bluuebunny/crossref_metadata_2025 huggingface dataset:
Patients' Understanding of the Roles of Interns, Residents, and Attending Physicians in the Emergency Department
Authors: Hemphill Robin R. , Santen Sally A. , Rountree C. Bart , Szmit Andrew R.
Published: January 2008

Abstract. Objective: To assess patients' knowledge of the responsibilities and roles of physician training in the ED. Methods: This was a prospective survey of a convenience sample of 345 adult patients and family members in an academic county ED. Thirty questions addressed the different roles, responsibilities, and hierarchies of physician levels of training. Four opinion‐based questions assessed patients' willingness to have physicians‐in‐training care for them. Results: 96.5% of the surveys were returned. Of the participants responding, 68% were Hispanic, 23% were non‐Hispanic white, and 55% were women. Forty percent of the participants indicated that they had education greater than a high school diploma. Most participants answered fewer than 50% of the questions correctly, indicating that they did not understand the levels of physician training. Participants with higher education were more likely to know the correct answer. Seventy‐nine percent of the participants believed that it is very important to know the level of training of their physicians. However, only 34% of the participants actually thought they knew the training level of their physicians when they were being treated. Twenty‐nine percent of the participants did not want learning to take place on themselves by physicians‐in‐training. Conclusion: Participants believe that it is important to know their physicians' level of training, but they do not understand the roles and responsibilities of physicians‐in‐training in the medical training system in which they receive care. In particular, patients who have less than a high school education seem to know least about this system.
The Risk of Appendiceal Rupture Based on Hospital Admission Source
Authors: Buckley Robert G. , Distefan Janet , Gubler K. Dean , Slymen Donald
Published: January 2008

Abstract. Objective: To determine whether admission source is a potential risk factor for appendiceal rupture. Methods: Administrative data were obtained from the California Office of Statewide Health Planning and Development for all patients in San Diego County with the primary diagnosis of appendicitis during 1993. The appendiceal rupture ratio was defined as those coded as ruptured (ICD‐9‐CM codes 540.0 and 540.1) divided by both ruptured and non‐ruptured cases (540.9). The odds ratio of appendiceal rupture from routine outpatient office or clinic venues vs those admitted through the ED were calculated using multivariate logistic regression analysis to adjust for age, sex, race, comorbidity, insurance status, and home address to hospital proximity. Results: There were a total of 1,906 patients, of whom 663 (34.8%) had appendiceal ruptures. Of the 1,360 (71.4%) admitted from the ED, 422 (31.0%) had ruptures, compared with 211 (43.3%) of the 487 admitted from outpatient sources (p < 0.0001). Patients with appendicitis directly admitted from outpatient sources were more likely to be complicated by appendiceal rupture than were those admitted through the hospital ED (adjusted odds ratio 1.62, 95% CI = 1.28 to 2.05, p < 0.0001). Conclusion: Patients with appendicitis admitted from outpatient sources are more likely to have appendiceal rupture than are those admitted from the ED.
Emergency Physician Treatment of Acute Stroke with Recombinant Tissue Plasminogen Activator: A Retrospective Analysis
Authors: Smith Rodney W. , Scott Phillip A. , Grant Robert J. , Chudnofsky Carl R. , Frederiksen Shirley M.
Published: January 2008

Abstract. Stroke teams are advocated for the rapid treatment of patients who have acute ischemic stroke (AIS) with recombinant tissue plasminogen activator (rt‐PA). An alternate model uses existing ED resources with specialist consultation as needed. Objectives: To evaluate the treatment of AIS with rt‐PA in this alternate ED model. Methods: A retrospective observational review was performed of consecutive patients with AIS treated with rt‐PA at four hospitals affiliated with an emergency medicine residency. Emergency physicians (EPs) were directly responsible for the treatment of all patients according to predefined guidelines. Records were evaluated from the implementation of the guidelines through December 15, 1997. Results: 37 patients with AIS received rt‐PA. Mean age ± SD was 63 ± 16 years (range 22‐87), with 25 (68%) male. Patients presented 67 ± 29 minutes after stroke onset. After ED arrival, they were seen by the EP in 14 ± 13 minutes, had CT in 46 ± 22 minutes, and were treated in 97 ± 35 minutes. Neurologist consultation occurred in the department for nine patients (24.3%), and by telephone for 14 (37.8%). Symptomatic intracerebral hemorrhage (ICH) occurred in four (10.8%, 95% CI = 0.8% to 20.8%). There were two deaths, neither associated with ICH. Neurologic outcome at discharge compared with presentation in survivors was normal for four patients (11.4%), improved for 16 (45.7%), unchanged for ten (28.6%), and worse for five (14.3%). Conclusions: In this analysis, EPs, with specialty consultation as required, successfully identified patients with AIS and delivered rt‐PA with satisfactory outcomes. Important elements of this model include early patient identification, preestablished protocols, and rapid access to CT scanning and interpretation.
Adrenal Dysfunction in Hemodynamically Unstable Patients in the Emergency Department
Authors: Rivers Emanuel P. , Blake Heidi C. , Dereczyk Barry , Ressler Julie A. , Talos Ellen L. , Patel Rakesh , Smithline Howard A. , Rady Mohamed Y. , Wortsman Jacobo
Published: January 2008

Abstract. Objective: Adrenal failure, a treatable condition, can have catastrophic consequences if unrecognized in critically ill ED patients. The authors' objective was to prospectively study adrenal function in a case series of hemodynamically unstable (high‐risk) patients from a large, urban ED over a 12‐month period. Methods: In a prospective manner, critically ill adult patients presenting to the ED were enrolled when presenting with a mean arterial blood pressure ≤60 mm Hg requiring vasopressor therapy for more than one hour after receiving fluid resuscitation (central venous pressure of 12‐15 mm Hg or a minimum of 40 mL/kg of crystalloid). Patients were excluded if presenting with hemorrhage, trauma, or AIDS, or if steroids were used within the previous six months. An adrenocorticotropic hormone (ACTH) stimulation test was performed and serum cortisol was measured. Treatment for adrenal insufficiency was not instituted. Results: A total of 57 consecutive patients were studied. Of these, eight (14%) had baseline serum cortisol concentrations of <20 μg/dL (<552 nmol/L), which was considered adrenal insufficiency (AI). Three additional patients (5%) had subnormal 60‐minute post‐ACTH‐stimulation cortisol responses (<30 μg/dL) and a delta cortisol ≤9 μg/dL, which is the difference between the baseline and 60‐minute levels. This is functional hypoadrenalism (FH). There were no laboratory abnormalities that distinguished patients with AI or FH from those with preserved adrenal function (PAF). Rates of survival to discharge did not differ between the AI group (7 of 8) and PAF patients (21 of 46; p = 0.052). Conclusions: Adrenal dysfunction is common in high‐risk ED patients. Overall, it has a frequency of 19% among a homogeneous population of hemodynamically unstable vasopressor‐dependent patients. The effect of physiologic glucocorticoid replacement in this setting remains to be determined.
Differentiating Systolic from Diastolic Heart Failure Using Impedance Cardiography
Authors: Summers Richard L. , Kolb James C. , Woodward LouAnn H. , Galli Robert L.
Published: January 2008

Abstract. Objective: Differentiating systolic from diastolic congestive heart failure (CHF) is often difficult in the ED. Impedance cardiography (IC) allows for the noninvasive evaluation of systolic function and measurement of diastolic time intervals. This study was designed to assess the ability of IC to accurately measure isovolumic relaxation time (IVRT) and determine relative cardiac contractility, thereby differentiating systolic from diastolic mechanisms in acute CHF. Methods: In an evaluation of the technique, the average differences in the diastolic time intervals measured in normal subjects by both IC tracings and phonocardiography were compared. Likewise, the average Heather index (HI) of patients with known systolic dysfunction (ejection fraction < 30% by echo‐cardiography) was compared with the mean HI measured in the normal subjects. In a retrospective analysis, the clinical performance of the method was examined by extracting the values of IVRT and HI from IC tracings of patients presenting with CHF. The determined IVRT and HI values were then correlated to clinical markers for diastolic and systolic dysfunction. Results: Analysis of 280 IC tracings in eight healthy volunteers revealed an average difference of 0.0075 seconds (95% CI = ‐0.0067 to 0.0217) when IVRT intervals measured by phonocardiography and IC are compared. The HI in this normal group averaged 14.2 (95% CI = 9.4 to 19.0), contrasting to the much lower value of 2.8 (95% CI = 1.98 to 3.62) seen in eight subjects with documented systolic dysfunction. In 26 patients with decompensated CHF, there was a close correlation (r = 0.81) of the measured IVRT to left ventricular hypertrophy by voltage criteria and while a fall in the HI was correlated with intravascular volume expansion. Though there was considerable overlap (46%) in mechanisms of CHF, 35% of the patients were found to have only systolic dysfunction (HI < 5 and IVRT < 0.125), while 19% had a predominantly diastolic etiology (IVRT > 0.125 and HI > 5) for their failure. Conclusion: IC measures of contractility and diastolic time intervals are a potentially effective method for differentiating the dominant mechanisms of CHF in the emergent setting and categorizing CHF patients into different subsets.
Extracorporeal Resuscitation of Cardiac Arrest
Authors: Younger John G. , Schreiner Robert J. , Swaniker Fresca , Hirschl Ronald B. , Chapman Robin A. , Bartlett Robert H.
Published: January 2008

Abstract. Objective: Extracorporeal support of heart and lung function (venoarterial perfusion) during cardiac arrest (ECPR) has been advocated as a means of improving survival following cardiac arrest. The authors retrospectively reviewed their institution's seven‐year experience with this intervention. Methods: Emergency department patients and inpatients in cardiac arrest or immediately postarrest were considered candidates. ECPR was instituted using venoarterial bypass and was continued until patients regained sufficient cardiopulmonary function to allow weaning from the device or until their condition was deemed irrecoverable. Results: ECPR was attempted in 25 patients and successfully instituted in 21. Four patients (16%) were converted from ECPR to ventricular assist devices, two of whom survived and await transplantation. Seven additional patients were discharged from the hospital, resulting in an overall survival of 36%. Because none of the children treated survived, there was a trend toward higher age among survivors (survivors 40 ± 14 yr, nonsurvivors 33 ± 15 yr, p = 0.29). The duration of conventional CPR was shorter among survivors (survivors 21 ± 16 min, nonsurvivors 43 ± 32 min, p = 0.04), as was the duration of extracorporeal support (survivors 44 ± 21 hr, nonsurvivors 87 ± 96 hr, p = 0.18). Survival was seen only in patients whose conditions were amenable to a definitive therapeutic intervention, particularly cardiac arrest due to respiratory or pulmonary embolic disease. While four of the five patients treated in the ED were successfully supported, none survived to discharge. Conclusion: In select patients with reversible disease, extracorporeal CPR can be used to successfully treat cardiac arrest. Further investigation into its most appropriate application is warranted.
A Retrospective Review of Air Bag Deaths
Authors: McKay Mary Patricia , Jolly B. Tilman
Published: January 2008

Abstract. Objective: To describe occupant and crash characteristics in the first 27 publicly released investigations of air‐bag‐related fatalities. Methods: A retrospective review of the first 27 released crash investigations of air‐bag‐induced fatalities was conducted. Data were obtained by the National Highway Traffic Safety Administration. Results: Three separate groups of occupants are described: adult drivers, school‐aged children riding in the right front passenger seat, and infants installed into rear‐facing infant car seats placed into the right front passenger seat. Female drivers were significantly likely to be shortstatured. Male drivers tended to be slumped over the wheel. Eleven children (100%) were improperly restrained and thrown forward by preimpact braking. Adults tended to have serious chest injuries, while children tended to have CNS or neck injuries. All three infants had fatal CNS injuries. The average deltaV (change in the vehicle's velocity at the moment of impact) was 12 mph and the average bumper crash was 8.8 inches. Conclusions: Air bags can cause fatal injury to car occupants in low‐ or moderate‐speed crashes. Data suggest that proximity to the air bag at the time of deployment is the critical risk factor for fatal injury.
Clinical Characteristics of Diabetic vs Nondiabetic Patients Who “Rule‐in” for Acute Myocardial Infarction
Authors: Richman Peter B. , Brogan Gerard X. , Nashed Ashraf N. , Thode Henry C.
Published: January 2008

Abstract. Objective: To compare the clinical characteristics of diabetic vs nondiabetic patients who present to the ED with acute myocardial infarction (AMI). Methods: This was a prospective, observational study at a suburban, university hospital ED of patients presenting to the ED during study hours between December 1993 and October 1996 with typical and atypical symptoms consistent with cardiac ischemia. Diabetic and nondiabetic patients with AMI were compared. Demographic, historical, and clinical data were recorded by trained research assistants using a standardized, closed‐question, data collection instrument. Final discharge diagnosis of AMI was assigned by WHO criteria. Continuous variables were analyzed by t‐tests. Clinical variables were analyzed by chi‐square tests. All tests were two‐tailed with alpha preset at 0.05. Results: There were 216 patients with AMI during the study period; 51 of these patients (24%) were diabetic. For diabetic vs nondiabetic patients with AMI, there was no significant difference in age (64.0 ± 13 vs 60.0 ± 14 years, p = 0.13), female gender (37% vs 26%, p = 0.13), and time to presentation from symptom onset (192 ± 238 vs 251 ± 456 minutes, p = 0.41). Hypertension was the only cardiac risk factor significantly more prevalent in diabetic vs nondiabetic patients with AMI (77% vs 50%, OR = 1.54, 95% CI = 1.24 to 1.91, p = 0.001), though elevated cholesterol (48% vs 33%, OR = 1.47, 95% CI = 1.02 to 2.12, p = 0.06) tended to be more prevalent in the diabetic group. There was no statistically significant difference between the two groups in terms of the frequency of chest pain (OR = 1.04, 95% CI = 0.95 to 1.14, p = 0.30), associated symptoms, and diagnostic ECGs (OR = 1.16, 95% CI = 0.76 to 1.79, p = 0.53). Conclusion: Diabetic patients with AMI may have similar symptoms upon presentation as do nondiabetic patients with AMI. Of the cardiac risk factors, hypertension is more prevalent in diabetic vs nondiabetic patients with AMI.
The Influence of Insurance Status on Nonurgent Pediatric Visits to the Emergency Department
Authors: Fong Christina
Published: January 2008

Abstract. Objective: To compare the effects of HMOs with the effects of other types of private health insurance on nonurgent ED visits in the pediatric population. Methods: Secondary analysis of the emergency component of the 1994 National Hospital Ambulatory Medical Care Survey (NHAMCS) on patients aged 15 years or less. Variables of interest included urgency of visit, age, sex, race, ethnicity, method of payment (HMO, private insurance/non‐HMO, and others), and chief complaint. A p‐value of 0.01 was used as the threshold for significance to offset the effects of increases in variability and significance of p‐values and narrow confidence intervals. Results: There were 6,744 observations. The overall rate of nonurgent ED visits was 58%. The rate of nonurgent visits for HMO patients was 51%, for private non‐HMO insurance 56%, and for other types of payment (Medicare, Medicaid, patient paid, no charge, and other government) 60%. Chief complaints for nonurgent visits were general symptoms, EENT (ear, eyes, nose, and throat) symptoms, and dermatologic symptoms. After multivariate analysis, the odds ratio for patients with private insurance for a nonurgent visit compared with HMO patients was 1.27, with a 95% CI = 1.07 to 1.51, after adjusting for age, sex, and chief complaint. Conclusion: Pediatric patients with private insurance were more likely to present for emergency care for nonurgent reasons when compared with HMO patients after adjusting for the above listed variables. The reasons for this disparity should be further explored.
What Is the Quality of Life for Survivors of Cardiac Arrest? A Prospective Study
Authors: Nichol Graham , Stiell Ian G. , Hebert Paul , Wells George A. , Vandemheen Kathy , Laupacis Andreas
Published: January 2008

Objective: To evaluate the quality of life of survivors of in‐hospital and out‐of‐hospital cardiac arrest, and to correlate quality of life with clinically important parameters. Methods: Cohort followed at least six months after hospital discharge. Eligible patients had survived to hospital discharge after sudden cardiac arrest in 1) EDs, wards, and intensive care units of five university hospitals and 2) all locations outside hospitals in two midsized cities. Of 126 patients discharged alive, 30 died before they could be interviewed. Of the 96 patients remaining, 86 (90% of available patients, 68% of survivors to discharge) completed the interview. Quality of life was assessed with the Health Utilities Index Mark 3, which describes health as a utility score on a scale from perfect health (equal to 1.0) to death (equal to 0.) Results: Mean age (±SD) of interviewed survivors was 65 ± 14 years, and 47 (55%) were male; mean time between collapse and initiation of CPR was 2.2 ± 2.6 minutes. Mean utility was 0.72 (±0.22). Utilities were significantly higher among patients who had a shorter duration of resuscitation (mean ? 0.81 for those who received less than 2 minutes of CPR, 0.76 for those who received 3 to 10 minutes, and 0.65 for others, p ? 0.05, r2? 0.07). Mean utilities of survivors were worse than those of the general population (mean ? 0.85 ± 0.16, p < 0.01) and those whose activities were not limited by chronic disease (mean ? 0.91 ± 0.08, p < 0.01). Conclusions: Although overall survival was poor, most survivors had acceptable health‐related quality of life. Therefore, concerns about poor quality of life are not a valid reason to abandon efforts to improve the health care system's response to victims of sudden cardiac arrest. Further research is necessary to identify effective strategies for improving both survival and quality of life after cardiac arrest.
The Evaluation of Cocaine‐induced Chest Pain with Acute Myocardial Perfusion Imaging
Authors: Feldman James A. , Bui Lynn D. , Mitchell Patricia M. , Perera Thomas B. , Lee Victor W. , Bernard Sheilah A. , Fish Susan S.
Published: January 2008

Objective: To use myocardial perfusion imaging to determine the etiology of cocaine‐induced chest pain in patients without ECG evidence of acute cardiac ischemia. Methods: The authors conducted a prospective study of consecutive consenting patients aged 18‐70 years with cocaine‐induced chest pain who reported cocaine use within three days and presented with a chief complaint of chest pain occurring within three hours and lasting longer than 15 minutes with a normal or nondiagnostic ECG. Patients were excluded if they had a clear‐cut noncardiac cause of chest pain, ECG evidence of acute cardiac ischemia, history of myocardial infarction, pregnancy, or lactation, required immediate hospitalization, or were unable to consent. Patients were injected with Tc‐99m tetrofosmin and imaged. Perfusion scans were independently read by two nuclear radiologists. Clinicians blinded to scan results determined patient disposition. Patients with abnormal scans were asked to return for follow‐up resting scans. Results: Fourteen patients were enrolled. Twelve of the 14 patients had chest pain at the time of Tc‐99m tetrofosmin injection. Ten of the 14 [(71%) 95% CI ? 48% to 95%] scans were normal or within normal limits. Four of the 14 [(29%) 95% CI ? 5% to 52%] were abnormal. Of the four patients with abnormal scans, two had follow‐up scans that demonstrated an irreversible perfusion abnormality, and two who did not return for follow‐up reported no subsequent hospitalizations for acute cardiac ischemia. Conclusion: Perfusion imaging did not demonstrate reversible ischemia in most patients (12/14, 86%) with cocaine‐induced chest pain without ECG evidence of ischemia. These results suggest that cocaine‐induced chest pain in most patients without ECG evidence of ischemia is not due to acute ischemia.
Patient and Family Attitudes Regarding the Practice of Procedures on the Newly Deceased
Authors: Manifold Craig A. , Storrow Alan , Rodgers Kevin
Published: January 2008

Performance of emergency lifesaving procedures is an integral part of emergency medicine resident training. Objective: To assess attitudes of ED patients regarding the practice of procedures on the newly deceased. Methods: A descriptive survey was administered to a convenience sample of ED patients and their families at two urban military Level‐1 trauma centers. Subjects were asked about their overall opinions regarding the practice of nontherapeutic procedural skills on themselves or relatives immediately after death in the ED. Subgroup analysis included the issue of advanced permission and opinions regarding procedures defined by the investigators as noninvasive (e.g., laryngeal mask airway) or invasive (e.g., cricothyrotomy). Data were analyzed descriptively and with chi‐square as appropriate. For comparison of proportions, a sample size of at least 140 was chosen for an alpha of 0.05 and a beta of 0.10 to detect an effect size of 0.3. Alpha was corrected for multiple comparisons prior to the study. Results: Three hundred seventeen surveys were collected and 88% (n ? 280) were complete. Seventy‐five percent (n ? 290) and 70% (n ? 273) of the respondents agreed to after‐death procedures on themselves or their relatives, respectively. However, only 40% (n ? 106) and 50% (n ? 131) would allow such procedures without prior permission. Seventy‐one percent (n ? 189) were willing to give permission in a living will, while 85% (n ? 238) indicated support of a wallet card format. There was no significant difference in permission rates when contrasting individual noninvasive and invasive procedures. Conclusion: Most patients are willing to have procedures performed on themselves or relatives shortly after death, yet the majority request that permission be obtained in advance. A living will or carried card would be acceptable for such permission.
Decreasing Length of Stay with Emergency Ultrasound Examination of the Gallbladder
Authors: Blaivas Michael , Harwood Robert A. , Lambert Michael J.
Published: January 2008

Abstract. Objective: To determine whether patients who received emergency screening ultrasound examinations (ESUEs) of the gallbladder by emergency physicians (EPs) have a shorter ED length of stay (LOS) than do those receiving ultrasound studies from radiology. Methods: A retrospective chart review from July 1995 to August 1998 identified 1,242 patients who received gallbladder ultrasound examinations. Seven hundred fifty‐three patients received ESUEs by EPs of varying levels of ultrasound experience. Four hundred eighty‐nine patients received gallbladder ultrasound examinations from radiology, and were not scanned by EPs. The LOSs of the two groups were compared. Significance was evaluated using a two‐tailed t‐test. Results: When patients received an ESUE by an EP, the median LOS was 7% (22 min) less than that for those who received an ultrasound examination by radiology (p = 0.017; 95% CI = 4 min to 41 min). When evaluated by disposition, patients discharged home and scanned by EPs had their median LOSs shortened by 11% or 32 minutes (p = 0.02; 95% CI = 5 min to 55 min). When evaluated by time of day, patients who presented after hours (6 PM‐6 AM) and were scanned by EPs spent 15% (52 min) less time in the ED (p = 0.0002; 95% CI = 26 min to 89 min). Those who were seen after hours and discharged home had their LOSs shortened by 20% (1 hr, 13 min, p = 0.001; 95% CI = 28 min to 1 hr, 56 min). Conclusions: In a teaching hospital with a residency program, ESUEs decrease ED LOS for these patients. The difference was most apparent for patients presenting after hours.
Do Patients with Acute Medical Conditions Have the Capacity to Give Informed Consent for Emergency Medicine Research?
Authors: Smithline Howard A , Mader Timothy J. , Crenshaw Bradley J.
Published: January 2008

Abstract. Objective: Because of stress and illness, conscious emergency medicine (EM) patients may be temporarily cognitively impaired and thus incapable of participating in the informed consent process for acute care research. This pilot study sought to assess the mental capacity of ED patients during their evaluation and treatment for acute myocardial infarction (AMI). Methods: A prospective observational design at a university tertiary referral center. EM patients with AMI from November 1996 to February 1997 were enrolled. While usual care was delivered, patients were administered three subtests of the Wechsler Adult Intelligence Scale—Revised (WAIS‐R) test. Subtest scaled scores range from 1 to 19, with abnormal being less than 5. Demographic, historical, and environmental parameters were recorded. Patients assessed how serious they perceived their conditions; and rated their degrees of pain, nausea, breathlessness, and anxiety on 10‐cm visual analog scales (VASs). Testing was repeated prior to hospital discharge. Results: Twenty‐five patients were enrolled. Of these, two (8%) were suspected by their emergency physicians to have insufficient capacity to give informed consent. However, five (20%) scored less than 5 on all of the WAIS‐R subtests (kappa = 0.5) and eight (32%) scored less than 5 on at least one of the subtests (kappa = 0.3). The initial median Digit Span, Comprehension, and Similarities subtest scores were 7, 5, and 6. By discharge, these improved to 8, 7, and 8, respectively. Conclusions: This pilot study suggests that some patients with AMI may have difficulty processing information necessary to give informed consent for acute care research. Routine clinical evaluation may not detect this cognitive defect.
History of Domestic Violence among Male Patients Presenting to an Urban Emergency Department
Authors: Mechem C. Crawford , Shofer Frances S. , Reinhard Sharon S. , Hornig Sarah , Datner Elizabeth
Published: January 2008

Abstract. Objective: To establish the prevalence of domestic violence committed by women against male patients presenting to an urban ED for any reason. Methods: This was a prospective survey in which male patients of legal age presenting to the ED over a 13‐week period were interviewed. Patients answered a series of six questions adapted from the George Washington University Universal Violence Prevention Screening Protocol. Patients who could not speak English, those refusing to participate, those unable to give informed consent, and those meeting regional criteria for major trauma were excluded. Results: Of 866 male patients interviewed, 109 (12.6%) had been the victims of domestic violence committed by a female intimate partner within the preceding year. Victims were more likely to be younger, single, African American, and uninsured. The most common forms of assault were slapping, grabbing, and shoving (60.6% of victims). These were followed by choking, kicking, biting, and punching (48.6%), or throwing an object at the victim (46.8%). Thirty‐seven percent of cases involved a weapon. Seven percent of victims described being forced to have sex. Nineteen percent of victims contacted the police; 14% required medical attention; 11% pressed charges or sought a restraining order; and 6% pursued follow‐up counseling. Conclusions: Almost 13% of men in this sample population had been victims of domestic violence committed by a female intimate partner within the previous year. Further attention to the recognition and management of domestic violence committed by women against men may be warranted.
Linking Emergency Department Patients to Primary Care: Phone vs Face‐to‐face Interaction
Authors: Kallis Jean Marie , Gonzalez DEL Rey Javier A. , Ruddy Richard M. , Schubert Charles J.
Published: January 2008

Abstract. Objective: To compare the patient compliances and time analyses of two methods of assigning primary care providers (PCPs) to ED patients who are without a PCP: phone interview vs face‐to‐face interaction. Methods: Prospective observational cohort study following an intervention, performed in a pediatric ED, serving a population of 1.7 million, with a census of 80,000 pediatric ED visits per year. Over one year, a consecutive sampling of 1,062 patients evaluated in the ED and without a PCP were approached to participate in our study (536 enrolled, 526 declined). Patients enrolled were addressed by a nurse practitioner/social worker (NP/SW) who arranged an appointment with a PCP, either in person (in ED) or by phone after discharge. The primary outcome measure was compliance with the arranged appointment. Secondarily, the authors analyzed the time necessary for each approach in person‐hours. Results: Of the 536 enrolled, 81 were excluded because data collection was incomplete at the time of the study's completion, leaving 455 study patients. Seventy‐six percent of the study patients were between the ages of 1 month and 12 years. Contact was made by phone for 151 (33%) patients and face‐to‐face for 304 (67%). Sixty‐two percent of the phone patients kept their appointments, compared with 52% of face‐to‐face patients (p = 0.048, RR = 1.20, 1.02 < RR < 1.41). Phone interaction was also more time effective. Conclusions: Linking ED patients without a medical provider to PCPs via phone is as effective as a face‐to‐face interaction.
A Health Promotion Intervention for Families in a Medicaid Managed Care Plan
Authors: Chande Vidya T. , Kimes Deana
Published: January 2008

Abstract. Objective: To determine whether implementation of an intervention based on a model of health promotion will encourage patients to seek care from their primary care provider (PCP) and reduce visits to the pediatric ED (PED) for minor illness. Methods: Prospective, randomized, controlled study in the PED of an urban children's hospital (CH). Children <13 months old, enrolled in a Medicaid managed care plan, who identified the CH as their site for primary care and presented to the PED for evaluation of minor illness were enrolled after being seen by the triage nurse, before being seen by a physician. Subjects were randomly assigned to the intervention (I) group or control (C) group. Parents of all enrollees completed a survey about health care utilization habits. Each family in the I group received health promotion teaching from a single investigator. The intervention consisted of a review of the child's medical record with the parents, an explanation of what to expect at future well‐child visits, and a discussion of the role of the PCP. A follow‐up appointment was also provided prior to discharge from the PED. The C group received usual care. Use of health care by all subjects was tracked for one year by medical record review and phone interviews at six and 12 months. Results: 102 subjects in the I group and 93 in the C group (mean ± SD ages 6.4 months ± 3.8 and 7.2 months ± 3.9, respectively, p = 0.15) were enrolled from March 1996 to November 1996. The two groups were similar with respect to demographics and overall health status at enrollment. At study entry: 94 of 102 (92%) subjects in I and 87 of 93 (94%) in C had made at least one visit to the PED in the previous 12 months (p = 0.11); 95 of 102 (93%) in I and 75 of 93 (81%) in C had seen their PCP at least once for wellchild care (p = 0.24). Twelve‐month follow‐up by medical record review was completed for all subjects; phone interviews were completed in 90 of 102 (88%) in I and 80 of 93 (86%) in C. At 12‐month follow‐up: 84 of 102 (82%) in I and 73 of 93 (78%) in C had made at least one visit to the PED (p = 0.59); 81 of 102 (79%) in I and 77 of 93 (83%) in C had made at least one visit to their CH PCP (p = 0.54). Conclusions: There was no difference in health care utilization between the intervention and control groups at 12‐month follow‐up. The health promotion intervention did not alter utilization habits.
The Integration of Primary Care Sports Medicine into an Academic Emergency Medicine Practice: Academic and Revenue Enhancement
Authors: Veenema Kenneth R.
Published: January 2008

Abstract. Objectives: To determine whether integrating primary care sports medicine into academic emergency medicine (EM) can enhance both revenue and the academic program. Methods: A retrospective descriptive review of all patients seen in a primary care sports medicine practice at a university hospital sports medicine clinic was done over a 24‐month period. All patients seen initially in the ED for a sports injury either by the author or by another EM faculty member with follow‐up by the author in the sports medicine clinic were included in the study group. The study group was analyzed for diagnoses, payor mix, and revenue generated by the ED follow‐up sports medicine clinic visits. Results: There were 199 patients who met the inclusion criteria. This resulted in 483 ED follow‐up sports medicine clinic visits. The author practiced 13 hours/week in the ED and 16 hours/week in the primary care sports medicine practice, which resulted in 1,536 sports medicine clinic hours. The study group accounted for 20% of the total patient volume in the author's primary care sports medicine practice. There were 111 lower‐extremity injuries (knee 52%, foot/ankle 40%, hip/pelvis 8%), 81 upper‐extremity injuries (hand/wrist 48%, shoulder 43%, elbow 9%), and seven spine injuries. Payor mix was 47% traditional indemnity, 45% HMO, 4% selfpay, and 4% Medicare/Medicaid. Total charges for the ED follow‐up sports medicine clinic visits were 44,767 ($92.68/visit) and net receipts were $30,276 ($62.68/visit). This represented 20% of the total charges and 16% of the net receipts in the author's sports medicine practice during this period. Revenue generated by the ED follow‐up sports medicine clinic visits could have supported 12% of the equivalent cost of the base pay for a full‐time EM faculty position. Conclusion: The integration of primary care sports medicine into an academic EM faculty practice can enhance revenue through the establishment of an ED follow‐up sports medicine clinic while also providing an opportunity to expand resident learning experiences.
Comparison of the Palatabilities of Standard and Superactivated Charcoal in Toxic Ingestions: A Randomized Trial
Authors: Fischer Thomas F. X. , Singer Adam J.
Published: January 2008

Abstract. Objective: To compare the palatabilities of two activated charcoal formulations in patients with potentially toxic ingestions. Methods: Prospective double‐blinded randomized controlled trial comparing the palatability of standard charcoal [Liqui‐Char (LC)] with that of a superactivated granulated form [(CharcoAid G (CA)]. Alert adult patients with known or suspected toxic ingestions requiring activated charcoal were randomly assigned to receive 60 g of either LC or CA diluted in a cola beverage to a volume of 340 mL. Standardized forms were used to collect data on patient demographics, time required to drink the charcoal, the remaining volume of activated charcoal, and any adverse reactions. Patients rated the palatability of the activated charcoal on a 100‐mm visual analog scale (VAS) with 100 indicating “best imaginable beverage.” Telephone follow‐up was obtained to identify complications. Student's t‐tests or Mann‐Whitney U tests were used to compare continuous variables (e.g., VAS, time, age). Fisher's exact tests were used to compare categorical variables. This study had a power of 0.9 to detect a 20‐mm difference in the VAS, alpha = 0.05. Results: There were 60 patients enrolled; 29 drank LC, 31 drank CA. Mean age was 34 years; 68% were female. The groups were similar for age, time from ingestion, ingested agents, time required to drink charcoal, and remaining volume. There were more females in the LC group. Patients receiving CA had significantly higher palatability scores than those receiving LC [35.9 (95% CI = 22.5 to 49.3 mm) vs 19.0 mm (95% CI = 9.3 to 28.6 mm) p = 0.04]. None of the patients aspirated. Of seven patients who vomited, five were given LC (p = 0.25). Conclusions: CharcoAid is more palatable to patients with toxic ingestions than the standard nongranulated form. Use of the granular charcoal may improve patient compliance.
Can Sick Children Tell Time?: Emergency Department Presentation Patterns of Critically Ill Children
Authors: Sacchetti Alfred , Warden Todd , Moakes Mary Ellen , Moyer Vern
Published: January 2008

Abstract. Objective: Children show a consistent pattern of ED use, with the majority of patients presenting during the late afternoon and evening hours. This study evaluated whether such a diurnal pattern also exists for critically ill children and the implications of such a presentation pattern on ED staffing. Methods: A review was performed of the ED diagnoses and times of presentation for children less than 12 years of age at 28 nonpediatric hospitals over the six‐year period from July 1990 to October 1996. In addition to total ED pediatric visits, a subset of critically ill children (CIC) were identified as those with an ED diagnosis of: meningitis, cardiac arrest, diabetic ketoacidosis, status epilepticus, meningococcemia, or epiglottitis, or those undergoing endotracheal intubation in the ED. A second group of non‐critically ill children (NCIC) was composed of children with an ED diagnosis of otitis media, tonsillitis, or pharyngitis. Data collected on each patient included age, diagnosis, site of care, and time of service. Presentation patterns for all three groups were compared for time of day, with statistical analysis through chi‐square, ANOVA, and Spearman's rho correlation. Results: A total of 409,820 pediatric ED visits were examined, with 688 CIC children and 28,344 NCIC identified. Presentation patterns for NCIC visits mirrored those of the total pediatric population, with the traditional increase in the late afternoon and evening hours (correlation 0.96). CIC presented much more erratically, with a distribution spread more uniformly throughout the day compared with the total pediatric population (correlation 0.72). Thirty‐seven percent of CIC presented during the evening hours of 16:00 to 24:00, compared with 49% for NCIC and 53% for the total pediatric population, while 22% of CIC presented from 24:00 to 08:00 compared with only 13% of NCIC and 10% of totalc pediatric patients (p < 0.001). Conclusion: Critically ill children present more uniformly throughout the day and do not have the same presentation patterns as ambulatory children. ED staffing should reflect this difference and not focus pediatric ED services simply on hours of peak pediatric visits.
Sabbatical Programs and the Status of Academic Emergency Medicine: A Survey
Authors: Bernstein Edward , James Thea , Bernstein Judith
Published: January 2008

Abstract. Objectives: The Society for Academic Emergency Medicine (SAEM) commissioned a survey in 1998 to describe sabbatical programs, academic rank, and tenure, and to shed light on factors affecting the continuum of faculty development, as a context for evaluating the potential importance of emergency medicine (EM) sabbatical programs. Methods: The chairs of 120 EM residency programs were surveyed. Results: The response rate was 90%. Of 108 responses, 44 were academic EM departments (AEMDs); ten were their affiliates. The setting was urban for 82%; 37% were publicly funded and 58% privately. AEMDs were more likely to have a tenure track and eligibility for a sabbatical program, but not more likely to use a sabbatical program. Among 2,042 ranked EM faculty, there were 121 professors and 346 associate professors. Mean sabbatical length was six months, provided at full pay requiring a mean of 5.7 years of employment. Among 39 programs reporting eligibility for an EM sabbatical, requirements included: tenure (43%), academic rank of associate professor (78%), an application with multiple approval levels (92%), and a formal report (75%). Thirteen EM programs used sabbaticals; only 40 faculty members altogether (9% of senior faculty) have taken sabbaticals. The mean value of sabbaticals (rated by users on a scale of 1 to 10) was 6.8. Reduced funding, lack of departmental status, difficulty retaining faculty, Health Care Financing Administration (HCFA) regulations, graduate medical education (GME) cutbacks, and no release time were identified as challenges for emergency physicians (EPs) wishing to participate in sabbaticals. Strategies proposed to overcome these obstacles include quality customer service, streamlined operations, outside contracts, computerization, hiring individuals with PhDs, collaboration, political activity, and faculty development. Conclusions: A sabbatical can be beneficial for individuals and their institutions, but presently EPs have not been able to maximize use of available opportunities. Some obstacles to successful participation of EM in sabbatical programs might be overcome with creative strategies and the active support of professional academic organizations.
First‐postgraduate‐year Resident Clinical Time Use on Three Specialty Rotations
Authors: Magnusson A. Roy , Hedges Jerris R. , Harper Richard J. , Greaves Paul
Published: January 2008

Abstract. Objective: To compare in‐hospital time uses by first‐postgraduate‐year (PGY1) residents during rotations in emergency medicine (EM), internal medicine (IM), and surgery (S). This article reports the clinical components of residency time use. Methods: A cross‐sectional, observational study of the clinical activities of EM PGY1 residents was performed while the residents were on duty during the three specialty rotations. The activities were recorded by an observer using a log with predetermined categories for clinical activities. A time‐blocked, convenience sample of resident shifts was observed for each service rotation. The sample was proportional to the total number of hours for which a PGY1 resident was expected to be in the hospital during a rotation on that service. No attempt was made to sample the same resident at all time periods or on all rotations. Proportions were compared by χ2; α= 0.0001. Results: Twelve PGY1 residents were observed for a total of 166 hours on S, 156 hours on IM, and 120 hours on EM. These hourly amounts were representative of a typical two‐week span of service on each rotation for the residents. On average, the residents spent 57% of their time on clinical or service‐oriented activities. During EM and IM rotations, the residents spent most of their time performing clinical information gathering and engaging in case management and data synthesis (52% of total clinical effort). Within this category, residents on EM were more involved with case discussion and review of ancillary test results than on IM (34% vs 20% of time in this category). Conversely, proportionately less time in this category was devoted to documentation on the EM vs IM rotation (56% vs 80%; p < 0.0001). The greatest opportunity to perform procedures was on the S rotation (31% of total clinical time vs 6% for other specialties; p < 0.0001). Conclusion: Awareness of the clinical activities performed on PGY1 rotations can help residency directors anticipate educational needs to balance their residents experience. Since 29% and 42% of total clinical time on PGY1 EM and IM rotations, respectively, is focused on documentation, efforts to enhance charting skills and efficiency are warranted. Also, efforts to enhance PGY1 procedural experience outside of the S rotation appear warranted.
Potential Errors in the Diagnosis of Pericardial Effusion on Trauma Ultrasound for Penetrating Injuries
Authors: Blaivas Michael , DeBehnke Daniel , Phelan Mary Beth
Published: January 2008

Abstract. Objective: To evaluate ultrasound error in patients presenting with penetrating injury with a potential for pericardial effusion. Methods: Residents and faculty from an emergency medicine training program at Level 1 trauma center with an active ultrasound program were asked to view digitized video clips of subxiphoid cardiac examinations in patients with chest trauma. Participants were asked to fill out a standardized questionnaire on each video clip asking whether a pericardial effusion was present. Other questions included size of effusion and presence of tamponade. The study also asked participants to rate their confidence in their impressions. Data were analyzed using interquartile ranges and confidence levels. Results: All participants had difficulty distinguishing between epicardial fat pads and true pericardial effusions. The overall sensitivity was 73% and specificity was 44%. Confidence shown by participants in their answers increased with level of training or experience, regardless of whether they were correct or incorrect. Additional views were frequently requested to help decide whether an effusion was present. Conclusions: A serious potential exists for misdiagnosing epicardial fat pads as pericardial effusion in critically ill trauma patients. Emergency physicians need to be aware of this and should consider one of two suggested alternative methods to improve the accuracy of diagnosis.
Clinical Errors in Emergency Medicine Experience at the Emergency Department of an Italian Teaching Hospital
Authors: Famularo Giuseppe , Salvini Paolo , Terranova Antonio , Gerace Carmen
Published: January 2008

Abstract. The level of commitment in the analysis of clinical errors made in the emergency department (ED) is currently focused on organization and processes rather than on individual action. Four major cases of clinical errors made in the ED of a teaching hospital were investigated. Analysis suggested that the process of clinical decision making and the overreliance on the use of patterns during the cognitive process had a major role in causing the errors, rather than factors related to procedures or organization. It appears hard to design system changes and tactics to significantly reduce the probability of making errors associated with the cognitive process involved in clinical decision making. The authors have initiated a systematic analysis of errors made during the diagnostic workup in their ED, and the rate of clinically significant errors is tracked. A file is being created with the purpose to use it for teaching and orientation of all new staff.
The Potential for Errors in Children with Special Health Care Needs
Authors: Sacchetti Alfred , Sacchetti Christina , Carraccio Carol , Gerardi Mike
Published: January 2008

Abstract. Children with special health care needs (CSHCN) are at risk for suboptimal treatment when presenting for emergent care to unfamiliar health care providers. Errors in their management may stem from failure to recognize occult conditions, lack of familiarity with rare or complex medical problems, or lack of prior knowledge of baseline physical findings. An emergency information form (EIF) that contains patient‐specific information on essential diagnostic and therapeutic interventions may provide a ready personal reference for the emergent care of CSHCN. Coupled with the use of medical identification jewelry and an electronic transmission system, an EIF has the potential to eliminate management errors in the care of these patients.