bluuebunny/crossref_metadata_2025 huggingface dataset:
The Clinical Utility of Serologic Markers in the Evaluation of the Acute Scrotum
Authors: Rivers Kandis K. , Rivers Emanuel P. , Stricker Hans J. , Lewis James , Urrunaga Julie , Karriem Varnada
Published: January 2008

Abstract. Objective: To examine the presence of interleukin‐1 (IL‐1), interleukin‐6 (IL‐6), and creatine phosphokinase‐MM (CPK‐MM) in patients with acute scrotal pain and assess their clinical utility in the diagnosis of testicular torsion (TT) and epididymitis. Methods: Twenty‐five patients with acute scrotal pain were prospectively enrolled over a two‐year period. History, physical examination, complete blood count, urinalysis, and scrotal ultrasound were performed. Testicular torsion was confirmed by surgical exploration. Epididymitis was diagnosed using physical examination, scrotal ultrasound, and positive urinalysis. Venous blood was assayed for IL‐1, IL‐6, and CPK‐MM in triplicate during the routine drawing of blood in the emergency department. The data are reported as medians ± interquartile ranges (IQRs). Results: Twenty‐five patients with acute scrotal pain were evaluated; 11 with TT, three with torsion of the appendix testis (TAT), ten with epididymitis, and one with varicocele. One patient had both TT and epididymitis. Interleukin‐1 was not detectable in either group. The CPK‐MM values between TT and epididymitis were virtually identical at 99.8 and 100 IU/L, respectively. The median value for IL‐6 was 1.03 (IQR = 0.19 to 2.86) vs 20.86 (IQR = 2.14 to 65.50) pg/mL in the torsion and epididymitis groups, respectively. The 97.5% CI for the difference of medians of 19.9 was 0.4 to 65.1, p = 0.02. Using receiver operating characteristic (ROC) curve analysis for IL‐6, the area under the curve was 0.82 for torsion and 0.67 for epididymitis. Using a cutoff value of IL‐6 ≥ 1.41 pg/mL, the positive predictive value of IL‐6 in diagnosing epididymitis was 78.6%, with a negative predictive value of 100% for TT. There were no cases of missed TT on follow‐up. Conclusions: This preliminary investigation of serologic markers demonstrates that IL‐6 is significantly elevated in epididymitis as compared with TT. Creatine phosphokinase‐MM and IL‐1 were not found to be of diagnostic utility. The small sample size of this study precludes a definitive conclusion as to the utility of these markers in the emergency department. However, IL‐6 may be clinically useful as an additional element in differentiating the causes of acute scrotal pain, and further study is warranted.
Clinical Clearance of Cervical Spinal Injuries by Emergency Nurses
Authors: Hsieh Margaret , Gutman Michael , Haliscak Debbie
Published: January 2008

Abstract. Objectives: To determine the interrater reliability between emergency nurses and emergency physicians on defined criteria for clinically clearing the cervical spine in blunt trauma patients. Methods: Blunt trauma patients, 12 years or older, arriving with cervical spinal precautions were prospectively enrolled as a convenience sample. Each member of the emergency physician‐nurse pair completed a questionnaire with regard to five criteria for clinically clearing the cervical spine for each patient. Interrater reliability was determined by calculating the κ statistics for the individual and combined criteria. Results: Physicians and nurses agreed on the presence or absence of the combined criteria in 175 of 211 patients (82.9%κ, 0.65). Agreements on individual criteria were as follows: 1) intoxication—203 patients (96.2%κ, 0.82); 2) altered consciousness—197 patients (93.4%κ, 0.60); 3) neck pain—185 patients (87.7%κ, 0.75); 4) distracting injury—160 patients (75.8%κ, 0.36); and 5) neurologic deficit—198 patients (93.8%κ, 0.45). If disagreements in which the physician would clinically clear the patient but the nurse would not were considered as agreements, then overall agreement would be 198 of 211 patients (93.8%κ, 0.88). On the assumption that nurses would assess patients prior to physicians, they would have cleared 35% of the patients before the physicians. However, they would have ordered 12% more radiographs and unsafely clinically cleared 5% of the patients. Conclusions: The interrater reliability for the combined cervical spinal injury criteria between emergency nurses and physicians was good to excellent. However, with the training given in this study, nurses would order more radiographs than physicians and would unsafely clinically clear cervical spines in some patients.
The Emergency Department as a Potential Site for Smoking Cessation Intervention: A Randomized, Controlled Trial
Authors: Richman Peter B. , Dinowitz Seth , Nashed Ashraf H. , Eskin Barnett , Sylvan Erik , Allegra Christine , Allegra John , Mandell Mark
Published: January 2008

Abstract. Objective: To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program. Methods: This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two‐page “Stop Smoking” pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post‐ED visit. Categorical data were analyzed by chi‐square and Fisher's exact tests. Rank data were analyzed by Mann‐Whitney tests and continuous data by t‐tests. All tests were two‐tailed with alpha set at 0.05. Results: One hundred fifty‐two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow‐up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0‐4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1]. Conclusion: The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.
Leprosy in the Emergency Department
Authors: Hoffner Richard J. , Esekogwu Victor , Mallon William K.
Published: January 2008

Abstract. Objectives: Los Angeles County—University of Southern California Medical Center, like many large urban hospitals, has a large immigrant population from regions of the world where leprosy is endemic. Emergency physicians (EPs) in these settings can expect to encounter leprosy patients. This study reviewed the emergency department (ED) course of patients with confirmed leprosy in an attempt to describe the most common presenting patterns so that future cases can be more easily recognized. Methods: This was a retrospective chart review of all patients followed in the Hansen's disease clinic. Demographics, leprosy type, clinical presentations to the ED, and medications were recorded. Results: Of the total number of patients (415), most were of Mexican (52%), Filipino (15%), Vietnamese (14%), and Chinese (5%) origin. Leprosy was classified as lepromatous (56%), borderline (40%), and tuberculoid (4%). There were a total of 118 ED visits by 74 patients. The mean age was 46 years, with 51% male and 49% female. Dermatologic (68%), neurologic (23%), and ophthalmologic (9%) complaints were the most common reasons for ED presentation related to leprosy. The EP did not elicit a history of leprosy in 34% of those patients followed in the leprosy clinic. The ED diagnosis of leprosy was made in 3 of 15 (20%) undiagnosed cases. Of the 63 patients prescribed medications in the leprosy clinic at the time of their ED visits, 22 (35%) ED charts did not report leprosy drugs. Conclusion: Patients with leprosy present to U.S. EDs, and new cases can be identified. Early recognition is important given leprosy's devastating consequences, major drug side effects of medications used for treatment, and improved prognosis with multidrug therapy. A history of leprosy and associated medications are often not documented in the ED chart, which may reflect a continued fear of stigmatization among these patients.
Do Football Helmets Reduce Acceleration of Impact in Blunt Head Injuries?
Authors: Lewis Lawrence M. , Naunheim Rosanne , Standeven John , Lauryssen Carl , Richter Chris , Jeffords Brian
Published: January 2008

Abstract. Several recent studies suggest that acceleration of the head at impact during sporting activities may have a detrimental effect on cognitive function. Reducing acceleration of impact in these sports could reduce neurologic sequelae. Objective: To measure the effectiveness of a regulation football helmet to reduce acceleration of impact for both low‐ and moderate‐force impacts. Methods: An experimental paired study design was used. Male volunteers between 16 and 30 years of age headed soccer balls traveling approximately 35 miles per hour bareheaded and with a helmet. An intraoral accelerometer worn inside a plastic mouthpiece measured acceleration of the head. The helmet also had an accelerometer placed inside the padding. For more forceful impacts, cadaver heads, both with and without helmets, were instrumented with intraoral (IO) and intracranial (IC) accelerometers and struck with a pendulum device. Simultaneous IO and IC accelerations were measured and compared between helmeted and unhelmeted cadaver heads. The main outcome was mean peak acceleration of the head and/or brain associated with low‐ and moderate‐force impacts with and without protective headgear. Results: Mean peak Gs, measured by the mouthpiece accelerometer, were significantly reduced when the participants heading soccer balls were wearing a helmet (7.7 Gs with vs 19.2 Gs without, p = 0.01). Wearing a helmet also significantly lowered the peak Gs measured intraorally and intracranially in cadavers subjected to moderate‐force pendulum impacts: 28.7 Gs with vs 62.6 Gs without, p < 0.001; and 56.4 Gs with vs 81.6 Gs without, p < 0.001, respectively. Conclusions: A regulation football helmet substantially reduced the peak Gs associated with “heading” a soccer ball traveling at moderately high velocities. A helmet was also effective in reducing the peak acceleration both intraorally and intracranially for impacts significantly more forceful than heading a soccer ball.
Outcome in Cardiac Arrest Patients Found to Have Cardiac Standstill on the Bedside Emergency Department Echocardiogram
Authors: Blaivas Michael , Fox John Christian
Published: January 2008

Abstract. Patients presenting in cardiac arrest frequently have poor outcomes despite heroic resuscitative measures in the field. Many emergency medical systems have protocols in place to stop resuscitative measures in the field; however, further predictors need to be developed for cardiac arrest patients brought to the emergency department (ED). Objective: To examine the predictive value of cardiac standstill visualized on bedside ED echocardiograms during the initial presentations of patients receiving cardiopulmonary resuscitation (CPR). Methods: The study took place in a large urban community hospital with an emergency medicine residency program and a high volume of cardiac arrest patients. As part of routine care, all patients arriving with CPR in progress were subject to immediate and brief subxiphoid or parasternal cardiac ultrasound examination. This was followed by brief repeat ultrasound examination during the resuscitation when pulses were checked. A 2.5‐MHz phased‐array probe was used for imaging. Investigators filled out standardized data sheets. Examinations were taped for review. Statistical analysis included descriptive statistics, positive and negative predictive values, and likelihood ratios. Results: One hundred sixty‐nine patients were enrolled in the study. One hundred thirty‐six patients had cardiac standstill on the initial echocardiogram. Of these, 71 patients had an identifiable rhythm on monitor. No patient with sonographically identified cardiac standstill survived to leave the ED regardless of his or her initial electrical rhythm. Cardiac standstill on echocardiogram resulted in a positive predictive value of 100% for death in the ED, with a negative predictive value of 58%. Conclusions: Patients presenting with cardiac standstill on bedside echocardiogram do not survive to leave the ED regardless of their electrical rhythms. This finding was uniform regardless of downtime. Although larger studies are needed, this may be an additional marker for cessation of resuscitative efforts.
Children with First‐time Simple Febrile Seizures Are at Low Risk of Serious Bacterial Illness
Authors: Trainor Jennifer L. , Hampers Louis C. , Krug Steven E. , Listernick Robert
Published: January 2008

Objective: To describe the rates of serious bacterial illness (SBI) in children presenting to emergency departments (EDs) with first‐time uncomplicated febrile seizures. Methods: The ED visits from seven Chicago metropolitan area hospitals (two tertiary pediatric EDs, five community general EDs) for all pediatric patients seen between July 1995 and December 1997 with a discharge diagnosis including the term “seizure” were retrospectively identified. Records of patients who met criteria for simple, first‐time febrile seizure were reviewed (age 6‐60 months; temperature ≥38.0°C; single, generalized, tonic—clonic seizure <20 minutes; absence of known central nervous system disease). Rates of bacteremia, urinary tract infection, bacterial meningitis, and pneumonia were determined. Results: Four hundred fifty‐five children were identified who had first‐time simple febrile seizures. The study participants had a mean age of 21 months and a mean temperature of 39.6°C, and 64% were male. Seventy‐three percent were seen in a community hospital setting. Blood cultures were obtained for 315 children (69%). Four children (1.3% [95% CI = 0.1% to 2.5%]) were bacteremic, all with Streptococcus pneumoniae; the rate of bacteremia did not differ in the subset at highest risk for bacteremia (6‐36 months, temperature >39°C). No demographic or laboratory data distinguished the bacteremic children from those with negative blood cultures. One hundred seventy‐one children (38%) had urine cultures obtained; 5.9% [95% CI = 2.4% to 9.4%] of the cultures grew >100,000 colony‐forming units/mL of a single pathogenic organism. One hundred thirty‐five children (30%) had cerebrospinal fluid cultures performed. None of these cultures grew a bacterial pathogen [95% CI = 0% to 2.2%]. Two hundred eight children (45.7%) had chest x‐rays performed; 12.5% [95% CI = 10.2% to 14.8%] (n= 26) of the x‐rays were read as consistent with pneumonia by the radiologist at the treating institution. None of the blood cultures performed on children with abnormal radiographs were positive (cultures drawn on 23 of 26 patients, 88%). Stool cultures were performed on 14 children (3.1%); two cultures (14.3% [95% CI = 0% to 32.6%]) grew a bacterial pathogen, both Shigella. Conclusions: Rates of SBI in this multi‐institution population of children with first‐time simple febrile seizures were low and are consistent with those published in the literature for febrile children without seizures.
Domestic Abuse in the Emergency Department: Can a Risk Profile Be Defined?
Authors: Zachary Mary J. , Mulvihill Michael N. , Burton William B. , Goldfrank Lewis R.
Published: January 2008

Objectives: The main purpose of this study was to determine whether any clinical or demographic characteristics could identify adult female patients presenting to the emergency department (ED) with a history of domestic abuse. A second objective was to describe the frequency, types, and severity of this abuse. Methods: This study was a crosssectional survey of 611 women conducted in an academically‐affiliated, urban ED. Domestic abuse was described as “recent” (within the preceding 12 months) or “lifetime” (recent or past). This included emotional, physical, and sexual abuse. Results: Recent (7.9%, n= 48) and lifetime (38%, n= 232) domestic abuse was reported. For recently abused women, violence had been severe (87.5%, n= 42) and was associated with 1) trauma (OR 5.4, 95% CI = 2.6 to 11.6), 2) obstetrical and gynecological syndromes (OR 5.6, 95% CI = 2.4 to 13.2), and 3) psychiatric symptoms and substance use (OR 7.3, 95% CI = 2.4 to 22.0). The sensitivities and positive predictive values of these risk factors individually (<27.1% and <25.0%, respectively) and in aggregate (56.3% and 20.9%, respectively) were low. These indicators predicted only 27 (56.3%) of recently abused women. Lifetime domestic violence was more likely in homeless women (OR 5.8, 95% CI = 2.2 to 15.0), although less likely in immigrants (OR 0.4, 95% CI = 0.3 to 0.7). Conclusions: Clinical presentations and demographic characteristics of women presenting to the ED may not be sensitive or predictive indicators of domestic abuse. In the absence of typical clinical or demographic findings, asking all women in the ED about domestic abuse remains a necessary priority.
The Effect of Lower‐extremity Position on Cerebrospinal Fluid Pressures
Authors: Abbrescia Kelly L. , Brabson Thomas A. , Dalsey William C. , Kelly John J. , Kaplan Justin L. , Young Tracey M. , Jenkins Donald , Chu John , Emery Michael S.
Published: January 2008

Abstract. Objective: To determine the effects of lower‐extremity positioning on cerebrospinal fluid opening pressure (CSFp). The authors believed that during lumbar puncture (LP), CSFp does not meaningfully decrease when the lower extremities are extended from flexion, as is often suggested. Methods: In a convenience sample of adult patients who clinically required LP in an urban emergency department, three sequential CSFp measurements were obtained in either sequence A (knee, hip, and neck flexion [90°], then extension, then flexion) or sequence B (extension, flexion, then extension) prior to CSF withdrawal. The neck was flexed at 30° when the lower extremities were flexed, while the thoracolumbar spine was kept in the neutral position for all measurements. Results: Nineteen patients were studied in each sequence. Although variable, overall within‐patient changes between positions were not clinically meaningful. Mean and 95% confidence intervals (95% CIs) for the decrease in CSFp from position 1 to position 3 (same position) were 0.2 cm H2O (1.7%) and 0.9 to ‐0.6 cm H2O (6% to ‐2.7%), respectively. Changing from flexion to extension decreased pressure measurements by a mean of 0.9 cm H2O (2.5%) [95% CI = 2.1 to ‐0.1 cm H2O (7.6% to ‐2.4%)]. Changing from extension to flexion increased CSFp by a mean of 1.1 cm H2O (6.1%) [95% CI = 0.2 to 2.0 cm H2O (1.3% to 11.5%)], a statistically but not clinically meaningful change. Conclusions: Changing lower‐extremity position did not meaningfully change mean CSFp. These data do not support the common suggestion that extending the lower extremities during LP meaningfully decreases CSF opening pressures.
Core Rewarming via Warm Lavage Liquid Ventilation in a Swine Model of Hypothermia‐associated Ventricular Fibrillation
Authors: Dickson Eric W. , Sivilotti Marco L. A. , Mangolds Ginger , Renzi Francis P. , Heard Stephen O. , Mori Kazuhisa , Burns Michael J.
Published: January 2008

Abstract. Objectives: To determine whether warm lavage liquid ventilation (LV) would provide rapid cardiopulmonary rewarming in swine with severe hypothermia and ventricular fibrillation. Methods: Intubated common swine (n= 3; mean ± SEM weight 26 ± 1.2 kg) were cooled to a mean aortic temperature of 26.4 ± 0.9°C. Ventricular fibrillation was induced by transthoracic electrical shock. Rewarming was initiated by continuous endotracheal instillation of warm (44°C) pre‐oxygenated, perfluorocarbon liquid at 5 mL/kg/min. Endotracheal instillation of perfluorocarbon occurred while standard gas ventilation continued. Manual chest compressions were performed throughout the 30‐minute rewarming process. Outcome measures were the absolute and relative rates of change of all temperatures. Results: After 30 minutes of warm lavage LV, the mean aortic and pulmonary artery temperatures increased by 6.6 ± 0.6°C, respectively. Esophageal, nasal, and rectal temperatures did not change significantly. In one animal, normal sinus rhythm spontaneously returned after 16 minutes of rewarming. Conclusions: During cardiac arrest, warm lavage liquid ventilation may produce rapid cardiopulmonary rewarming.
Emergency Ultrasonography in the Evaluation of the Acute Scrotum
Authors: Blaivas Michael , Sierzenski Paul
Published: January 2008

Abstract. Acute scrotal pain accounts for approximately 0.5% of total emergency department (ED) visits. Despite this relatively low percentage, these patients can present a considerable challenge to the treating emergency physician (EP) since the etiologies of acute scrotal pain range from organ‐threatening disease to minor idiopathic pain. Few data exist on EP use of bedside ultrasound to evaluate scrotal pain, but there is some suggestion that this may represent a beneficial future application for emergency ultrasonographers. This paper briefly describes the technology and technique involved with the performance of testicular ultrasound examination and briefly discusses its potential application at bedside in the ED.
Post‐resuscitative Hypothermic Bypass Reduces Ischemic Brain Injury in Swine
Authors: Mori Kazuhisa , Itoh Yasushi , Saito Jota , Takeyama Yoshihiro , Kurata Yoshiaki , Kaneko Masamitsu , Asai Yasufumi , Torigoe Toshihiko , Dickson Eric W.
Published: January 2008

Objectives: Increasing human and laboratory evidence suggests thatpost‐resuscitative brain hypothermia reduces the pathologic consequences of brain ischemia. Using a swine model of prolonged cardiac arrest, this investigation sought to determine whether unilateral hypothermic carotid bypass was capable of inducing selective brain hypothermia and reducing neurohistologic damage. Methods: Ventricular fibrillation was induced in common swine (n? 12). After 20 minutes of cardiopulmonary arrest (without ventilatory support or cardiopulmonary resuscitation), systemic extracorporeal bypass was instituted to restore coronary and cerebral perfusion, followed by restoration of normal sinus rhythm. Animals randomized to the normal brain temperature (NBT) cohort received mechanical ventilation and intravenous fluids for 24 hours. The selective brain hypothermia (SBH) cohort received 12 hours of femoral/carotid bypass at 32°C. The bypass temperature was then increased one degree per hour until reaching 37°C and continued at this temperature until completion of the protocol (24 hours). Histopathologic damage was evaluated in two areas of the hippocampus. Results: Normal sinus rhythm was restored in all animals after the systemic (femoral/femoral) bypass was initiated. Nasal temperature (surrogate measure of brain temperature) remained higher than 37.0°C throughout the 24‐hour recovery period in the NBT animals. In the SBH cohort, right nasal temperature dropped to the mild hypothermic range (<34°C) two hours after institution of femoral/carotid bypass. This was maintained throughout the 12‐hour cooling period without hemodynamic compromise. There was a significant improvement in the neurohistology scores in the CA1 region of the hippocampus of the SBH treated animals as compared with those of the NBT cohort. Conclusions: Post‐resuscitative selective brain hypothermia reduced regional ischemic brain damage in swine with prolonged ventricular fibrillation.
Dispatcher Assistance and Automated External Defibrillator Performance among Elders
Authors: Ecker Rob , Rea Thomas D. , Meischke Hendrika , Schaeffer Sheri M. , Kudenchuk Peter , Eisenberg Mickey S.
Published: January 2008

Objectives: Automated external defibrillators (AEDs) provide an opportunity to improve survival in out‐of‐hospital, ventricular fibrillation (VF) cardiac arrest by enabling laypersons not trained in rhythm recognition to deliver lifesaving therapy. The potential role of emergency dispatchers in the layperson use of AEDs is uncertain. This study was performed to examine whether dispatcher telephone assistance affected AED skill performance during a simulated VF cardiac arrest among a cohort of older adults. The hypothesis was that dispatcher assistance would increase the proportion who were able to correctly deliver a shock, but might require additional time. Methods: One hundred fifty community‐dwelling persons aged 58‐84 years were recruited from eight senior centers in King County, Washington. All participants had received AED training approximately six months previously. For this study, the participants were randomized to AED operation with or without dispatcher assistance during a simulated VF cardiac arrest. The proportions who successfully delivered a shock and the time intervals from collapse to shock were compared between the two groups. Results: The participants who received dispatcher assistance were more likely to correctly deliver a shock with the AED during the simulated VF cardiac arrest (91% vs 68%, p ? 0.001). Among those who were able to deliver a shock, the participants who received dispatcher assistance required a longer time interval from collapse to shock [median (25th, 75th percentile) ? 193 seconds (165, 225) for dispatcher assistance, and 148 seconds (138, 166) for no dispatcher assistance, p ? 0.001]. Conclusions: Among older laypersons previously trained in AED operation, dispatcher assistance may increase the proportion who can successfully deliver a shock during a VF cardiac arrest.
Access to Care A Review of the Emergency Medicine Literature
Authors: Richardson Lynne D. , Hwang Ula
Published: January 2008

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of “nonurgent ED visits” as “inappropriate” and high ED charges led to the targeting of non‐emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify “inappropriate” ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, “de facto” denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.
Rationing and the Role of the Emergency Department as Society's Safety Net
Authors: Glauser Jonathan
Published: January 2008

Emergency medicine has an integral role in the establishment of universal access to health care for all persons living in the United States. Currently, emergency departments provide the only unfunded mandate available to millions of American residents who otherwise have no access to health care coverage. Any effort to establish universal care must accept health care rationing as a basic principle, and establish a minimum standard of benefits to which all human beings are entitled in this country. People and employers should be allowed to purchase additional care based on their willingness and ability to pay, but under no circumstances should anyone be denied a basic package of health care benefits. Emergency care must be part of those basic benefits. Emergency medicine charges should be structured so that they are not unduly onerous to society, and should reflect true expenses, including marginal costs for nonurgent care. Emergency physicians (EPs) and hospital administrations should recognize their critical role in serving society in roles that are not strictly medical, and allocate resources to benefit the general population in the greatest way. This role will be expanded to include preventive care, to provide for basic pharmacologic coverage as needed, and to provide necessary immunizations when traditional primary care has failed. We have a moral obligation to recognize that resources are limited and to allocate them so as to benefit the greatest number of patients in the greatest way. As members of the medical profession best equipped to assume such a task, it is incumbent upon EPs to act as advocates to the public to enable us to fulfill this mission.
Neurotensin Analog NT69L Induces Rapid and Prolonged Hypothermia after Hypoxic Ischemia
Authors: Katz Laurence M. , Wang Yuanfan , McMahon Beth , Richelson Elliott
Published: January 2008

Objective: To determine whether the neurotensin analog NT69L, administered systemically, could induce mild brain hypothermia after asphyxial cardiac arrest (ACA) in rats. Methods: The study design was experimental, blinded, randomized, and approved by the animal use committee. All rats had continuous monitoring of brain temperature and sustained 8 minutes of ACA, resuscitation, and either saline or NT69L intravenously afterreturn of spontaneous circulation (ROSC). Rats surviving 14 days after ACA had a neurological deficit score (NDS) and a Morris Water Maze (MWM) test. Results: Seven of eight rats in each group survived 14 days. Brain temperature was less than 35°C 13.1 ± 3 minutes (mean ± standard deviation) after NT69L vs controls that remained 37.5°C at the same ambient temperature (p < 0.05 ANOVA). The NT69L group remained below 35°C for 300 ± 100 minutes while the controls remained at 37.5 ± 0.5°C. The NDS in the NT69L rats was 3 ± 3% vs controls 26 ± 8% (p < 0.05, Kruskal‐Wallis, 0%= normal, 100%= brain dead). The NT69L rats performed better on the MWM vs the controls (22 ± 8 sec vs 45 ± 26 sec, respectively, p < 0.05 ANOVA). Conclusions: NT69L induced rapid and prolonged mild brain hypothermia after ACA in this ratmodel and reduced neurological deficits.
Snowmobile Injuries in Utah
Authors: Guenther Skokan Elisabeth , Olson Lenora M. , Cook Lawrence J. , Corneli Howard M.
Published: January 2008

Objective: To describe the epidemiology of snowmobile injuries in Utah.

Methods: Analysis of probabilistically linked statewide emergency department (ED), hospital admission, and death certificate data for 1996 and 1997.

Results: There were 625 cases of snowmobile‐related injuries. The majority (83%) were evaluated in the ED only. Median ED patient age was 29 years (range 3‐74 years), and 66% were male. The leading diagnoses were open wounds to the head (7.8%), back strains (5.4%), and contusions of the trunk and lower extremities (5.2% and 5.0%, respectively). An Injury Severity Score (ISS) of ≥4 (range 1‐75) was found in 37% of the ED patients. The median charge was $373 per patient, with two‐year cumulative charges of $266,283. One hundred seven patients required inpatient hospital care. Median inpatient age was 32 years (range 4‐92 years), and 60% were male. Leading inpatient diagnoses were fracture of the vertebral column (9.3%), lower extremity fracture (9.3%), upper extremity fracture (6.5%), and pelvis fracture (3.7%). An ISS of ≥4 (range 1‐38) was found in 70% of the hospitalized patients. Average length of stay was 3 days, with a range of 1 to 68 days. Median inpatient charge was $6,003 per patient, with two‐year cumulative charges of $1,333,218. Ten inpatients required transfer for rehabilitation or skilled nursing care. There were a total of six fatalities, three of which occurred in the ED, one in the inpatient population, and two identified from the death certificate database.

Conclusions: By combining ED, inpatient, and death certificate data sets, probabilistic linkage provides a comprehensive description of snowmobile‐related injuries and a baseline evaluation of morbidity, mortality, and financial burden.
Droperidol vs. Prochlorperazine for Benign Headaches in the Emergency Department
Authors: Miner James R. , Fish Sara J. , Smith Stephen W. , Biros Michelle H.
Published: January 2008

Objective: To compare the efficacy of droperidol with that of prochlorperazine for the treatment of benign headaches in emergency department (ED) patients. Methods: Prospective, randomized clinical trial in an urban ED. Patients were given either droperidol, 5 mg intramuscular (IM) or 2.5 mg intravenous (IV), or prochlorperazine, 10 mg IM or 10 mg IV. Measurements included side effects and the patient's pain perception as measured on a 100‐mm visual analog scale (VAS) at baseline, 30, and 60 minutes after the medication was given. Data were analyzed using chi‐square, two‐tailed t‐tests, and two‐way analysis of variance (ANOVA) when appropriate. Results: During an eight‐month period, 168 patients were enrolled. Eighty‐two (48.8%) of the patients received droperidol; 86 (51.2%) received prochlorperazine. In the droperidol group, 49 (59.6%) received IM administration and 33 (40.4%) IV. In the prochlorperazine group, 57 (66.3%) received IM administration and 29 (33.7%) IV. Sixty minutes after the medication, the mean decrease in the VAS scores was 81.4% for droperidol and 66.9% for prochlorperazine (p ? 0.001). At 30 minutes, 60.9% of the patients receiving droperidol and 44.2% of the patients receiving prochlorperazine had obtained at least a 50% reduction in their VAS scores (p ? 0.09). At 60 minutes, 90.2% of the patients receiving droperidol and 68.6% of the patients receiving prochlorperazine had at least a 50% reduction in their VAS scores (p ? 0.017). No difference between IM dosing and IV dosing was detected. Side effects, including dystonia, akathisia, and decreased level of consciousness, were seen in 15.2% of the patients receiving droperidol and 9.61% of the patients receiving prochlorperazine. No significant or persisting morbidity was detected. Conclusions: Droperidol was more effective than prochlorperazine in relieving pain associated with benign headaches.
Doing unto Others? Emergency Medicine Residents' Willingness to Be Treated by Moonlighting Residents and Nonphysician Clinicians in the Emergency Department
Authors: Larkin Gregory L. , Kantor Walter , Zielinski John J.
Published: January 2008

Objective: Contentious moonlighting policies and the proliferation of nonphysician clinicians (NPCs) in academic emergency departments (EDs) send conflicting messages to emergency medicine (EM) residents regarding appropriate ED staffing patterns. The objective was to assess EM resident (EMR) views on the ED utilization of unsupervised residents and NPCs from their perspectives as both physicians and prospective patients. Methods: A survey was mailed to a random sample of senior EMRs (sampling fraction, 68%) from the Emergency Medicine Residents Association membership list. Respondents were instructed to assume the role of patient when presented with hypothetical clinical scenarios of increasing severity; outcomes included provider preferences and the impacts of medical urgency, time delays, costs, and supervision on those preferences. Survey items asked about willingness to see residents, nurse practitioners (CRNPs), and physician assistants (PAs), and perceived impact of NPCs on professional identity. Results: A total of 251 EMRs responded. Senior EMRs are more willing to have their care handled by residents as opposed to mid‐level providers. For a moderate illness or injury scenario, 54% agreed to be seen by a resident alone compared with only 17% and 24% willing to be seen by a CRNP and PA, respectively. Only a small fraction of the residents (22.7%) would allow another resident to treat them for a major injury or illness. Residents are more willing to be seen by mid‐level providers if a savings in time can be realized but showed little interest in using NPCs to save money. Approximately one‐third (34%) of the residents view mid‐level providers as a professional threat, but logistic regression reveals this perception to be 2.25 (1.3, 4.0) times higher in male EMRs and 1.94 (1.1, 3.4) times higher in those with higher household incomes (≥$75,000). Conclusions: When assuming the patient role, senior EMRs have preferences for ED care that are consistent with restrictive EMR moonlighting and NPC staffing policies.
The Effects of Octylcyanoacrylate on Scarring after Burns
Authors: Singer Adam J. , Thode Henry C. , McClain Steve A.
Published: January 2008

Abstract. Objective: To compare the effects of octylcyanoacrylate (OCA), silver sulfadiazine (SSD), polyurethane film (PU), and dry gauze (G) on scarring three months after partial‐thickness burns. Methods: This was a prospective, blinded, controlled experimental trial using isoflurane‐anesthetized swine. Standardized partial‐thickness burns were inflicted by applying an aluminum bar preheated to 80°C to the backs and flanks of a young pig for 20 seconds. Four equal sets of ten burns each were randomly treated with OCA spray, SSD, PU, or G. Dressing changes were performed on days 1, 2, 3, and 4 after injury. Digital images of the burns were obtained immediately and three months later for masked computerized determination of scar surface area. Full‐thickness biopsies were taken at three months for masked histopathological evaluation. The primary outcome was the percent reduction in residual wound area (RWA) calculated by subtracting the area of each individual burn from the area of the largest burn and dividing this value by the area of the largest burn (intraobserver correlation, r = 0.99). Secondary outcomes were the proportion of burns with the presence of scar tissue (abnormal collagen under polarized light; intraobserver agreement, κ= 0.93) and the cosmetic appearance on a 100‐mm visual analog scale marked “best scar” at the high end (inter‐observer correlation, r = 0.82). Analysis of variance (ANOVA) and χ2 tests were used for group comparisons as appropriate. This study had 80% power to detect a 33‐percentage‐point difference in RWA among groups (α= 0.05). Results: A total of 40 burns were inflicted on the pig. There was no difference in percent RWA across the groups (OCA = 25%, SSD = 40%, PU = 25%, G = 32%; p = 0.13). There was no difference in the proportion of wounds with scarring among the groups (OCA = 10%, SSD = 22%, PU = 2%, G = 30%; p = 0.89). There was also no difference in the cosmetic scores among the groups (OCA = 78 mm, SSD = 75 mm, PU = 74 mm, G = 74 mm; p = 0.96). Conclusions: The effects of OCA spray, SSD, PU, and dry gauze on scarring three months after burns in pigs are similar.
Evaluation of Missed Diagnoses for Patients Admitted from the Emergency Department
Authors: Chellis Mary , Olson James E. , Augustine James , Hamilton Glenn C.
Published: January 2008

Abstract. Objective: To define a quality assurance instrument to evaluate errors in diagnostic processes made by physicians in the emergency department (ED). Methods: This was a retrospective clinical investigation of inpatient ED records. Over a six‐year period, 5,000 medical records of admitted patients were randomly selected for evaluation. Each record was initially examined by one of five physician evaluators. If the primary ED diagnosis differed from the primary discharge diagnosis, the ED record was inspected to determine reasons for the misdiagnosis. The authors considered several aspects of the diagnostic process, including patient history, tests ordered, interpretation of clinical data, choice and performance of procedures, injury pattern recognition, reasoning, and evaluation. Records that demonstrated errors in the diagnostic process were reevaluated for the same diagnostic process errors by a sixth physician. Disagreements regarding suspected errors in the diagnostic process were settled by discussion. Finally, to determine potential medical consequences of the misdiagnosis, one individual reviewed the complete medical records of patients whose ED medical records were scored with errors by both evaluators. Interevaluator reliability was assessed using Cochran's Q‐test with a selected series of medical records. Results: Twenty‐eight records (0.6%) were found to contain one or more errors in the diagnostic process that contributed to misdiagnosis. For these patients appropriate diagnosis was not made until one to 16 days after admission. Three patients of 18 whose records were available for detailed review may have suffered complications that resulted, in part, from the delay in diagnosis and subsequent treatment. Significant interevaluator reliability for identification of errors in the diagnostic process was obtained (p > 0.1). Conclusions: A two‐tiered evaluation of ED records selected by inconsistent initial and final diagnoses can be used reliably to screen for errors in the diagnostic process made by emergency physicians (EPs). The rate of physician error contributing to a misdiagnosis is very low, suggesting that EPs are delivering quality patient care.
Frequent Overcrowding in U.S. Emergency Departments
Authors: Derlet Robert W. , Richards John R. , Kravitz Richard L.
Published: January 2008

Abstract. Objective: To describe the definition, extent, and factors associated with overcrowding in emergency departments (EDs) in the United States as perceived by ED directors. Methods: Surveys were mailed to a random sample of EDs in all 50 states. Questions included ED census, frequency, impact, and determination of overcrowding. Respondents were asked to rank perceived causes using a five‐point Likert scale. Results: Of 836 directors surveyed, 575 (69%) responded, and 525 (91%) reported overcrowding as a problem. Common definitions of overcrowding (>70%) included: patients in hallways, all ED beds occupied, full waiting rooms >6 hours/day, and acutely ill patients who wait >60 minutes to see a physician. Overcrowding situations were similar in academic EDs (94%) and private hospital EDs (91%). Emergency departments serving populations ≤250,000 had less severe overcrowding (87%) than EDs serving larger areas (96%). Overcrowding occurred most often several times per week (53%), but 39% of EDs reported daily overcrowding. On a 1‐5 scale (±SD), causes of overcrowding included high patient acuity (4.3 ± 0.9), hospital bed shortage (4.2 ± 1.1), high ED patient volume (3.8 ± 1.2), radiology and lab delays (3.3 ± 1.2), and insufficient ED space (3.3 ± 1.3). Thirty‐three percent reported that a few patients had actual poor outcomes as a result of overcrowding. Conclusions: Episodic, but frequent, overcrowding is a significant problem in academic, county, and private hospital EDs in urban and rural settings. Its causes are complex and multifactorial.
Implementation and Refinement of the Emergency Severity Index
Authors: Wuerz Richard C. , Travers Debbie , Gilboy Nicki , Eitel David R. , Rosenau Alex , Yazhari Ramine
Published: January 2008

Abstract. Objectives: To implement a new five‐level emergency department (ED) triage algorithm, the Emergency Severity Index (ESI), into nursing practice, and validate the instrument with a population‐based cohort using hospitalization and ED length of stay as outcome measures. Methods: The five‐level ESI algorithm was introduced to triage nurses at two university hospital EDs, and implemented into practice with reinforcement and change management strategies. Interrater reliability was assessed by a posttest and by a series of independent paired patient triage assignments, and a staff survey was performed. A cohort validation study of all adult patients registered during a one‐month period immediately following implementation was performed. Results: Eight thousand two hundred fifty‐one ED patients were studied. Weighted kappa for reproducibility of triage assignments was 0.80 for the posttest (n= 62 nurses), and 0.73 for patient triages (n= 219). Hospitalization was 28% overall and was strongly associated with triage level, decreasing from 5863 (92%) of patients in triage category 1, to 12/739 (2%) in triage category 5. Median lengths of stay were two hours shorter at either triage extreme (high and low acuity) than in intermediate categories. Outcomes followed a‐priori predictions. Staff nurses rated the new program easier to use, and more useful as a triage instrument than previous three‐level triage. They provided feedback, which resulted in significant revisions to the algorithm and educational materials. Conclusions: Triage nurses at these two hospitals successfully implemented the ESI algorithm and provided useful feedback for further refinement of the instrument. Emergency Severity Index triage reproducibly stratifies patients into five groups with distinct clinical outcomes.
MEDIA REVIEWS
Authors: DeIorio Nicole M.
Published: January 2008

Abstract. Iserson's Getting into a Residency A Guide for Medical Students, Fifth Edition By Kenneth V. Iserson. Tucson, AZ: Galen Press, Ltd., 2000; 624 pp; $36.95 (softcover).
Short‐term Outcome of Seizure Patients Who Refuse Transport after Out‐of‐hospital Evaluation
Authors: Mechem C. Crawford , Barger Jennifer , Shofer Frances S. , Dickinson Edward T.
Published: January 2008

Abstract. Objective: To determine the short‐term outcome of patients with a known seizure disorder who have a seizure, are evaluated by out‐of‐hospital care providers, and refuse transport. Methods: This was a prospective study conducted over a 15‐month period. Philadelphia Fire Department paramedics contacted a medical command physician whenever they encountered a patient with a known seizure disorder who had had another seizure and was refusing transport. After confirming that the patient had the mental capacity to refuse care and understood the associated risks, the physician recorded the patient's name, address, and telephone number. Beginning three days later, a registered nurse attempted to reach the patient by telephone and administer a brief questionnaire about his or her medical outcome. Patients not reached by telephone were sent a certified letter. The names of patients lost to follow‐up were compared with medical examiner records to confirm that they had not died during the follow‐up period. Results: Of 63 patients enrolled in the study, 52 (82.5%) were reached in follow‐up. Of these, three (5.8%) had another seizure within 72 hours and recontacted 911. One of these patients (1.9%) was hospitalized. Twenty (38.5%) patients contacted their primary care physicians. There were no deaths, including patients lost to follow‐up. Conclusions: Most patients (94.2%) who were evaluated by out‐of‐hospital care providers for a seizure and refused transport had no further seizure activity in the subsequent 72 hours. However, because there is a risk of recurrence, out‐of‐hospital care providers and medical command physicians should ensure that patients understand the risks of refusal.
Ethics Seminars: Consent and Refusal in an Urban American Emergency Department: Two Case Studies
Authors: Geiderman Joel M.
Published: January 2008

Abstract. Patients in the emergency department frequently voice refusals of care or are unable or unwilling to consent to care. While general principles surrounding consent and refusal can be articulated in theory, it is often far more complicated in the real setting. Further, it is impossible to contemplate in advance every possible situation that might arise. In order to properly care for patients, the emergency physician has an obligation to understand ethical principles and the reasoning process one must go through to resolve an ethical dilemma. Emergency physicians face such complex decisions on a routine basis. Ethical reasoning skills are obviously a core competence in emergency medicine, even if easy answers are elusive. Two cases are presented that illustrate this complexity, and routes to resolution are discussed.