bluuebunny/crossref_metadata_2025 huggingface dataset:
Low‐frequency Sonophoresis: Pathologic and Thermal Effects in Dogs
Authors: Singer Adam J. , Homan Clark S. , Church Adam L. , McClain Steve A.
Published: March 2010

Objective: Low‐frequency sonophoresis has recently been shown to significantly facilitate transdermal permeability of various substances (e.g., insulin) in animal models, thus eliminating the need to inject such agents. Prior to human trials, the authors studied the safety profile of low‐frequency sonophoresis in dogs by evaluating microscopic and temperature changes in the skin after sonophoresis.

Methods: An evaluator‐blinded canine study of sonophoresis using different energy intensities and probe diameters was performed. Low‐frequency ultrasound was applied for 60 seconds to the clipped abdominal skin of 3 anesthetized adult mongrel dogs using a sonicator operating at a frequency of 20 KHz with a maximal energy output of 400 W. The sonicator was immersed in normal saline, and intensities of 4%, 10%, 20%, 30%, and 50% were applied during 600 msec of every second (pulsed mode). Three probes, 1‐cm cylindrical, 5‐cm cylindrical, and 10‐cm disc‐shaped, were evaluated. Each experimental condition was performed twice. Subcutaneous temperatures were measured by temperature probe before and after sonophoresis. At 30 minutes post‐sonophoresis, full‐thickness skin biopsies were taken for blinded histopathologic evaluation.

Results: Minimal urticarial reactions were noted with the 1‐cm probe at intensities of ≤20% and with the 5‐cm probe at 4% intensity. With higher intensity, thermal injuries were observed grossly with erythema and vesicles. The microscopic correlates were papillary and dermal edema with neutrophils and telangiectasia. The conditions producing vesicles grossly had foci of epidermal necrosis, subepidermal vesicles, and degeneration of papillary dermal collagen. With still higher intensities, confluent epidermal necrosis became apparent. Use of the 10‐cm probe did not result in any injury.

Conclusions: Low‐frequency ultrasound at low intensities appears safe for use to enhance the topical delivery of medications, producing only minimal urticarial reactions. Higher‐intensity conditions resulted in second‐degree burns, most likely attributable to localized heating.
Effect of Phlebotomy Technique on Serum Bicarbonate Values
Authors: Berns Scott D. , Matchett Jessica L.
Published: March 2010

Objectives: To determine whether the following phlebotomy technique factors result in spuriously low serum bicarbonate values: 1) small needle size, 2) prolonged tourniquet time, and 3) underfilling of Vacutainer tubes.

Methods: Thirty‐eight healthy young adult student volunteers from Brown University (mean age = 22 years) were randomly assigned to 1 of 2 (24‐ga or 20‐ga) IV needle size groups. With a tourniquet applied, the subjects had blood sampled initially and then at 3 intervals 1 minute apart. In addition, the initial blood sample was separated into four 4‐mL Vacutainer tubes in blood volumes of 0.5, 1, 2, and 3 mL. Serum bicarbonate values (mmol/L) were compared using these techniques.

Results:1) Small needle size did not affect serum bicarbonate values (p > 0.60); 2) prolonged tourniquet time resulted in a statistically significant serum bicarbonate elevation (32.0, 32.5, 33.8, and 33.6, respectively; p < 0.01); and 3) underfilling of Vacutainer tubes resulted in significantly lower serum bicarbonate values for all 4 Vacutainer blood volume groups (21.4, 23.0, 25.0, and 26.2, respectively; p < 0.001).

Conclusions: Small needle size does not affect serum bicarbonate values. Prolonged tourniquet time results in a statistically significant elevation of serum bicarbonate, although this elevation may not be clinically meaningful. Underfilling of Vacutainer tubes significantly influences the accuracy of serum bicarbonate values.
Medical Student Career Advice Related to Emergency Medicine
Authors: Blumstein Howard A. , Cone David C.
Published: March 2010

Objective: To describe the advisors and the advice given to residency candidate interviewees interested in specializing in emergency medicine (EM).

Methods: All interviewees at a university‐based EM residency program were surveyed. Data were collected anonymously and included demographic information, characteristics of each applicant's medical school, career advice by non‐EM faculty, and access to advisors who are residency‐trained in and practicing EM.

Results: Of 114 interviewees, 104 (91%) completed the survey. Only 45% of the respondents reported they were assigned an emergency physician (EP) advisor by their school, and 38% sought advice informally from an EP. Of those students receiving advice from an EP, 70% reported their advisor was residency‐trained in EM. Most (57%) respondents reported receiving negative advice concerning a career in EM from non‐EM medical school faculty. Of the 59 students reporting negative advice, 18 (31%) received negative comments from non‐EM residency program directors, 23 (39%) from non‐EM department chairs, and 4 (7%) from medical school deans. The presence of a residency training program increased the chances of a student's being assigned an EP advisor, but neither an EP advisor nor the departmental status of EM within the students' institutions was associated with receipt of negative advice.

Conclusions: Students considering specializing in EM often receive negative advice or have no assigned EP advisor. These factors may adversely affect entry into the field of EM.
Local Anesthesia for Lacerations: Pain of Infiltration inside vs outside the Wound
Authors: Bartfield Joel M. , Sokaris Stephen J. , Raccio‐Robak Nancy
Published: March 2010

Objective: To compare the pains of infiltration of a local anesthetic for simple lacerations when used from within the wound vs through intact skin.

Methods: A randomized, prospective, single‐blind, experimental protocol was conducted on a convenience sample of adults with simple lacerations. Subjects received two 0.5‐mL injections of buffered lidocaine in each of the sites being compared. Immediately following each injection, pain was measured using a visual analog pain scale. Pain scores were converted to a numerical score and analyzed by a Wilcoxon signed‐rank test. Subjects also were asked which injection hurt more, the first or the second (analyzed by a x2 test).

Results: A total of 63 subjects were enrolled. The first injection was within the wound and the second injection through intact skin (group 1) for 32 patients, and the order was reversed for 31 patients (group 2). Median pain scores for all inside‐the‐wound injections (14 mm) were lower than those with intact skin injections (37 mm; p < 0.0001). In group 1, 4 subjects reported the first injection (within wound) hurt most, 23 thought the second (intact skin) hurt most, and 5 found no difference. In group 2, 18 subjects reported the first injection (intact skin) hurt most, 5 believed the second injection (within wound) hurt most, and 8 found no difference, p < 0.0001.

Conclusion: Local anesthesia is less painful when injected from within a laceration as compared with intact skin.
Effectiveness of 50% Nitrous Oxide/50% Oxygen during Laceration Repair in Children
Authors: Burton John H. , Auble Thomas E. , Fuchs Susan M.
Published: March 2010

Objective: To determine the effect of an inhaled 50% nitrous oxide/50% oxygen mixture on measures of observed anxiety in children during laceration repair.

Methods: A prospective, randomized, placebo‐controlled, double‐blind comparison of an inhaled 50% nitrous oxide/50% oxygen mixture (treatment group) with 100% oxygen (control group) during repair of lacerations was performed. The study population was a convenience sample of children aged 2–7 years in an urban pediatric ED. The primary outcome variable was the change in scores before and during laceration repair with a 10‐point modified Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) assessment. The secondary outcome variable was a 4‐point anxiety scale measured before and during the procedure.

Results: Thirty patients were entered into the study. Seventeen children inhaled the 50% nitrous oxide/oxygen mixture and 13 inhaled 100% oxygen during laceration repair. There was no statistically significant difference in initial CHEOPS and anxiety scores between the 2 groups (p = 0.687 and 0.809, respectively). The median CHEOPS scores in the treatment group decreased by 5 points, while those of the control patients increased by 3 (p < 0.001). The median anxiety scores in the treatment population decreased by 1 point, with an increase of 1 for the control patients (p < 0.001).

Conclusion: Administration of a 50% nitrous oxide/50% oxygen mixture to children during their laceration repair resulted in a significant decrease in measures of anxiety when compared with inhalation of 100% oxygen.
Intramuscular Ketorolac vs Oral Ibuprofen in Emergency Department Patients with Acute Pain
Authors: Neighbor Martha L. , Puntillo Kathleen A.
Published: March 2010

Objective: To determine whether IM ketorolac is superior to oral ibuprofen in patients presenting to an ED in moderate to severe pain.

Methods: This prospective, randomized, double‐blind study involved a convenience sample of 119 patients aged a 18 years who presented to an urban teaching hospital ED with a self‐assessed pain intensity score of 5, 6, 7, or 8 (on a numerical rating scale of 0–10). Patients were randomized to receive either 60 mg of IM ketorolac and a placebo capsule or 800 mg of oral ibuprofen and a saline injection. Pain scores were measured at 0, 15, 30, 45, 60, 90, and 120 minutes after dosing. Supplemental analgesics were allowed in accordance with standard medical practice.

Results: There were 18 patients excluded who did not remain in the ED for the full 2‐hour study period. Of those completing the trial, 53 patients received ketorolac and 48 patients received ibuprofen. There were no significant differences in pain scores between ketorolac and ibuprofen at any time during the study. However, there was a statistically significant decrease in pain over time in both treatment groups. Yet, 40% of the patients continued to report pain intensity scores of 5–8 at 2 hours after treatment.

Conclusions: IM ketorolac and oral ibuprofen provide comparable levels of analgesia in ED patients presenting with moderate to severe pain. Unfortunately, 40% of all the patients had inadequate pain relief (pain score ≥5) from either ketorolac or ibuprofen.
Emergency Medical Technician Schedule Modification: Impact and Implications during Short‐ and Long‐term Follow‐up
Authors: Boudreaux Edwin , Mandry Cris , Brantley Phillip J.
Published: March 2010

Objective: To determine whether modifying work schedules from 24‐ to 12‐hour shifts results in favorable improvements across a range of psychological and social variables among emergency medical technicians (EMTs).

Method: Sequential (before and after) surveys were completed voluntarily by EMTs at 1 month prior to, 2 months after, and 1 year after a workshift modification (change from 24‐ to 12‐hour shifts). The surveys assessed job satisfaction, occupational burnout, and attitudes toward work schedules. The questionnaires were completed at emergency medical service stations.

Results: Of 70 EMTs in the system, 51 (73%) completed the first 2 stages of this study; 35 (50%) completed all 3 stages. Paired‐sample t‐tests revealed significant differences between baseline and 2‐month posttest scores on the following variables: the Maslach Burnout Inventory: Emotional Exhaustion Scale (less perceived exhaustion at 2 months); the Schedule Attitudes Survey: General Affect (perceived more positive view toward schedule at 2 months); Social/Family Impact (perceived less disruption of social/family life at 2 months); and Composite (less overall disruption in quality of life at 2 months). Statistically significant differences between baseline and 1‐year posttest scores were found on the following: Schedule Attitudes Survey: General Affect (more positive view toward schedule at 1 year); Social/Family Impact (less disruption in social/family life at 1 year); and Composite (less overall disruption in quality of life at 1 year).

Conclusion: Modifying EMTs' work schedules from 24‐ to 12‐hour shifts was associated with improvements in EMTs' general attitudes toward their schedules, less disruption of social and family life, and decreased levels of emotional exhaustion at 2 months after the change. While the improvements in EMTs' attitudes toward their schedules persisted at the 1‐year follow‐up, the measure of emotional exhaustion returned to baseline.
Emergency Physicians' Attitudes toward and Use of Clinical Decision Rules for Radiography
Authors: Graham Ian D. , Stiell Ian G. , Laupacis Andreas , O'Connor Annette M. , Wells George A.
Published: March 2010

Objectives:1) To assess Canadian emergency physicians' (EPs') use of and attitudes toward 2 radiographic clinical decision rules that have recently been developed and to identify physician characteristics associated with decision rule use; 2) to determine the use of CT head and cervical spine radiography by EPs and their beliefs about the appropriateness of expert recommendations supporting the routine use of these radiographic procedures; and 3) to determine the potential acceptance of clinical decision rules for CT scan in patients with minor head injury and cervical spine radiography in trauma patients.

Methods: A cross‐sectional anonymous mail survey of a random sample of 300 members of the Canadian Association of Emergency Physicians using Dillman's Total Design Method for mail surveys.

Results: Of 288 eligible physicians, 232 (81%) responded. More than 95% of the respondents stated they currently used the Ottawa Ankle Rules and were willing to consider using the newly developed Ottawa Knee Rule. Physician characteristics related to frequent use of the Ottawa Ankle Rules were younger age, fewer years since graduating from medical school, part time or resident employment status, working in a hospital without a CT scanner, and believing that decision rules are not oversimplified cookbook medicine or too rigid to apply. Eighty‐five percent did not agree that all patients with minor head injuries should receive a CT head scan and only 3.5% stated they always refer such patients for CT scan. Similarly, 78.5% of the respondents did not agree that all trauma patients should receive cervical spine radiography and only 13.2% said they always refer such patients for cervical spine radiography. Ninety‐seven and 98% stated they would be willing to consider using well‐validated decision rules for CT scan of the head and cervical spine radiography, respectively. Fifty‐two percent and 67% of the respondents required the proposed CT and C‐spine to be 100% sensitive for identifying serious injuries, respectively.

Conclusions: Canadian EPs are generally supportive of clinical decision rules and, in particular, have very positive attitudes toward the Ottawa Ankle and Knee Rules. Furthermore, EPs disagree with recommendations for routine use of CT head and cervical spine radiography and strongly support the development of well‐validated decision rules for the use of CT head and cervical spine radiography. Most EPs expected the latter rules to be 100% sensitive for acute clinically significant lesions.
Collaboration in Emergency Medicine Research: A Consensus Statement
Authors: Lewis Lawrence M. , Callaham Michael L. , Kellermann Arthur L. , Marx John A. , White J. Douglas
Published: March 2010

The role of collaboration in medical research and how it applies to emergency medicine (EM) research are discussed. The guidance of the Division of Health Sciences Policy of the Institute of Medicine is reviewed. Application of the principles of collaborative efforts and recognition of each individual's contribution are overviewed. Emergency physicians can and should be invaluable contributors to collaborative research. Collaborative research relationships, whether established at individual institutions or through national clinical trials, must be developed deliberately. The specialty of EM must make the necessary commitment of time and resources to ensure that these occur.
Development of New Methods to Assess the Outcomes of Emergency Care
Authors: Cairns Charles B. , Garrison Herbert G. , Hedges Jerris R. , Schriger David L. , Valenzuela Terence D.
Published: March 2010

This article provides information supporting the need for new outcome measures in emergency care. It also addresses the use of these measures in emergency care, the impact of emergency care, identification of at‐risk groups, new approaches to measuring patient satisfaction, quality of life, and cost‐effectiveness, and the related unique implications for emergency medicine.
Funding Strategies for Emergency Medicine Research
Authors: Carden Donna L. , Dronen Steven C. , Gehrig George , Zalenski Robert J.
Published: March 2010

The importance of adequate funding for sustaining research efforts cannot be overemphasized. This article addresses funding strategies for emergency physicians, including the necessity of establishing a research track record, developing a well‐written grant proposal, and anticipating the grant review process. Funding sources are reviewed with an emphasis on federal institute support and private foundations (including the Emergency Medicine Foundation) in the United States. Sources of current grant support information available from the Internet are provided. Recommendations for enhancing research funding in emergency medicine (EM) are made, including enhancement of formal research training, promotion of EM research and investigators, federal study section membership, and collaboration with established investigators.
The Potential Benefit of a Home Fire Safety Intervention during Emergency Medical Services Calls
Authors: Pirrallo Ronald G. , Rubin Jonathan M. , Murawsky Gloria A.
Published: March 2010

Objective: To determine how often house fires occur at 1‐ and 2‐family dwellings visited previously by emergency medical services (EMS) personnel and whether these visits were missed opportunities for a point‐of‐contact home fire safety intervention.

Methods: A retrospective, consecutive, case series analysis of all Milwaukee Fire Department alarm responses during 1994 was performed. Measurements included date of service, type of response, property type, dollar loss estimate, number of injuries and fatalities, cause of alarm, and presence of an operational smoke detector. Descriptive, x2. and relative risk statistics were used to describe the relationship between EMS responses and fire responses at 1‐ and 2‐family dwellings.

Results: The Milwaukee Fire Department dispatched 94,378 requests for service to 43,556 addresses. 16, 150 addresses generated multiple requests; 7.2% (1,162/16,150) were for an “alarm of fire” response [relative risk 1.83 (95% CI: 1.69–1.99) for addresses with multiple requests vs those with a single request for service]. Most [62% (721/1,162)] of the addresses were visited by EMS personnel prior to the alarm; 28% (205/721) were 1‐ and 2‐family dwellings. A mean of 1.8 (376/205) EMS responses occurred prior to the “alarm of fire” response; 121 addresses received 1 response, 46 received 2, 18 received 3, and 20 received s4 responses. Of 169 addresses with complete data, there was a total fire dollar loss of $1,963,020 (1994) along with 32 injuries and 0 fatalities. While 47% (80/169) of the 1‐ and 2‐family dwellings had a smoke detector present, only 17% (29/169) of the dwellings had an operational smoke detector.

Conclusions: A point‐of‐contact home fire safety intervention appears of potential benefit for frequent users of EMS care. Determination of the presence of an operational smoke detector in 1‐ and 2‐family dwellings may be a useful injury prevention act during such EMS calls.
Autonomic Regulation of Gastric Ulcerogenesis after Cervical Cord Transection in the Rat
Authors: Waldrop Ron D. , Strain George M.
Published: March 2010

Objective: To examine the role of anticholinergic and sympathomimetic drugs in preventing gastric ulcerogenesis after cervical cord transection (CCT) in the rat.

Methods: A randomized, prospective, interventional trial was performed comparing pirenzepine (muscarinic type I receptor antagonist) and ephedrine (nonspecific sympathomimetic) in the prevention of gastric ulcerogenesis after CCT in the rat. After isoflurane‐induced general anesthesia, group 1 (n= 12) received sham CCT with no pretreatment, group 2 received CCT with no pretreatment, group 3 received CCT with pirenzepine pretreatment (0.01/mg/kg IP), and group 4 received CCT with ephedrine pretreatment (3 mg/kg IP). Six hours after intervention, all the rats were euthanized with isoflurane, stomachs were dissected, and a gastric ulcer index was determined.

Results: The mean (± SD) ulcer index was 0.08 ± 0.1 for group 1, 2.33 ± 0.5 for group 2 (p = 0.01), 0.41 ± 0.7 for group 3 (p = 0.037 compared with group 2), and 0.75 ± 0.7 for group 4 (p = 0.0005 compared with group 2). Groups 3 and 4 were not significantly different from each other (p = 0.30). Conclusions: Gastric ulcerogenesis after CCT in the rat is decreased by anticholinergic and sympathomimetic drug pretreatment.
Incorporation of a “Coping with the Death of a Child” Module into the Pediatric Advanced Life Support (PALS) Curriculum
Authors: Wolfram R. Wayne , Timmel Daniel J. , Doyle Cindy R. , Ackerman Alice D. , Lebet Ruth
Published: March 2010

Objective: To develop an educational module for health professionals (HPs) addressing the clinical reality of death as an outcome of pediatric resuscitation efforts. Module goals were to: 1) reduce HPs' discomfort with situations involving patient death and survivor grief, 2) assist HPs coping with their own emotions surrounding a patient death, and 3) provide specific strategies useful in clinical management. The module was designed to be presented as part of the American Heart Association (AHA) and the American Academy of Pediatrics (AAP) Pediatric Advanced Life Support (PALS) provider course.

Methods: A multidisciplinary team created a module addressing both survivors' and HPs' needs regarding a PALS course “Coping with the Death of a Child” module. The module was presented to 964 PALS course participants. Content was revised after analysis of survey data collected from these participants.

Results: The revised module was presented to 601 PALS course participants; evaluations were obtained from 590 participants. On a 4‐point Likert scale, ratings were: 79%“excellent,” 18%“good,” 2%“fair,” and <1%“poor.”

Conclusion: The PALS course offers an opportunity to target HPs likely to encounter pediatric deaths for special education. While this is a challenging and potentially controversial topic to present to a diverse audience, incorporation of a “Coping with the Death of a Child” module into the PALS provider curriculum appears to be both feasible and useful.
Program for Reducing Pedestrian‐Motor Vehicle Crashes
Authors: Macias Darryl , Olson Lenora , Sandvig Joan , Collins Kimberly , Sklar David
Published: March 2010

Injury prevention has been identified as a component of emergency medicine. However, involvement of emergency physicians in injury prevention has been hindered by clinical responsibilities, lack of financial support, and limited expertise in skills necessary for effective injury prevention programs. This article describes the development and content of a statewide pedestrian safety plan prepared by the Department of Emergency Medicine at the University of New Mexico. The plan included a written document, community input through focus groups, and a public information campaign. The written document included a synthesis of published literature, state‐specific data, information on community interventions, and recommendations for state agencies and other groups interested in reducing pedestrian injuries. This project can be modeled at other academic EDs with an interest in injury prevention and pedestrian safety.
Incidence and Characteristics of Fall‐related Emergency Department Visits
Authors: Mathers Lawrence J. , Weiss Harold B.
Published: March 2010

Abstract. Objective: Unintentional falls are the leading cause of injury and the second most common cause of unintentional injury deaths in the United States, and place a great burden on EDs. In this study, the objective was to describe the incidence and characteristics of ED visits associated with unintentional falls in the United States.

Methods: The authors performed a secondary analysis on data from the National Center for Health Statistics' National Hospital Ambulatory Medical Care Survey for 1992–1994. An ED visit was defined as fall‐related if an ICD‐9‐CM cause of injury code was reported as E880.0–886.9 or E888.

Results: There were an estimated 7,946,000 fall‐related ED visits per year, corresponding to an annual rate of 3.1 per 100 persons (95% CI = 2.8 to 3.4). Children under 5 years of age comprised the largest proportion of visits (14%). Among those visits coded with respect to place of occurrence, the rate of visits associated with falls occurring at home (1.7/100; 95% CI = 1.6 to 1.9) was significantly higher than that associated with falls occurring in all other locations combined (1.1/100; 95% CI = 1.0 to 1.2). The mean injury severity score increased significantly with the age of the patient. Fall‐related ED visits resulted in an estimated 860,000 hospitalizations, 62% of which involved individuals aged 65 years and older. An estimated $2.45 billion per year was paid for fall‐related ED visits. Government sources paid all or part of 41% of visits.

Conclusions: This study reports nationally representative data describing the incidence and characteristics of fall‐related ED visits. These data expand what is known about the epidemiology of falls and help to define the burden that fall injuries place on EDs in the United States. The results of this study could serve as a benchmark to evaluate the effectiveness of future fall prevention efforts.
Does the Use of Ultrasonography Improve the Outcome of Children with Appendicitis?
Authors: Roosevelt Genie E. , Reynolds Sally L.
Published: March 2010

Abstract. Objective: To determine whether the use of ultrasonography (US) improves the outcome of children with appendicitis.

Methods: All cases of patients (< 17 years old) with pathologically confirmed appendicitis treated in the ED between July 1992 and December 1995 were retrospectively reviewed.

Results: 231 charts met criteria for analysis. 100 (43%) patients had US prior to surgery. Age, race, and insurance status were similar for children in the US and non‐US groups; there were no differences between the groups at presentation in mean temperature, mean WBC count, or percentage of children with vomiting, diarrhea, abdominal tenderness, or guarding. Those in the non‐US group were more often male (71%, p = 0.002) and more frequently had right lower quadrant pain (65%, p = 0.003). Time from ED triage to the OR was 17.1 hours (US group) vs 10.4 hours (non‐US group) (p = 0.002). The perforation rates and the complication (abscess, wound infection, wound dehiscence) rates were similar for children in the two groups. Hospital charges were higher in the US group than in the non‐US group ($14,123 vs $13,021, p = 0.007).

Conclusion: The use of US did not result in early diagnosis of appendicitis, nor was it associated with a reduction in perforation or complication rates. Among children with clinical evidence of appendicitis, US was associated with a delay in surgery and an increase in hospital charges.
Out‐of‐hospital Treatment of Hypoglycemia: Refusal of Transport and Patient Outcome
Authors: Socransky Steven J. , Pirrallo Ronald G. , Rubin Jonathan M.
Published: March 2010

Abstract. Objectives: Patient refusal of transport after treatment of hypoglycemia is common in urban emergency medical services (EMS) systems. The rate of relapse is unknown. The goal of this study was to compare the outcomes of diabetic patients initially refusing transport (refusers) and those transported to an ED.

Methods: All paramedic runs from January to July 1995 were retrospectively reviewed. Inclusion criteria were adult patients with a field assessment of hypoglycemic signs/symptoms, and a fingerstick glucose < 80 mg/dL. Data for analysis included paramedic run duration, patient demographics, and refusal or acceptance of transport. Patient outcome was obtained from a review of hospital and medical examiner records. Relapse was defined as hypoglycemia necessitating EMS activation or an ED visit within 48 hours of the initial episode. Student's t‐test and x2 analysis were used to compare means and rates, respectively.

Results: Over the 7 months, 374 patients made 571 calls to 9‐1‐1 that met inclusion criteria (5.2% of all paramedic runs). Of these, 412 were refusers (72.2%) and 159 were transported patients (27.8%). The hospital records of 4 transported patients were unavailable. Sixty‐three transported patients were admitted (11.2%), with 1 death from prolonged hypoglycemia. The rates of relapse did not differ between the refusers and the transported patients (p < 0.05). Twenty‐five relapses occurred among the refusers (6.1%), with 14 repeat refusals, 11 transports, 5 admissions, and no deaths. There were 7 relapses among the transported patients (4.4%), with 2 refusals, 5 transports, 2 admissions, and no deaths. The paramedic run time was significantly shorter for the refusers than for the transported patients (p < 0.05).

Conclusions: The out‐of‐hospital treatment of hypoglycemic diabetic patients appears to be effective and efficient. Independent of the patient's refusal or acceptance of transport, the out‐of‐hospital treatment of hypoglycemic patients in this system appears to be safe.
Does the Clinically Significant Difference in Visual Analog Scale Pain Scores Vary with Gender, Age, or Cause of Pain?
Authors: Kelly Anne‐Maree
Published: March 2010

Abstract. Objectives: To determine the minimum clinically significant difference in visual analog scale (VAS) pain scores for acute pain in the ED setting and to determine whether this difference varies with gender, age, or cause of pain.

Methods: A prospective, descriptive study of 152 adult patients presenting to the ED with acute pain. At presentation and at 20‐minute intervals to a maximum of three measurements, patients marked the level of their pain on a 100‐mm, nonhatched VAS. At each follow‐up they also gave a verbal rating of their pain as “a lot better,”“much the same,”“a little worse,” or “much worse.” The minimum clinically significant difference in VAS pain scores was defined as the mean difference between current and preceding scores when pain was reported as a little worse or a little better. Data were compared based on gender, age more than or less than 50 years, and traumatic vs nontraumatic causes of pain.

Results: The minimum clinically significant difference in VAS pain scores is 9 mm (95% CI, 6 to 13 mm). There is no statistically significant difference between the minimum clinically significant differences in VAS pain scores based on gender (p = 0.172), age (p = 0.782), or cause of pain (p = 0.84).

Conclusions: The minimum clinically significant difference in VAS pain scores was found to be 9 mm. Differences of less than this amount, even if statistically significant, are unlikely to be of clinical significance. No significant difference in minimum significant VAS scores was found between gender, age, and cause‐of‐pain groups.
Changes in Academic Attributes Associated with Establishment of Departments of Emergency Medicine
Authors: Gallagher E. John , Henneman Philip L. ,   For the Task Force on the Development of Emergency Medicine at Academic Medical Centers
Published: March 2010

Abstract. Objective: To test the hypothesis that establishment of academic departments of emergency medicine (EM) is associated with improvements in attributes valued by traditional academic medicine.

Methods: Cross‐sectional, observational analysis of academic departments of EM at all accredited allopathic medical schools, as of July 1, 1996. Nonre‐spondents were mailed questionnaires three times, followed by phone contact. All variables were examined as before‐after comparisons associated with department formation. Findings were reported as absolute differences, bounded by 99% confidence intervals (99% CIs), adjusted for multiple comparisons.

Results: Of 50 departments, 49 responded. Department formation was associated with a 25% (99% CI 5% to 46%) increase in accredited EM residencies, a 33% (99% CI 9% to 56%) increase in extramural grant funding, and 46% (99% CI 23% to 69%) and 34% (99% CI 8% to 58%) increases in departmental representation on medical school curriculum and promotions committees, respectively. The mean increase in academic faculty full‐time equivalents (FTEs) was 6.7 (99% CI 3.3 to 10.1). There were average increments of 2.1 FTEs (99% CI 1.4 to 2.7) and 0.8 FTEs (99% CI 0.4 to 1.1) attaining senior ranks of associate professor and professor, respectively. With a top possible Likert scale score of 3, departmental status was associated with essentially identical improvements in the quality of faculty [2.6 (99% CI 2.4 to 2.8)], EM residents [2.6 (99% CI 2.4 to 2.8)], student teaching [2.7 (99% CI 2.5 to 2.9)], and overall academic productivity [2.8 (99% CI 2.7 to 3.0)].

Conclusion: Establishment of academic departments of EM at medical schools is associated with quantitatively and statistically significant improvements in many academic attributes that are mutually beneficial for both the institution and the specialty.
A Comparison of Standardized and Narrative Letters of Recommendation
Authors: Girzadas Daniel V. , Harwood Robert C. , Dearie Joseph , Garrett Shayla
Published: March 2010

Abstract. Objective: To compare the Council of Emergency Medicine Residency Directors' (CORD's) standardized letters of recommendation (SLORs) with traditional narrative letters of recommendation (NLORs) with regard to interrater reliability, consistency, and time of interpretation.

Methods: In part I of the study, four members of the residency selection committee each evaluated the same 20 SLORs and 20 NLORs from which all identifying characteristics had been deleted. Using Likert‐type scales of the global assessment, each letter was assigned a numeric value from 1 to 7. The interrater reliability was calculated for both types of letters using the Kendall coefficient of concordance. Average time to interpretation of the letters was also determined. In part II, using the same numeric values as in part I, 207 single‐author SLOR/NLOR pairs were evaluated to determine whether the global assessment of the SLOR was consistent with that of its partner NLOR. Interpretation of the NLOR was performed blinded to the SLOR. Statistical analysis was calculated using Spearman correlation coefficients.

Results: In part I of the study, the interrater reliability of the SLOR was 0.97, as compared with 0.78 for the NLOR. The average time to interpret the global assessment of the SLOR was 16 seconds, vs 90 seconds for the NLOR. In part II of the study, of the 207 SLOR/NLOR pairs, 112 (54%) were assigned the same numeric value, 80 (39%) differed by one, 13 (6%) differed by two, and two (1%) differed by three, for an overall correlation of 0.58.

Conclusions: Compared with NLORs, the CORD SLOR offers better interrater reliability with less interpretation time. Single‐author SLOR/NLOR pairs submitted for a single applicant do not correlate well. Residency selection committees must decide whether the added work of interpreting NLORs is beneficial.
Prevalence of Aspirin Use among Patients Calling 9‐1‐1 for Chest Pain
Authors: Jaffy Matthew B. , Meischke Hendrika , Eisenberg Mickey S.
Published: March 2010

Abstract. Objective: Early aspirin administration during an acute myocardial infarction (AMI) decreases morbidity and mortality. This investigation examined the extent to which patients with a complaint of chest pain, the symptom most identified with AMI by the general population, self‐administer aspirin before the arrival of emergency medical services (EMS) personnel.

Methods: In this prospective, cross‐sectional prevalence study, data were derived through the analysis of EMS incident reports for patients with a complaint of chest pain from June 1, 1997, to August 31,1997.

Results: The study included 694 subjects. One hundred two (15%) took aspirin for their chest pain before the arrival of EMS personnel. Of the 322 subjects who reported taking aspirin on a regular basis, 82 (26%) took additional aspirin for their acute chest pain. Only 20 (5%) of the 370 patients who were not using regular aspirin therapy self‐administered aspirin acutely (p < 0.001). In addition, patients with lower intensity of chest pain (p = 0.03) were more likely to take aspirin for their chest pain.

Conclusion: Only a relatively small fraction of individuals calling 9‐1‐1 with acute chest pain take aspirin prior to the arrival of EMS personnel. These individuals are more likely to self‐administer aspirin if they are already taking it on a regular basis. It is also possible that they are less likely to take aspirin if their chest pain is more severe.
The Tolerability of Lactated Ringer's Solution and BSS Plus for Ocular Irrigation with and without the Morgan Therapeutic Lens
Authors: Jones James B. , Schoenleber Dana B. , Gillen James P.
Published: March 2010

Abstract. Objective: To evaluate two solutions, lactated Ringer's (LR) and a balanced salt solution (BSS Plus, Alcon Laboratories, Ft. Worth, TX), compared with normal saline solution (NSS), for ocular irrigation in healthy adult volunteers with and without the Morgan therapeutic lens (MTL).

Methods: This was a prospective, double‐blind, randomized study of healthy volunteers who were at least 18 years of age. Exclusion criteria included the use of analgesics within four hours of the study. A complete ophthalmologic examination was performed at baseline and at the completion of the study. Following randomization and prior to any intervention, baseline discomfort scores were obtained by means of a verbally administered, horizontal, 100‐mm, unnumbered analog discomfort scale. Both eyes of each volunteer were irrigated simultaneously for 15 minutes, with additional discomfort scores being recorded every 5 minutes using the same 100‐mm, unnumbered analog discomfort scale. A global evaluation to assess the method of irrigation and the solutions used for irrigation was completed by both the physician blinded to the treatment groups and the volunteers. The volunteers were continuously monitored for any adverse effects resulting from the irrigation solutions or MTL.

Results: Sixty‐three volunteers were recruited into the study, with 61 entered in the final analysis. Age and gender were balanced within each group. There was no significant difference in discomfort scores between the two groups; however, all discomfort scores decreased over time (p = 0.008). A lens‐solution interaction was identified, with LR being the most tolerated when administered with the MTL. A statistically higher ocular pH difference was seen between the pre‐ and postirrigation readings for the control eye in volunteers irrigated with MTL (p = 0.046). Analysis of the global evaluations for each group revealed no difference in the distributions of physician and volunteer scores. No adverse event was reported in either group.

Conclusion: There does not appear to be any difference in discomfort scores between the ocular irrigation fluids when used without the MTL. Overall, the use of the MTL appears well tolerated by healthy, adult volunteers. However, there does appear to be a significant lens‐solution effect on volunteers' discomfort scores, with LR having significantly lower discomfort scores when used for ocular irrigation with the MTL. The authors conclude that the use of the MTL for ocular irrigation is well tolerated and recommend using LR as the irrigation solution for maximal patient comfort.
Strengthening Emergency Medicine in Poland: A Training and Partnership Model
Authors: Wolff Marie , Pirrallo Ronald G. , Hargarten Stephen W.
Published: March 2010

Abstract. Objective: To report a qualitative evaluation of the Partnerships in Health Care/EMS Project between Poland and the United States. The goal of the partnership was to strengthen the emergency medical services (EMS) system in three Polish cities, Krakow, Bialystok, and Lodz.

Methods: The Polish participants were interviewed in Poland approximately eight months after a U.S.‐based training program. They were asked to evaluate the effectiveness of the partnership project and discuss their experiences incorporating U.S. emergency medicine (EM) knowledge and technology in the Polish EMS system.

Results: The Polish physicians identified three major factors that had the greatest impact on the implementation of U.S. EM knowledge in Poland. These factors were the substantive differences between Polish and U.S. EM knowledge and technology, staffing differences in Polish and U.S. ambulances, and the differing role the EMS system plays in the delivery of primary care in the two countries.

Conclusions: The Polish physicians succeeded in training EM providers in the three cities, thus strengthening clinical skills of EMS providers. They also were able to adapt the principles of U.S. EM that they had learned to fit the specific circumstances that characterize Polish emergency care. As in the United States, the health care system in Poland is inseparable from the social, political, and economic realities of the nation.
Professionalism in Emergency Medicine
Authors: Adams James , Schmidt Terri , Sanders Art , Larkin Gregory L. , Knopp Robert ,   for the SAEM Ethics Committee
Published: March 2010

Abstract.The Society for Academic Emergency Medicine (SAEM), with the support and participation of the American Board of Emergency Medicine (ABEM), the Council of Residency Directors (CORD), the American College of Emergency Physicians (ACEP), the Emergency Medicine Residents Association (EMRA), the American Academy of Emergency Medicine (AAEM), and the Association of Academic Chairs of Emergency Medicine (AACEM), initiated a project entitled Professionalism in Emergency Medicine. Its concepts were developed by the SAEM Ethics Committee, and are intended to describe proper behaviors and attitudes of the successful practitioner of emergency medicine. The behaviors described are not primarily scientific or technical, since those are defined by the core curriculum for residency training and are tested through certification examinations. This document identifies attitudes and behaviors that enhance trust by placing the patient's interest above other interests. This concept serves as the operative definition of professionalism. The purpose of this article is to clarify the professional attitudes and knowledge that are important to the emergency physician (EP). While no physician is likely to meet idealized standards, all EPs must meet basic standards while striving for the ideal. Awareness of these standards must begin early in the socialization process of emergency medical professionals. The standards must be integrated into residency training as well as the clinical practice of all EPs.
Patients with Alcohol Problems in the Emergency Department, Part 1: Improving Detection*
Authors: D'Onofrio Gail , Bernstein Edward , Bernstein Judith , Woolard Robert H. , Brewer Phillip A. , Craig Sandra A. , Zink Brian J. ,   for the SAEM Substance Abuse Task Force
Published: March 2010

Abstract. Medical and social problems related to alcohol use are frequently seen in the ED. Often, the tempo of emergency medicine practice seems to preclude assessment beyond that required by the acute complaint. However, detection of ED patients with alcohol problems can occur using brief screening tools. This article was developed by members of the SAEM Substance Abuse Task Force, and describes screening tools that have been used successfully to identify atrisk and dependent drinkers. Their brevity, reproducibility, and accuracy vary somewhat, but screening can be realistically performed in the busy ED setting. The early detection of patients with alcohol problems would provide the opportunity for early intervention, and may reduce subsequent morbidity and mortality in this patient population.
The Ability of a Single Serum Progesterone Value to Identify Abnormal Pregnancies in Patients with Beta‐Human Chorionic Gonadotropin Values Less than 1,000 mlU/mL
Authors: Dart Robert , Dart Linda , Segal Mona , Page Charlotte , Brancato John
Published: March 2010

Objective: To determine the test performance of a single serum progesterone value <5.0 ng/mL for detecting ectopic pregnancy or other abnormal pregnancies in symptomatic ED patients with β‐hCG levels <l,000 mlU/mL.

Methods: A prospective study of progesterone levels was performed in consecutive ED patients presenting to an urban teaching hospital from December 1995 to March 1997 with abdominal pain and/or vaginal bleeding, a positive qualitative 3‐hCG, and a quantitative β‐hCG value <l,000 mlU/mL. Patients were excluded if they were status‐post a dilatation and evacuation procedure, had insufficient serum to run the progesterone assays, or were lost to follow‐up. Progesterone values were measured from the original P‐hCG sample. Final patient diagnosis was abstracted from hospital records.

Results: 127 patients met eligibility criteria. 39 patients were excluded, leaving a total of 88 enrolled patients. 76 patients with abnormal pregnancies were identified [9 ectopic pregnancies, 62 abnormal intrauterine pregnancies (IUPs), 5 abnormal IUPs vs ectopic pregnancies], 71 of whom had progesterone values <5.0 ng/mL [sensitivity 71/76 (94%), 95% CI 86–98%]. 12 patients with normal pregnancies were identified, all of whom had progesterone values ≥5.0 ng/mL [specificity 12/12 (100%), 95% CI 78–100%].

Conclusion: A single progesterone value <5.0 ng/mL has high sensitivity and specificity in detecting abnormal pregnancy in symptomatic ED patients with β‐hCG values < 1,000 mlU/mL. Key words: progesterone; ectopic pregnancy; tubal pregnancy; intrauterine pregnancy; ultrasound; diagnosis.
Relationships between Ambulance Transports for Alcohol Intoxication and Assault
Authors: Fullerton Lynne , Olson Lenora , Crandall Cameron , Lee M. Jack , Sklar David
Published: March 2010

Objective: To evaluate the association between ambulance transports for assault and those for alcohol intoxication.

Methods: A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault.

Results: Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001).

Conclusions: Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.