bluuebunny/crossref_metadata_2025 huggingface dataset:
Multivariate Predictive Models for Group A Beta‐hemolytic Streptococcal Pharyngitis in Children
Authors: Attia Magdy , Zaoutis Theoklis , Eppes Stephen , Klein Joel , Meier Frederick
Published: January 2008

Objectives: To create predictive models for the clinical diagnosis of group A beta‐hemolytic streptococcal (GABHS) pharyngitis in children. Methods: Patients aged 6 months to 18 years presenting to a pediatric ED with suspected GABHS pharyngitis were prospectively enrolled in the study. Clinicians recorded pertinent clinical information using a standardized form and obtained a throat swab to culture GABHS using a reference standard method. Twelve demographic and clinical features of patients with positive throat cultures were compared with the features of patients with negative throat cultures. Significantly different features were entered in a stepwise logistic regression analysis to create predictive models for the diagnosis. Results: Eighty‐five patients (29%) were culture‐positive and 212 (71%) were culture‐negative for GABHS. Respective mean ages were 6.2 years and 6.1 years in the two groups. Univariate chi‐square analysis of the 12 features identified six variables that were significantly associated with GABHS. All significant features were initially included in a stepwise logistic regression analysis. In model I, four independent variables were identified: moderate to severe presentation of tonsillar swelling, moderate to severe tenderness and enlargement of cervical lymph nodes, the presence of scarlatiniform rash, and the absence of moderate to severe coryza, yielding a 95% probability for GABHS. Excluding the rare scarlatiniform rash, the remaining variables were used in the second regression analysis. In model II, three independent variables were identified: moderate to severe tonsillar swelling, moderate to severe tenderness and enlargement of cervical lymph nodes, and absence of moderate to severe coryza, yielding a probability of 65% for the diagnosis. A probability of <15% was observed in the absence of scarlatiniform rash, the absence of moderate to severe tenderness and enlargement of cervical lymph nodes, and the presence of moderate to severe coryza. Conclusions: In children with moderate to severe presentation of tonsillar swelling, tenderness and enlargement of cervical lymph nodes, and the absence of coryza, the probability of a positive throat culture is >65%. Conversely, in the absence of a moderate to severe presentation of tonsillar swelling, enlargement of cervical nodes, and the presence of coryza, the probability of a positive throat culture is <15%. If prospectively validated, these models could be integrated into a consistent treat, test, and no treatment/no testing approach to the clinical management of childhood pharyngitis.
Rapid‐sequence Intubation at an Emergency Medicine Residency: Success Rate and Adverse Events during a Two‐year Period
Authors: Tayal Vivek S. , Riggs Russell W. , Marx John A. , Tomaszewski Christian A. , Schneider Robert E.
Published: January 2008

Objectives: Rapid‐sequence intubation (RSI) is an active airway intervention used frequently in emergency medicine (EM). The authors hypothesized that RSI can be performed safely in the setting of an EM training program at a tertiary care center. Methods: Observational study of RSI at an urban ED/Level 1 trauma center with annual census of 100,000 patients. Consecutive patients who underwent RSI during a two‐year period were studied. Data included age, gender, type of patient (medical/trauma), indication for intubation, number of intubation attempts (laryngoscope passes), training level of operator, and major immediate adverse events (clinical deterioration within 10 minutes of RSI). Results: RSI was used in 417 of 596 (70%) critically ill patients requiring emergent intubation. The patient demographic distribution was the following: adults 89.7%, male 58%, and trauma 44%. Primary indications for intubation among RSI patients were as follows: mechanical ventilation 57.4%, airway protection 41.3%, and cardiac arrest 1.3%. Distribution of intubations by level of EM training was PGY1, 5%; PGY2, 52%; PGY3, 40%; and attendings, 3%. Intubations were successfully completed within two attempts in 97% of the patients. Major immediate adverse events were encountered in six patients (1.4%) (hypotention = 2, hypoxemia = 1, dysrhythmia = 3). There was no death attributable to RSI. The rate of intubations requiring two or fewer attempts and without major immediate adverse events was 96%. Three patients required cricothyrotomy. Conclusion: In the setting of an EM residency at a tertiary care ED, RSI can be performed successfully with few major immediate adverse events.
Research Fundamentals
Authors: O'Neil Brian J. , Kline Jeffrey A. , Burkhart Keith , Younger John
Published: January 2008

Animal research has provided important information about many aspects of the pathophysiology of human disease. Well‐performed animal studies can determine the potential benefit of many proposed therapeutic interventions, and experimental results from animal studies have served as the basis for many landmark clinical trials. Many animal research models are described in the research literature, and choosing the appropriate model to answer a research question can be a daunting task. Even more challenging is developing a new model when none of the existing systems are relevant to the proposed question. This article was prepared by members of the SAEM Research Committee to provide an overview of animal modeling. Important considerations in choosing, applying, and developing animal research models are outlined. Practical discussions of potential problems with animal models are also provided.
The Effects of Acute and Chronic Alcohol Ingestion on Outcome following Multiple Episodes of Mild Traumatic Brain Injury in Rats
Authors: Biros Michelle H. , Kukielka Denise , Sutton Richard L. , Rockswold Gaylan L. , Bergman Thomas A.
Published: January 2008

Objective: Recent studies suggest that in some circumstances, alcohol intoxication at the time of severe head injury may be neuroprotective. The objective of this study was to determine the effect of acute and chronic alcohol ingestion on outcome in rodents sustaining multiple episodes of mild traumatic brain injury while intoxicated. Methods: For two weeks before experimentation, adult male Sprague‐Dawley rats received intoxicating levels of 95% ethanol (3 g/kg) or normal saline (NS) every other day by orogastric instillation. On the day of experimentation, the animals were randomized to receive alcohol or NS. Two hours later, the animals received either mild (1.2 ± 0.4 ATA) fluid percussion injury (FPI) or no injury. The injured animals received a total of three episodes of FPI (once every four days). Mean reflex recovery time (RRT) was determined (seconds ± SEM) immediately after each episode. Mean latency time (seconds ± SEM) for Morris Water Maze (MWM) performance was assessed at posttrauma days 11‐19. Results: The chronic alcohol‐exposed (CA) and the non‐alcohol‐exposed (NA) animals intoxicated when injured had prolonged escape, righting, and corneal RRTs after each FPI compared with the nonintoxicated injured animals and the non‐injured shams. However, the CA animals had significantly shorter RRTs when compared with the NA rats. All the injured animals had MWM deficits on testing days 1‐6 compared with the noninjured controls. On the last two MWM testing days, the injured NA animals had significantly better MWM performance than the injured CA rats. Conclusions: The injured intoxicated CA animals had a more rapid recovery of reflexes compared with the injured intoxicated NA animals. Despite initial MWM deficits, the injured NA rodents eventually began to learn the MWM. The injured CA rats never learned the maze. Under the conditions of this study, acute alcohol intoxication at the time of multiple episodes of minor head trauma did not provide neuroprotection for NA or CA rodents.
A Standardized Letter of Recommendation for Residency Application
Authors: Keim Samuel M. , Rein Judith A. , Chisholm Carey , Dyne Pamela L. , Hendey Gregory W. , Jouriles Nicholas J. , King Randall W. , Schrading Walter , Salomone Joseph , Swart Gary , Wightman John M.
Published: January 2008

Emergency medicine (EM) program directors have expressed a desire for more evaluative data to be included in application materials. This is consistent with frustrations expressed by program directors of multiple specialties, but mostly by those in specialties with more competitive matches. Some of the concerns about traditional narrative letters of recommendation included lack of uniform information, lack of relative value given for interval grading, and a perception of ambiguity with regard to terminology. The Council of Emergency Medicine Residency Directors established a task force in 1995 that created a standardized letter of recommendation form. This form, to be completed by EM faculty, requests that objective, comparative, and narrative information be reported regarding the residency applicant.
Critical Appraisal of Papers Describing Triage Systems
Authors: Hardern Richard D.
Published: January 2008

This article seeks to provide readers with a framework to enable them to assess the quality of the published description or evaluation of a triage system. Similarities between the triage process and the process of diagnosis and the nature of clinical decision rules are noted. Criteria that triage evaluations should meet are recommended, based on methodology suggested from evidence‐based medicine, the development of clinical decision rules, and evaluation of diagnostic tests.
Effect of a Practice Guideline for Emergency Department Care of Falls in Elder Patients on Subsequent Falls and Hospitalizations for Injuries
Authors: Baraff Larry J. , Lee Thomas J. , Kader Susan , Penna Richard Della
Published: January 2008

Objective: To determine the effect of a practice guideline for the ED management of falls in community‐dwelling elders on selected health outcomes. Methods: The experimental design was a pre‐post‐intervention comparison with one‐year pre‐ and post‐intervention phases. The guideline was presented to emergency physicians and nurses during a two‐week interval between these two periods. The intervention also included health information provided to the subjects and a one‐time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters. Results: 1,899 patients were eligible for the study; 1,140 pre‐intervention and 759 post‐intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre‐intervention and 21% of the post‐intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture. Conclusions: The attempted implementation of a practice guideline for the ED management of falls in community‐dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures.
Patient Satisfaction with an Emergency Department Asthma Observation Unit
Authors: Rydman Robert J. , Roberts Rebecca R. , Albrecht Gary L. , Zalenski Robert J. , McDermott Michael
Published: January 2008

Objective: To compare levels of patient satisfaction between the diagnostic and treatment protocols in an ED‐based asthma observation unit (AOU) and those with standard inpatient hospitalization. Methods: This was a prospective, randomized, controlled trial with a sample of 163 patients presenting to the ED with acute asthma exacerbations over a 30‐month period. Eligible patients were those who could not resolve their symptoms after three hours of standard ED therapy. Patients were then randomly assigned to an ED‐based AOU (experimental group) or to customary inpatient care (control group). Patient satisfaction and problems with care processes were assessed by standardized instrumentation at discharge in both groups. Results: The AOU patients scored higher than those randomized to the inpatient hospitalization protocol on four summary ratings of patient satisfaction measures: received service wanted, recommendation of the service to others, satisfaction with the service, and overall satisfaction. The AOU patients reported fewer total number of problems with care received, and fewer specific problems with communication, emotional support, physical comfort, and special needs, than did the inpatient group. However, the AOU patients reported more problems regarding their knowledge of financial costs and liabilities for their service than did the inpatients. Conclusion: Patients were more satisfied and had fewer problems with rapid diagnosis and treatment in the AOU than they did with routine inpatient hospitalization. Since AOUs represent a new ambulatory service modality, patients would benefit from greater awareness of the costs and coverage for AOUs as compared with hospital inpatient care. These findings have important implications for the future short‐ and long‐term success and feasibility of ED‐based AOUs.
Comparison of Topical Anesthetics and Vasoconstrictors vs Lubricants Prior to Nasogastric Intubation: A Randomized, Controlled Trial
Authors: Singer Adam J. , Konia Nadine
Published: January 2008

Objective: To determine whether pretreatment of the nose and throat with topical anesthetics and vasoconstrictors would reduce the pain associated with nasogastric (NG) intubation. Methods: This was a prospective, randomized, controlled trial assessing the pain of NG intubation in patients pretreated with topical anesthetics and vasoconstrictors vs surgical lubricants alone. The subjects were 40 alert, cooperative adult patients requiring NG intubation without allergies to the study medications or contraindications to their use from a suburban university‐based ED. The patients in the experimental group had phenylephrine 0.5% sprayed in their noses followed by instillation of 5 mL of 2% lidocaine jelly. Their throats were sprayed with 2% tetracaine and 14% benzocaine. The control patients received intranasal lubrication only. The primary outcome measured was pain of NG intubation on a 100‐mm visual analog scale. Other outcomes included nasal pain, discomfort from gagging, and the incidences of vomiting, choking, and epistaxis. Results: The mean age (±SD) was 54.8 ± 22.3 years; 20 (50%) were female. The patients who had a combination of topical anesthetics and vasoconstrictors inserted prior to NG intubation experienced significantly less overall pain/discomfort than did the control patients [28.6 mm (95% CI = 17.3 to 39.9 mm) vs 57.5 mm (95% CI = 44.9 to 70.1 mm), p = 0.001]. The patients in the experimental group also experienced significantly less nasal pain than did the patients in the control group [18.1 mm (95% CI = 8.0 to 28.2 mm) vs 44.4 mm (95% CI = 30.4 to 58.6 mm), p = 0.003] and significantly less discomfort from gagging than the patients receiving pretreatment with a lubricant alone [24.1 mm (95% CI = 11.1 to 37.1 mm) vs 50.9 mm (95% CI = 36.7 to 65.1 mm), p = 0.006]. There was no between‐group difference in the frequencies of adverse effects. Conclusions: Use of topical lidocaine and phenylephrine for the nose and tetracaine with benzocaine spray for the throat prior to NG intubation results in significantly less pain and discomfort than use of a nasal surgical lubricant alone. Widespread use of topical anesthetics and vasoconstrictors prior to NG intubation is recommended.
The Effect of a Quality Improvement Program on Paramedic On‐scene Times for Patients with Penetrating Trauma
Authors: Eckstein Marc , Alo Kathy
Published: January 2008

Objective: To decrease paramedic onscene times (OSTs) for major trauma patients through a focused quality improvement (QI) program. Methods: A prospective study was conducted from 1993 through 1997 to determine the impact of a QI program on paramedic OSTs. All penetrating trauma patients transported by paramedics to Los Angeles County/USC Medical Center, a Level‐1 trauma center, were included, and all cases with OSTs > 20 minutes were reviewed in detail for extenuating circumstances. Cases including multiple victims or unsecured scenes were considered “acceptable deviations.” All others were considered “fallouts,” which prompted extensive review with the paramedics and their field supervisors. Results: Prior to the inception of the QI project there was a 4.1% fallout rate of penetrating trauma patients with OSTs > 20 minutes. This fallout rate fell to 1.5% in 1997 (p < 0.01). Mortality rates among these fallouts decreased from 5.1% to 0.8% during the study period (p < 0.01). Conclusions: An intensive QI program can have a significant, positive impact on paramedic OSTs among patients with penetrating trauma.
Retrospective Review of Emergency Department Patients with Non‐variceal Upper Gastrointestinal Hemorrhage for Potential Outpatient Management
Authors: Tham Kum‐Ying , Kimura Hiroyuhi , Nagurney Tobias , Volinsky Fred
Published: January 2008

Objective: To determine the number of ED patients with non‐variceal upper gastrointestinal hemorrhage (NVUGIH) who could have been managed as outpatients through application of previously developed clinical guidelines. Methods: Descriptive study based on retrospective chart review of patients who presented with acute upper gastrointestinal hemorrhage (UGIH) to the ED of an urban teaching hospital from July 1 to December 31, 1996. Applying the clinical guidelines published by a health maintenance organization (HMO) group (no high‐risk endoscopic features/varices/portal hypertensive gastropathy, no debilitation, no orthostatic vital sign change, no severe liver disease, no serious concomitant disease, no anticoagulation or coagulopathy, no fresh, voluminous hematemesis or multiple episodes of melena on the day of presentation, no severe anemia, and adequate home support), patients who could have been managed as outpatients after esophagogastro‐duodenoscopy (EGD) were identified and analyzed. Results: 145 UGIH patients were seen in the ED, of whom 128 (88%) were admitted and 111 (77%) underwent EGD. 21 (19%) had varices, leaving 90 (81%) with NVUGIH. 18 of these 90 patients (20%, 95% CI = 12% to 28%) fulfilled guidelines for outpatient management and had the following characteristics with p < 0.05: younger age [mean 54.2 ± 5.5 (SEM) vs 63.8 ± 1.9 years], less transfusion (0.9 ± 0.3 vs 3.7 ± 0.4 units), and shorter length of stay (2.1 ± 0.4 vs 5.3 ± 0.7 days). None of the 18 outpatient management patients had any complications. Conclusion: In a non‐HMO urban teaching hospital, 18 patients with NVUGIH met criteria for outpatient management in a six‐month period and none developed a complication during a mean in‐hospital stay of 2.1 days.
Disturbing TrendsThe Epidemiology of Pediatric Emergency Medical Services Use
Authors: Sapien Robert E. , Fullerton Lynne , Olson Lenora M. , Broxterman Kimberly J. , Sklar David P.
Published: January 2008

Objective: To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints. Methods: An out‐of‐hospital database for the primary transporting service in an urban area was analyzed for patients 0‐20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed. Results: There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0‐11‐year‐olds (4.2%); 11‐16‐year‐olds (17.5%); and 17‐20‐year‐olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group. Conclusions: A substantial proportion of pediatric emergency medical services transports are for high‐risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.
Metabolic Acidosis in Restraint‐associated Cardiac ArrestA Case Series
Authors: Hick John L. , Smith Stephen W. , Lynch Michael T.
Published: January 2008

The mechanism of death in patients struggling against restraints remains a topic of debate. This article presents a series of five patients with restraint‐associated cardiac arrest and profound metabolic acidosis. The lowest recorded pH was 6.25; this patient and three others died despite aggressive resuscitation. The survivor's pH was 6.46; this patient subsequently made a good recovery. Struggling against restraints may produce a lactic acidosis. Stimulant drugs such as cocaine may promote further metabolic acidosis and impair normal behavioral regulatory responses. Restrictive positioning of combative patients may impede appropriate respiratory compensation for this acidemia. Public safety personnel and emergency providers must be aware of the life threat to combative patients and be careful with restraint techniques. Further investigation of sedative agents and buffering therapy for this select patient group is suggested.
Research Utilization and Interdisciplinary Collaboration in Emergency Care
Authors: Hansen Helen E. , Biros Michelle H. , Delaney Nicole M. , Schug Vicki L.
Published: January 2008

Abstract. Objectives: To examine perceptions of nurse—physician collaboration and research utilization in a large, county medical center with an emergency medicine (EM) residency program, to assess differences among nurses, residents, and attending physicians, and to explore the relationship between collaboration and research utilization. Methods: A cross‐sectional, exploratory, correlational design. Questionnaires measuring four aspects of collaboration—leadership, communication, problem solving, and coordination—and four aspects of research utilization—support, attitude, availability, and use—were distributed to 115 nurses, 18 attending physicians, and 33 EM residents (n = 166). A 59% response rate was achieved. Results: The survey instruments demonstrated acceptable reliability at 0.70 or better Cronbach's alpha except for communication timeliness (α= 0.64) and predictive validity. Overall, physicians and nurses rated measures of collaboration and research favorably. However, there were significant differences (p < 0.05) between physicians and nurses on four measures of collaboration (i.e., physician leadership, communication openness within group, communication openness between groups, and problem solving within group) and research utilization (research use), with physicians holding more favorable views than nurses. Three measures of collaboration predicted 47% of the variance in research use for physicians; only one measure of collaboration was important for nurses, explaining 9.3% of the variance in research use. Conclusion: Interdisciplinary collaboration showed some significance in promoting research use in the ED, especially for physicians. However, nurse—physician differences in perceptions of collaboration and research use should be examined more fully.
Assessing Research Methodology Training Needs in Emergency Medicine
Authors: Supino Phyllis G. , Richardson Lynne D.
Published: January 2008

Abstract. Objective: To determine the perceptions of emergency medicine (EM) academic faculty leaders and other academic emergency physicians regarding importance and knowledge of specific research methodology content areas and training priorities. Methods: The authors conducted a confidential mail survey of 52 EM academic chairs, 112 residency directors, 116 research directors, and 400 randomly selected other members of the Society for Academic Emergency Medicine (SAEM). Respondents rated the importance of knowledge about each of 12 content areas for enhancing research productivity, rated their own knowledge of these areas, and identified training priorities. Standard descriptive statistics were used to characterize the study population; subgroup differences were examined by nonparametric statistics. Results: 551 (81%) of those sampled returned surveys. Most (90%) respondents thought that knowledge about all selected content areas was important for enhancing research productivity; however, 7‐37% (depending on the topic) reported little knowledge or experience in specific areas. Research directors reported highest overall knowledge levels (p < 0.001), followed by chairs, residency directors, and other SAEM members. Top training priorities (identified by all subgroups) included study planning (70%), problem identification/hypothesis construction (41%), and proposal writing (38%). Conclusions: These data support the continued need to offer broad training in research methodology, but suggest that greater emphasis be given to concepts involved in initiating and planning a study and to strengthening research proposal writing skills. These results should be of interest to academic departments who must address their own training needs, and help support the development of research methodology curricula on regional and national levels to advance the state of research in the specialty of EM.
Demonstration of High‐fidelity Simulation Team Training for Emergency Medicine
Authors: Small Stephen D. , Wuerz Richard C. , Simon Robert , Shapiro Nathan , Conn Alasdair , Setnik Gary
Published: January 2008

Abstract. Emergency medicine (EM) presents many cognitive, social, and systems challenges to practitioners. Coordination and communication under stress between and among individuals and teams representing a number of disciplines are critical for optimal care of the patient. The specialty is characterized by uncertainty, complexity, rapidly shifting priorities, a dependence on teamwork, and elements common to other risky domains such as perioperative medicine and aviation. High‐fidelity simulators have had a long tradition in aviation, and in the past few years have begun to have a significant impact in anesthesiology. A national, multicenter research program to document the costs of teamwork failures in EM and provide a remedy in the form of an Emergency Team Coordination Course has developed to the point that high‐fidelity medical simulators will be added to the hands‐on training portion of the course. This paper describes an evolving collaborative effort by members of the Center for Medical Simulation, the Harvard Emergency Medicine Division, and the MedTeams program to design, demonstrate, and refine a high‐fidelity EM simulation course to improve EM clinician performance, increase patient safety, and decrease liability. The main objectives of the paper are: 1) to present detailed specifications of tools and techniques for high‐fidelity medical simulation; 2) to share the results of a proof‐of‐concept EM simulation workshop introducing multiple mannequin/three‐patient scenarios; and 3) to focus on teamwork applications. The authors hope to engage the EM community in a wide‐ranging discussion and handson exploration of these methods.
Trauma Resuscitation/Critical Care Fellowship for Emergency Physicians: A Necessary Step for the Future of Academic Emergency Medicine
Authors: Bozeman William P. , Gaasch Wade R. , Barish Robert A. , Scalea Thomas M.
Published: January 2008

Abstract. Emergency physicians (EPs) have long been de‐facto providers of trauma resuscitation and critical care in academic and community hospital settings, and are significantly involved in out‐of‐hospital trauma care and trauma research. A one‐year fellowship has been developed and implemented to provide advanced training in trauma resuscitation and critical care to EPs with a special interest in the field. This fellowship provides additional depth and breadth of training to prepare graduates for leadership roles in academic and specialized trauma centers. This is the first fellowship of its kind for EPs, and may serve as a model for fellowships at other institutions.
Academic Emergency Medicine Staffing Nonacademic Emergency Department Sites: A National Survey
Authors: Meldon Stephen W. , Cydulka Rita K. , Jouriles Nicholas J. , Emerman Charles L.
Published: January 2008

Abstract. Changing health care markets have threatened academic health centers and their traditional focus on teaching and research. Objectives: To determine the number of academic emergency medicine departments (AEMDs) that staff additional nonacademic ED sites and to determine whether clinical reimbursement monies from those ED sites are used for academic purposes. Methods: A two‐part survey of all 119 academic EM programs listed in the 1997‐1998 Graduate Medical Education Directory was conducted. Questionnaries were addressed to each AEMD chair. AEMDs and ED sites were characterized. Hiring difficulties, EM faculty academic productivity, and use of ED site reimbursement monies for academic activities were assessed. Results: Ninety‐nine of 119 (83%) AEMDs responded. Twenty‐three (23%) AEMDs staffed 28 added ED sites. These sites tended to be urban (65%), with moderate volumes (25,000‐35,000 patients/year), and had an equal or better reimbursement rate than the AEMD (89%). ED sites were commonly staffed by academic EM faculty (79%) and EM residents (29%). Ninety‐six percent of the AEMDs had hired additional faculty; hiring new faculty was considered easy. Academic productivity at AEMDs with added ED sites was reported as unchanged. Reimbursement monies from these ED sites were commonly used for faculty salary support, faculty development, and EM research and residency activities. Conclusions: Academic EM departments are often affiliated with nonacademic ED sites. These additional sites are commonly staffed by academic EM faculty and EM residents. Academic productivity does not appear to decrease when additional ED sites are added. Reimbursement monies from these ED sites commonly supports academic activities.
In‐vivo Myocardial Substrate Alteration during Perfused Ventricular Fibrillation
Authors: Angelos Mark G. , Torres Carlos A. A. , Rath Dipti P. , Zhu Hui , Beckley Philip D. , Robitaille Pierre‐Marie L.
Published: January 2008

Abstract. Objectives: Earlier work suggests the invivo heart alters its substrate utilization as a function of cardiac work. Previous work has also demonstrated the high oxygen requirements of the heart during ventricular fibrillation (VF). The authors hypothesized that myocardial substrate utilization during VF with perfusion is similar to the normal beating heart under conditions of increased workload. Methods: Myocardial substrate selection was studied in the invivo porcine myocardium using 13carbon nuclear magnetic resonance (13C NMR) under conditions of increased cardiac work (dobutamine group) and VF with extracorporeal perfusion (VF group). Once the animal preparation was completed, metabolic steady state was achieved with the infusion of unlabeled acetate into the left anterior descending (LAD) coronary artery. The infused substrate was then changed to [2‐13C] acetate and glutamate pool labeling was monitored by 13C NMR. The glutamate C4 resonance areas at baseline and after intervention of either increased workload (dobutamine group) or perfused VF (VF group) were compared within groups using paired t‐tests. Results: Baseline aortic and great cardiac vein lactates, glucose levels, blood gases, hemoglobin levels, and temperatures were similar between groups. In both groups, there was a significant decrease from baseline in the labeling of C4 glutamate peaks (dobutamine group: 20.2 ± 14.9 vs 84.7 ± 32.7, p = 0.002; and VF group: 49.8 ± 24.4 vs 83.9 ± 24.4, p = 0.02), indicating selection against acetate oxidation in favor of other endogenous substrates. Conclusions: In the in‐vivo heart, despite the absence of functional contractions, changes in substrate utilization during perfused VF are similar to changes that occur with increased workload in the normal beating heart.
A Comparison of Two Automated External Defibrillator Algorithms
Authors: Verbeek P. Richard , Turner Daniel , Lane Captain John , Carter Captain Craig
Published: January 2008

Abstract. Objective: To compare the interval to delivery of the first shock by first responders in mannequin‐based cardiac arrest scenarios using two automated external defibrillator (AED) algorithms. Methods: Thirty‐six (18 pairs) of Toronto firefighters (FFs) trained in two AED algorithms, algorithm I (A‐I) and algorithm II (A‐II), were studied. A‐II mandates the immediate application of the AED once pulselessness is established. In contrast to A‐I, A‐II dictates that no CPR be initiated until it is required by the AED voice prompts. Each FF pair alternated roles while performing “shock‐indicated,” mannequin‐based scenarios according to A‐I and A‐II. The interval from mannequin contact to delivery of the first shock was recorded. Five pairs were videotaped. The intervals to complete predetermined steps were compared between algorithms to determine in which step(s) time saving occurred. Results: The mean (±SD) interval to the first shock in A‐I was 80.7 seconds (±10.5 sec) (95% CI = 77.2 to 84.2 sec) vs 61.1 seconds (±8.75 sec) (95% CI = 58.2 to 64.0 sec) in A‐II (p < 0.001). A‐II shortened the interval to the first shock by 19.6 sec (±11.5) (95% CI = 15.8 to 23.4 sec). The time saving was a direct result of delaying CPR in A‐II. Conclusion: A‐II reduced the interval from mannequin contact to the first shock in standard training scenarios.
Octylcyanoacrylate for the Treatment of Partial‐thickness Burns in Swine: A Randomized, Controlled Experiment
Authors: Singer Adam J. , Berrutti Luis , Thode Henry C. , McClain Steve A.
Published: January 2008

Abstract. Objective: To compare re‐epithelialization rates of superficial partial‐thickness burns treated with octylcyanoacrylate (OCA), silver sulfadiazine (SSD), and dry gauze (controls) in swine. Methods: This was a prospective, longitudinal, blinded, controlled, experimental trial using anesthetized swine. Sixty‐three standardized burns were created by applying an aluminum bar preheated to 80°C for 20 seconds to the flanks of four young pigs. Three equal sets of 21 burns were randomly treated with OCA spray, SSD, or dry gauze (controls). Full‐thickness biopsies were taken after 30 minutes and at seven and 14 days for blinded histopathologic evaluation by two dermatopathologists using hematoxylin and eosin staining. The percent of wound re‐epithelialization was measured at days 7 and 14, calculated by dividing the length of the regenerated epidermis by the measured width of the biopsy. Analysis of variance (ANOVA) and repeated‐measures ANOVA controlling for the individual pig were used for comparisons among groups. This study had 80% power to demonstrate a large between‐group difference in percent re‐epithelization (alpha = 0.05). Results: There were 63 burns and 126 biopsies. Ten biopsies were excluded for technical reasons. At seven days, there was a significant between‐group difference in percent re‐epithelialization. Percent re‐epithelialization was greatest in the OCA group (65.0%), followed by the SSD group (37.6%), and lowest in the control group (8.8%). At 14 days, all wounds demonstrated near complete re‐epithelialization and there was no significant difference in the percent of re‐epithelialization among the groups. There was only one wound infection in the OCA group. Conclusions: Under these study conditions, treatment of partial‐thickness burns with OCA spray resulted in a higher percent of re‐epithelialization at seven but not 14 days when compared with both SSD and control, with no significant increase in infection rates. Future studies should evaluate the use of OCA for the treatment of burns in humans.
Radial Head Subluxation: Comparing Two Methods of Reduction
Authors: McDonald Julia , Whitelaw Christine , Goldsmith L. Jane
Published: January 2008

Abstract. Objectives: To determine whether reduction of radial head subluxation (RHS) is more successful using pronation and flexion (PF) vs the more widely used supination and flexion (SF) method. Methods: Prospective study in a tertiary care children's hospital ED from August 1996 through December 1997. Inclusion criteria included age <7 years with an upper‐extremity injury. Exclusion criteria included neurologic impairment, congenital malformation, or obvious bony deformity or edema. Patients were randomized to receive either PF or SF. Reduction was considered successful if the child used the injured arm. Both the physician and the parent rated the child's pain during the procedure using a descriptive ordinal scale, from 0 (no pain) to 3 (severe pain). Results: 148 patients were enrolled; 13 were excluded. Success was achieved on the first attempt in 53/67 (80%, 95% CI = 0.67 to 0.88) of patients receiving PF and in 47/68 (69%, 95% CI = 0.57 to 0.80) of those receiving SF (p = 0.186). For those injuring the left arm, 29/41 (71%, 95% CI = 0.54 to 0.84) were successfully reduced using SF, while 33/37 (89%, 95% CI = 0.75 to 0.97) were successfully reduced using PF (p = 0.044). Physicians perceived PF to be less painful than SF (p = 0.013). There was no significant pain score difference rated by parents. Conclusions: Both PF and SF can be used with success to reduce RHS. For left arm injuries, PF should be attempted first, since it may decrease the need for further treatment. PF may be less painful, particularly for first reduction attempts.
Procedural Competency in Emergency Medicine: The Current Range of Resident Experience
Authors: Hayden Stephen R. , Panacek Edward A.
Published: January 2008

Abstract. Objectives: To evaluate the recorded range of procedures tracked by emergency medicine (EM) programs, and to determine whether differences in procedural experience occur in various types of residency or hospital settings. Methods: The program directors of 112 approved EM programs were asked to send actual procedure logs. The requested information included the average total number of a given procedure per graduating resident, for all procedures that were tracked. Data were categorized by program format, hospital type, and ED volume. To assess the global procedural experience among programs, a set of 22 “index procedures” were identified; all procedures the EM residency review committee (RRC‐EM) required to be tracked were included in this set. The means per graduating resident for each index procedure were added together to generate a “mean index procedure sum” (MIPS) per graduating resident for each residency program. These MIPSs for a residency were then compared by program format, hospital type, and ED volume. A similar analysis was performed for all resuscitations, and a “mean index resuscitation sum” (MIRS) per graduating resident was generated. Results: An overall response rate of 82% was achieved; a number of programs had not graduated a residency class and were not included. Sixty‐five of 85 eligible programs (76%) provided procedural data. The average number of a given procedure per graduating resident (95% CI in parentheses) for selected procedures is as follows: oral intubation 65 (46 to 85), intubation unspecified 75 (62 to 87), nasal intubation 6 (4 to 9), cricothyroidotomy 2 (1 to 2), subclavian catheter 23 (16 to 30), chest tubes 17 (14 to 20), intraosseous line 2 (1 to 3), thoracotomy 3 (2 to 5), and vaginal deliveries 17 (13 to 21). The only statistically significant differences in subgroup comparisons were in diagnostic peritoneal lavage, trauma resuscitations, and pediatric medical resuscitations when compared by postgraduate year format, and intubation—unspecified and cricothyroidotomy when compared by hospital type. There was no statistically significant difference when MIPSs were compared by format, hospital type, or ED volume. Conclusions: To the authors' knowledge, this is the first study of the range of EM resident procedure experience across the spectrum of EM residency types and settings. Overall, there are few statistically significant differences in procedure experience among different program formats. Similar experiences are recorded in a variety of different hospital types or ED volumes. However, some programs report very limited EM resident experience with selected critical procedures. There is a large variation in the types and numbers of procedures recorded by EM programs.
Health Status Disparities among Public and Private Emergency Department Patients
Authors: Alter Harrison J. , Braun Russ , Zazzali James L.
Published: January 2008

Abstract. Objective: To explore whether patients in a public ED had poorer health than patients in a private ED, the authors compared the physical and mental health statuses of patients seeking emergency care. Methods: A cross‐sectional observational study of all adult patients, regardless of acuity, seen during two 24‐hour periods in spring 1997 in an urban county trauma center (68,000 annual visits) and a private community ED (35,000 annual visits). Scores on the Physical Component Summary (PCS) and the Mental Component Summary (MCS) scales of the Medical Outcomes Study 12‐Item Short‐Form Health Survey (SF‐12) were compared between sites, with published national norms, and with hospital admission. Results: Of 571 eligible patients, 392 (69%) completed the SF‐12. Patients in the public ED had a mean PCS score of 40.1, compared with 43.7 for patients in the private ED, for a difference of 3.6 points (p < 0.01; 95% CI = 0.9 to 6.1). After controlling for age, sex, ethnicity, triage acuity, ambulance arrival, and insurance status, this difference increased to 3.9 points (p = 0.02; 95% CI = 0.7 to 7.0). The mean MCS score among public ED patients was 44.1, compared with 46.5 in the private ED population, for a difference of 2.4 (p = 0.08; 95% CI = ‐0.3 to 5.0); after adjustment this difference increased to 2.5 (p = 0.15; 95% CI = ‐0.9 to 5.8), but remained statistically not significant. While all scores were significantly lower than national norms (mean PCS 50.1, mean MCS 50.0), patients in the public ED scored consistently lowest. PCS score was significantly inversely correlated with admission, with each point decrease in PCS score increasing the odds of admission by 0.05 (95% CI = 0.01 to 0.08), and conferring an odds ratio of 5.1 (95% CI = 1.2 to 21.1) for admission among the 25th percentile for PCS scores. Conclusions: Patients seeking care in the public ED had lower adjusted physical health status scores than comparable patients obtaining care in a private ED. The SF‐12 is sufficiently responsive to detect hypothesized differences between ED populations, and correlates well with admission decisions.
Normal Intrauterine Pregnancy Is Unlikely in Patients Who Have Echogenic Material Identified within the Endometrial Cavity at Transvaginal Ultrasonography
Authors: Dart Robert , Dart Linda , Mitchell Patricia
Published: January 2008

In first‐trimester patients with abdominal pain or vaginal bleeding, pelvic ultrasonography (US) is often performed to assess the status of the pregnancy. Identification of echogenic material within the endometrial cavity in the absence of a gestational sac has been attributed to the presence of either retained products of conception or clotted blood. However, to the authors' knowledge, no study has directly addressed whether this finding reliably excludes the diagnosis of a normal intrauterine pregnancy (IUP). Objective: To determine whether the identification of echogenic material within the endometrial cavity at transvaginal US excludes the diagnosis of a normal IUP. Methods: Data were collected retrospectively from August 1991 to August 1997 on consecutive urban teaching hospital ED patients with abdominal pain or vaginal bleeding who had a transvaginal US performed during the ED visit that demonstrated echogenic material within the endometrial cavity. Patients were excluded if they had a dilatation and evacuation (D+E) procedure performed prior to the exclusion of a normal IUP by other means [open cervical os, falling quantitative beta‐human chorionic gonadotropin (β‐hCG) values, a progesterone value <5.0 ng/mL or β‐hCG >3,000 mIU/mL] or if they were lost to follow‐up. Patients were followed until a final diagnosis was ultimately determined. Results: A total of 83 patients with echogenic material were identified. Of these, three patients were excluded because a D+E was performed prior to an IUP being excluded by other means, and two patients were lost to followup. Of the 78 enrolled patients, none had a final diagnosis of normal IUP. Ectopic pregnancy was confirmed in nine patients, five of whom had no adnexal or cul de sac findings to suggest this diagnosis. Conclusion: In symptomatic patients who have echogenic material but no gestational sac visualized within the endometrial cavity at US, the likelihood of a normal IUP is low.
Predicting Regional Variations in Mortality from Motor Vehicle Crashes
Authors: Clark David E. , Cushing Brad M.
Published: January 2008

Objective: To show that the previously‐observed inverse relationship between population density and per‐capita mortality from motor vehicle crashes can be derived from a simple mathematical model that can be used for prediction. Methods: The authors proposed models in which the number of fatal crashes in an area was directly proportional to the population and also to some power of the mean distance between hospitals. Alternatively, these can be parameterized as Weibull survival models. Using county and state data from the U.S. Census, the authors fitted linear regression equations on a logarithmic scale to test the validity of these models. Results: The southern states conformed to a different model from the other states. If an indicator variable was used to distinguish these groups, the resulting model accounted for 74% of the variation from state to state (Alaska excepted). After controlling for mean inter‐hospital distance, the southern states had a per‐capita mortality 1.37 times that of the other states. Conclusions: Simply knowing the mean distance between hospitals in a region allows a fairly accurate estimate of its per‐capita mortality from vehicle crashes. After controlling for this factor, vehicle crash mortality per capita is higher in the southern states, for reasons yet to be explained.
Emergency Medical Services in China
Authors: Thomas Tamara L. , Clem Kathleen J.
Published: January 2008

The objective of this article is to identify and describe Chinese emergency medical services (EMS) components. Chinese EMS system development began in the 1980s with “importing” of EMS principles from other systems. China is now attempting to unify these principles. Chinese EMS systems are absent in most rural areas. Urban ambulance dispatch or “rescue” centers provide both transport and inpatient care. Ambulances are staffed with either a physician or a driver. There is not extensive overlap between hospital emergency physicians and ambulance physicians and no out‐of‐hospital providers at the paramedic or emergency medical technician level exist. Access to EMS is accomplished by dialing 1‐2‐0. Emergency calls go directly to the rescue center and a physician is dispatched. No on‐line radio communication between hospitals and ambulances typically takes place. China has assimilated both traditional and unique EMS components and is undergoing development. It remains unclear whether a systematized EMS structure will emerge.