-1506-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Nigrovic LE, Neville DN, Balamuth F. A minority of children diagnosed with Lyme disease recall a preceding tick bite. Ticks Tick Borne Dis 2019; 10: 694–696. doi: 10.1016/j.ttbdis.2019.02.015 [DOI] [PubMed] [Google Scholar]
- 12.Kim JY, Shim JH, Hong SJ. Sufficient explanation of management affects patient satisfaction and the practice of post-treatment management in spinal pain, a multicenter study of 1007 patients. Korean J Pain 2017; 30: 116–125. doi: 10.3344/kjp.2017.30.2.116 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Weeger S, Farin E. The effect of the patient-physician relationship on health-related quality of life after cardiac rehabilitation. Disabil Rehabil 2017; 39: 468–476. doi: 10.3109/09638288.2016.1146360 [DOI] [PubMed] [Google Scholar]
- 14.Jain R, Huang P, Ferraz RM. A new tool to improve delivery of patient-engaged care and satisfaction in facial treatments: the Aesthetic Global Ranking Scale. J Cosmet Dermatol 2017; 16: 132–143. doi: 10.1111/jocd.12297 [DOI] [PubMed] [Google Scholar]
- 15.Tabrizi JS, Rezapour R, Saadati M. Medical waste management in community health centers. Iran J Public Health 2018; 47: 286–291. [PMC free article] [PubMed] [Google Scholar]
- 16.Bariya BR, Chauhan GD, Jadeja A. Assessment of bio medical waste management practices of staff nurses according to newer guidelines in a teaching hospital of rural Vadodara, Gujarat. Int J Community Med Public Health 2017; 4: 3922–3926. doi: 10.18203/2394-6040.ijcmph20174275 [DOI] [Google Scholar]
- 17.The Republic of Turkey 5199 Animal Protection Law https://www.resmigazete.gov.tr/eskiler/2004/07/20040701.htm#2 (Accessed Jan. 28, 2020)