bluuebunny/crossref_metadata_2025 huggingface dataset:
America's Health Care Safety Net Intact or Unraveling?
Authors: Richardson Lynne D. , Hwang Ula
Published: January 2008

In virtually every community in this nation, the emergency department (ED) is an integral part of the health care safety net, often serving as the only available point of access to the health care system for many vulnerable and disenfranchised individuals. The authors present a brief overview of the March 2000 report released by the Institute of Medicine that described and assessed the current status of the nation's health care safety net. The authors discuss the role of the ED as a safety net provider and as a window onto the status of the rest of the health care system. The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.
The Emergency Medical Treatment and Labor Act as a Federal Health Care Safety Net Program
Authors: Fields W. Wesley , Asplin Brent R. , Larkin Gregory L. , Marco Catherine A. , Johnson Loren A. , Yeh Charlotte , Ghezzi Keith T. , Rapp Michael
Published: January 2008

Despite the greatest economic expansion in history during the 1990s, the number of uninsured U.S. residents surpassed 44 million in 1998. Although this number declined for the first time in recent years in 1999, to 42.6 million, the current economic slow‐down threatens once again to increase the ranks of the uninsured. Many uninsured patients use hospital emergency departments as a vital portal of entry into an access‐improverished health care system. In 1986, Congress mandated access to emergency care when it passed the Emergency Medical Treatment and Labor Act (EMTALA). The EMTALA statute has prevented the unethical denial of emergency care based on inability to pay; however, the financial implications of EMTALA have not yet been adequately appreciated or addressed by Congress or the American public. Cuts in payments from public and private payers, as well as increasing demands from a larger uninsured population, have placed unprecedented financial strains on safety net providers. This paper reviews the financial implications of EMTALA, illustrating how the statute has evolved into a federal health care safety net program. Future actions are proposed, including the pressing need for greater public safety net funding and additional actions to preserve health care access for vulnerable populations.
Tying a Knot in the Unraveling Health Care Safety Net
Authors: Asplin Brent R.
Published: January 2008

The U.S. health care system continues to rely on a diverse and poorly organized health care safety net to provide care for its uninsured and underinsured residents. Last year, the Institute of Medicine (IOM) published a report entitled America's Health Care Safety Net: Intact but Endangered. The IOM cited several threats to the safety net, including inadequate monitoring of safety net function, poor integration of services, financial threats for core safety net providers, and the destabilizing effects of a rapid shift from traditional Medicaid to Medicaid managed care products. This paper reviews the findings of the IOM report, highlighting the key issues for emergency medicine. In response to the IOM's challenges, emergency departments should be used more effectively to monitor local safety net viability and to enhance the integration of community health care safety net delivery systems.
Child Health Insurance Outreach through the Emergency Department A Pilot Study
Authors: Gordon James A. , Dupuie Terry A.
Published: January 2008

In 1997 the U.S. government funded the Children's Health Insurance Program (CHIP), but the $48 billion initiative has had limited success in finding and enrolling uninsured children. While such children are more likely to receive care in emergency departments (EDs), no national initiative has targeted EDs for child health insurance outreach. Objective: As a pilot study for a national multicenter study, this study evaluated the effectiveness of child health insurance outreach in an ED setting. Methods: This was a prospective observational study of the outreach efforts of a single case manager from August 1998 to July 1999, performed at Foote Hospital ED in Jackson, Michigan (45,000 visits/year). All patients ≤18 years old presenting during the duty‐hours of the intervention worker were eligible. The case manager approached the parent of all uninsured children and provided information and an application for government‐sponsored health insurance. She followed up with a brief phone interview of each parent to determine whether the targeted child had received the insurance, and whether the new coverage was due to the ED referral. Missing information was confirmed from state insurance records. Data were analyzed with frequency tabulations and 95% confidence intervals. Results: Seventy‐eight children participated (median age 7 years; 55% male; 87% white). Forty‐four percent (95% CI ? 32% to 55%) of families referred for government‐sponsored child health insurance successfully obtained it; 31% (95% CI ? 21% to 42%) could be traced directly to intervention efforts by interview (n ? 17) or by state records (n ? 7). Nineteen percent (95% CI ? 11% to 30%) got other private insurance. Of those who got government‐sponsored insurance due to the intervention, all but one were covered by Medicaid. Conclusions: The ED may be an important outreach site for child health insurance programs. National efforts to address the lack of insurance among children should include partnerships with the ED.
Recently Discharged Inpatients as a Source of Emergency Department Overcrowding
Authors: Baer Ryan B. , Pasternack Joel S. , Zwemer Frank L.
Published: January 2008

Objective: To assess the impact on the emergency department (ED) of recently discharged inpatients and how they contribute to and worsen the current situation of ED overcrowding. Methods: Retrospective, observational study of medical records and billing data of all patients presenting to the ED within seven days of inpatient discharge from the hospital (“returns”) in September 2000. The data were collected from electronic logs. Billing charges were used to estimate ED resources. Medical records were reviewed to classify visits: 1) new problem, 2) related problem, likely preventable, 3) related problem, not likely preventable, 4) unable to classify, or 5) incomplete chart. Results: One‐hundred seventy‐four returns occurred among 6,290 total ED visits (3%). Significant differences between returns and total ED patients were noted for length of stay (LOS) (6.58 vs 5.22 hours, p ? 0.000), percent admitted (47% vs 19%, p ? 0.000), and ED billing ($1,415.67 vs $391.00, p ? 0.000). The highest rate of admission was for patients presenting 48‐72 hours after inpatient discharge (65.4%). Admission rate was higher for patients presenting >48 hours than <48 hours (54% vs 33%, p ? 0.01). A review of the medical records (117/174) revealed: 15 new problems (13%); 16 related, likely preventable (14%); 72 related, not likely preventable (62%); 4 unable to assess (2%); and 10 incomplete charts (9%). Conclusions: The ED is appropriately utilized as a safety net for discharged inpatients. Though “returns” are a small percentage of ED patients, they have longer LOSs, have higher ED charges, and are more frequently admitted. Returns increase the strain on an already overcrowded ED.
Tricyclic Antidepressants Directly Depress Human Myocardial Mechanical Function Independent of Effects on the Conduction System
Authors: Heard Kennon , Cain Brian S. , Dart Richard C. , Cairns Charles B.
Published: January 2008

Objectives: To measure the effect of tricyclic antidepressant drugs (TCAs) on human myocardial contractility. Methods: Human atrial tissue was obtained during cardiac bypass surgery. The tissue was harvested, suspended in a Tyrode buffer at 37°C, and perfused with a 95%/5% oxygen—carbon dioxide mixture. Developed force was continuously measured using a force transducer and recorded by computer. After an equilibration period, escalating doses of amitriptyline or desipramine were added to the bath. All strips were exposed to the following five concentrations of each drug: 0 (control) 0.4, 4, 40, and 400 μM. The results for each experiment were expressed as the difference between the developed force measured prior to the addition of each concentration of drug and the developed force measured after a 30‐minute exposure to the drug. Results: Desipramine decreased the developed force by 27%, 49%, and 74% at concentrations of 0.4, 40, and 400 μM, respectively. Amitriptyline decreased the developed force by 38% at the 40‐μM concentration and by 89% at the 400‐μM concentration. Untreated strips retained 94% of baseline developed force at 150 minutes. Conclusions: Tricyclic antidepressants depress human myocardial function in a dose‐dependent fashion independent of the effects on the cardiac conduction system. While previous work has demonstrated the effect of therapies for the reversal of impaired cardiac conduction following TCA poisoning, to the best of the authors' knowledge, no reports have documented the effects of therapy on direct myocardial depression. Additional therapies targeted at reversing the direct cardiodepressive effects of TCA may improve outcome following TCA poisoning.
Identification of Prearrest Clinical Factors Associated with Outpatient Fatal Pulmonary Embolism
Authors: Courtney D. Mark , Kline Jeffrey A.
Published: January 2008

Massive pulmonary embolism (MPE) is an important cause of outpatient sudden death, and description of these patients is critical for identification and treatment. Objective: To test whether MPE patients can be distinguished from patients suffering sudden death from other causes based on clinical, demographic, and historical data. The hypothesis was that MPE cases would be more likely to manifest components of a clinical triad of 1) overt dyspnea, 2) alteration of mental status or syncope, and 3) shock index (pulse divided by systolic blood pressure) >0.8.

Methods: Retrospective case—control study of medical examiner data from 1992 to 1999 including all patients with nontraumatic death, aged 18‐65 years, transported to an emergency department, with autopsy‐determined cause of death. Analysis was done by 95% confidence interval (95% CI) for difference in proportions and multivariate logistic regression for odds ratios.

Results: The MPE patients (n = 37) were younger than the control subjects (n = 347) (40.2 vs 46.5 years, unpaired t‐test p < 0.001). At least two of the three components of the triad were present in 56.8% of MPE cases vs 3.5% of controls (95% CI for difference in proportions = 37.3% to 68.0%). Significant variables (and odds ratios) for MPE after multivariate analysis included: dyspnea (13.8), shock index >0.8 (23.6), immobilization or fracture (14.6), seen by a physician within two weeks (5.1), and African American female status (6.4).

Conclusions: Patients in this community with fatal MPE were young with risk factors for pulmonary embolism, and commonly manifested components of a triad including: dyspnea, alteration of mental status/syncope, and shock prior to death.
Provider Adherence to a Clinical Practice Guideline for Acute Asthma in a Pediatric Emergency Department
Authors: Scribano Philip V. , Lerer Trudy , Kennedy Dayna , Cloutier Michelle M.
Published: January 2008

Critics of the use of clinical practice guidelines (CPGs) in an emergency department (ED) setting believe that they are too cumbersome and time‐consuming, but to the best of the authors' knowledge, potential barriers to CPG adherence in the ED have not been prospectively evaluated.

Objectives: To measure provider adherence to an ED CPG based on National Asthma Education and Prevention Program (NAEPP) recommendations, and to determine factors associated with provider nonadherence.

Methods:Prospective, cohort study of children aged 1‐18 years with the diagnosis of an acute exacerbation of asthma who were seen in a pediatric ED and requiring admission, as well as a random selection of children discharged to home following pediatric ED care. The following adherence parameters were assessed: at least three nebulized albuterol treatments in the first hour; early steroid administration (after the first nebulizer treatment); clinical assessments using pulse oximetry and peak expiratory flow (PEF) (for children >6 years old); and use of a clinical score to assess acute illness severity (Asthma Severity Score). Nonadherence was defined as any deviation of the above parameters

Results: Between July 1, 1998, and June 30, 1999, 369 patients were studied. Of these, 38% (139) were discharged to home, 38% (140) were admitted to the observation unit, and 24% (90) were admitted to the inpatient unit. Illness severities at initial presentation to the ED were: 24% (86) had mild exacerbations, 59% (212) had moderate exacerbations, and 17% (62) had severe exacerbations. Sixty‐eight percent (95% CI = 63% to 73%) of the patients were managed with complete adherence to the CPG. Of the 32% with some form of nonadherence, most (63%) were children older than 6 years; in this group 64% (48/75) were nonadherent due to lack of PEF assessment. When PEF assessment was disregarded, an 83% (95% CI = 79% to 87%) adherence to the CPG was achieved. Other nonadherence factors included: lack of at least three nebulized albuterol treatments provided timely within the first hour (5%); delay in steroid administration (6%); lack of pulse oximeter use (0.5%); and failure to record clinical score to assess severity (1.1%). Patient age, illness severity (acute and chronic), first episode of wheezing, and high ED volume periods (evenings and weekends) did not worsen adherence.

Conclusions: Clinical practice guidelines can be used successfully in the pediatric ED and provide a more efficient management and treatment approach to acute exacerbations of childhood asthma. With a systematic and concise CPG, barriers to adherence in a pediatric ED appear to be minimal, with the exception of using PEF in the routine ED assessment.
Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments
Authors: Lahn Michael , Friedman Benjamin , Bijur Polly , Haughey Marianne , Gallagher E. J.
Published: January 2008

Objective: Ten years have passed since Congress enacted the Patient Self‐Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs).

Methods: This was an observational, cross‐sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12‐hour data collection shifts.

Results: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do‐not‐resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful.

Conclusions: Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three‐fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care.
Risk Factors for Cardiovascular and Cerebrovascular Death among African Americans and Hispanics in Los Angeles, California
Authors: Henderson Sean O. , Bretsky Philip , Henderson Brian E. , Stram Daniel O.
Published: January 2008

Objective: To describe the risk factors associated with cardiovascular mortality in the African American (AA) and Hispanic populations in Los Angeles County in an effort to define causes for the excess mortality seen in AAs.

Methods: This was a longitudinal analysis of all‐cause, cardiovascular, and cerebrovascular mortality in a large, prospective multiethnic cohort of individuals aged 45‐74 years. Death rates between AA and Hispanic men and women during the six‐year period from 1993 to 1998 due to hypertension, cardiomyopathy, acute myocardial infarction (AMI), ischemic heart disease, and stroke were compared.

Results: There were 1,157 deaths due to cardiovascular disease (CVD) or cerebrovascular disease among the 71,798 eligible members of the cohort included in these analyses. Age‐adjusted mortality rates were two to five times higher in AAs as compared with Hispanics (e.g., 373.15 in AAs for hypertensive disease vs 50.37 in Hispanics). A history of hypertension was the most common significant risk factor for CVD; other risk factors significantly associated with CVD mortality included cigarette smoking and a past history of diabetes and stroke. Adjusting for these factors did not remove the significance of AA ethnicity as a risk factor for CVD mortality in either subjects reporting or subjects not reporting hypertension at baseline.

Conclusions: The evidence for both higher relative severity and higher incidence of hypertensive disease among AAs, and the consistency of the effect across gender, suggests that a major determinant of risk may be a gene environment interaction.
Mental Health Aspects of Emergency Medical Services for Children Summary of a Consensus Conference
Authors: Horowitz Lisa , Kassam‐Adams Nancy , Bergstein Jack
Published: January 2008

Objective: To address the mental health needs of children involved in emergency medical services (EMS).

Methods: A multidisciplinary consensus conference convened to identify mental health needs of children and their families related to pediatric medical emergencies, to examine the impact of psychological aspects of emergencies on recovery and satisfaction with care, and to delineate research questions related to mental health aspects of medical emergencies involving children.

Results: The consensus group found that psychological and behavioral factors affect physical as well as emotional recovery after medical emergencies. Children's reactions are critically affected by age and developmental level, characteristics of the emergency medical event, and parent reactions. As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families.

Conclusions: Ecological changes in emergency departments, such as linkages to mental health follow‐up services, training of EMS providers and mental health professionals, and focused research that provides an empirical basis for practice, are necessary components for improving current standards of health care.
Ethics Seminars HIV Testing, Consent, and Physician Responsibilities
Authors: Parsa Michael , Walsh Matthew J.
Published: January 2008

Emergency physicians constantly have multiple ethical obligations in the emergency department. They must understand these sometimes conflicting obligations and learn to prioritize. A case discussion is presented that exemplifies the conflict between patient privacy and society's right to know. Specific aspects of HIV testing and obtaining patient consent are presented. Teaching physicians are encouraged to use such common cases for “ethics case discussion.”
Are Emergency Department Patients at Risk for Herb—Drug Interactions?
Authors: Rogers Emily A. , Gough John E. , Brewer Kori L.
Published: January 2008

Objectives: To determine the prevalence of herbal and/or dietary supplement use and identify patients at risk for herb—drug interactions. Methods: A convenience sample of 944 patients were surveyed to determine the prevalence and types of supplements used. Patients with heart disease, diabetes, psychiatric disorders, and/or hypertension were assessed for potential interactions. Results: One hundred thirty‐five (14.3%) patients reported regular use. Of these, 79.3% were taking supplements concurrently with prescription medications, and 80.0% were administered medication(s) in the emergency department. Cardiac: 19.8% (n? 33) reported regular use, with four potential interactions. Hypertension: 20.3% (n? 54) reported regular use, with two potential interactions. Diabetes: 15.9% (n? 20) reported regular use, with no known interactions. Psychiatric: 15.9% (n? 10) reported regular use, with one potential interaction. Conclusions: Six patients were identified at risk for seven known herb—drug interactions. The prevalence of undisclosed herbal supplement use and lack of research on these supplements suggest that more patients may be at risk.
Role of the Peripheral Intravenous Catheter in False‐positive D‐dimer Testing
Authors: Heffner Alan C. , Kline Jeffrey A.
Published: January 2008

Abstract. Objective: To determine whether inserting a peripheral intravenous catheter (IV) can significantly increase the circulating D‐dimer concentration. Methods: Twenty healthy young adult volunteers underwent cannulation of an antecubital vein with a 20‐gauge Teflon IV. Time 0 venous blood was drawn during IV insertion. The IV was salinelocked and left in place for 90 minutes, at which time a second venipuncture was performed in a contralateral antecubital vein (+90 min). A qualitative D‐dimer assay [erythrocyte‐agglutination assay, SimpliRED (SRDD)] and a quantitative spectrophotometric assay [enzyme‐linked immunosorbent assay (EIA), Dimertest Gold] were performed on all samples. Time 0 means (±SD) were compared with +90 min means by paired t‐test, and SRDD pairs were compared with McNemar's test. Results: Time 0 initial venipuncture blood samples yielded a mean D‐dimer concentration of 15 ± 24 ng/mL, with 2/20 SRDD tests read as positive (95% CI = 1% to 32%). At +90 min, the D‐dimer concentration was 33 ± 21 ng/mL (p = 0.04 vs time 0), with 5/20 SRDD tests read as positive (95% CI = 9% to 49%, p = 0.248). Conclusions: Insertion of an IV increased the circulating D‐dimer concentration (determined by EIA), but did not lead to a significant increase in false‐positive conversion of the SRDD. An effort should be made to perform D‐dimer testing on “first‐stick” blood to optimize specificity. However, a strongly positive D‐dimer reaction cannot be ascribed to the presence of an IV.
An Evaluation of a System‐change Training Model to Improve Emergency Department Response to Battered Women
Authors: Campbell Jacquelyn C. , Coben Jeffrey H. , McLoughlin Elizabeth , Dearwater Stephen , Nah Gregory , Glass Nancy , Lee Debbie , Durborow Nancy
Published: January 2008

Abstract. Objectives: To evaluate a system‐change model of training from the Family Violence Prevention Fund and the Pennsylvania Coalition Against Domestic Violence for improving the effectiveness of emergency department (ED) response to intimate partner violence (IPV). Methods: An experimental design with outcomes measured at baseline, 9‐12, and 18‐24 months post‐intervention. Twelve hospitals in Pennsylvania and California with 20,000‐40,000 annual ED visits were randomly selected and randomly assigned to experimental and control conditions. Emergency department teams (physician, nurse, social worker) from each experimental hospital and a local domestic violence advocate participated in a two‐day didactic information and team planning intervention. Results: The experimental hospitals were significantly higher than the control hospitals on a staff knowledge and attitude measure (F = 5.57, p = 0.019), on all components of the “culture of the ED” system‐change indicator (F = 5.72, p = 0.04), and in patient satisfaction (F = 15.43, p < 0.001) after the intervention. There was no significant difference in the identification rates of battered women (F = 0.411, p = 0.52) (although the linear comparison was in the expected direction) in the medical records of the experimental and control hospitals. Conclusions: A system‐change model of IPV ED training was effective in improving staff attitudes and knowledge about battered women and in protocols and staff training, as well as patient information and satisfaction. However, change in actual clinical practice was more difficult to achieve and may be influenced by institutional policy.
Delay in Seeking Emergency Care
Authors: Rucker Donald W. , Brennan Troyen A. , Burstin Helen R.
Published: January 2008

Abstract. Objective: To determine whether patient clinical and socioeconomic characteristics predict patient delay in coming to the emergency department (ED). Methods: Adult ED patients at five urban teaching hospitals were surveyed regarding self‐reported delay in coming to the ED. Delay was measured by self‐perception as well as by the number of days ill and unable to work. Patient socioeconomic and clinical characteristics were obtained by survey questionnaire and chart review. Cross‐sectional analysis within a prospective study of 4,094 consecutive patients was performed using a subset of 1,920 patients (84% eligible rate) to whom questionnaires were administered. Results: Overall, 32% of the patients completing the survey reported delay in seeking ED care. Of these patients reporting delay, 71% thought their problem would go away or was not serious. Patients who were older, had higher acuity, or were frequent ED users reported less delay in coming to the ED, while patients without a regular physician or who were African American reported more delay. Perception of increased number of days ill prior to visiting the ED was reported by frequent ED users and those with worse baseline physical function, while patients who had higher acuity reported fewer days ill prior to coming to the ED. Conclusions: A patient's decision to delay coming to the ED often reflects a belief that his or her illness is either self‐limited or not serious. The decision to delay correlates with patient characteristics and access to a regular physician. The correlates of delay in seeking ED care may depend on the delay measure used. Better understanding of patients at risk for delaying care may influence interventions to reduce delay.
Diversity in Emergency Medicine—A Model Program
Authors: Heron Sheryl , Haley Leon L.
Published: January 2008

Abstract. Emergency medicine's (EM's) development as a specialty has spanned the last 25 years, with the first certifying examination administered by the American Board of Emergency Medicine in 1980. National census data project that the new millennium will bring a U.S. population that will be 40% minority. In the year 2000, the U.S. population had a projected minority population of 28%. The diversity of the patients we treat demonstrates the need for EM programs to diversify their faculty and residency staff. Strategies include expanding recruitment and supporting retention of underrepresented students, faculty, and trainees, addressing barriers that may exist for promotion of underrepresented women and minorities, mentoring underrepresented minority (URM) faculty in research and education, providing opportunities for URMs to advance in the field, and mentoring URMs at the junior high and high school levels in the sciences to expand the applicant pool in the field. The authors describe an academic EM program that is a model program for diversity within our specialty.
LET versus EMLA for Pretreating Lacerations: A Randomized Trial
Authors: Singer Adam J. , Stark Mary Jo
Published: January 2008

Abstract. Objective: To compare the anesthetic efficacy of EMLA cream (eutectic mixture of local anesthetics) with that of LET solution (lidocaine, epinephrine, tetracaine) for pretreating lacerations prior to lidocaine injection. Methods: This was a randomized, double‐blind clinical trial in a convenience sample of 60 patients aged 1 to 59 years with traumatic lacerations. Eligible wounds were uncomplicated, clean lacerations ≤ 6 hours old. Finger and toe lacerations were excluded. At the time of initial presentation to triage, patients were randomized to LET or EMLA. A nurse applied the topical anesthetic into the laceration with a 5‐mL syringe. A physician assessed the laceration edges for the presence of blanching and adequacy of anesthesia to a 27‐gauge needlestick. Supplemental lidocaine was then infiltrated through the wound edges and the pain of infiltration was recorded by the patient (or guardian) on a 100‐mm visual analog scale marked “most pain” at the high end. A sample of 44 patients had 90% power to detect a 20‐mm difference in injection pain (two‐tailed α= 0.05). Results: Sixty patients were randomized to LET (29) or EMLA (31). Median age was 8.5 years; 23% were female. Most lacerations were facial and closed with sutures. There was no difference in baseline characteristics between groups. More wounds treated with LET were anesthetic to a needlestick than wounds treated with EMLA (73% vs 40%, p = 0.01); however, there was no between‐group difference in the median pain of lidocaine infiltration (LET—12 mm vs EMLA—13 mm, p = 0.89). Conclusions: Pretreatment of simple lacerations with LET or EMLA at the time of patient presentation results in similar amounts of pain of subsequent local infiltration of lidocaine
The Emergency Medicine Subinternship—A Standard Experience for Medical Students?
Authors: Coates Wendy C. , Gill Andrew M.
Published: January 2008

Abstract. Objective: To determine whether emergency medicine (EM)‐bound and non‐EM‐bound senior medical students on the EM subinternship have a uniform experience with respect to number and acuity of patients seen and procedures performed. Methods: Prospective observational analysis of patient diagnosis and procedures recorded in logs by students at a public teaching hospital over 12 consecutive months. Logs were reviewed blindly and assigned an acuity level based on predetermined criteria. Preselected procedures were categorized as general or surgical and tallied. Identity, specialty choice, gender, and month of rotation for each student were identified. Results: Seventy of 74 students completed logs. On average, 34 EM‐bound students saw 59.82 patients (95% CI = 55.19 to 64.45) and performed 10.58 procedures (95% CI = 8.62 to 12.56); 36 non‐EM‐bound students saw 51.17 patients (95% CI = 47.41 to 54.90) and performed 8.33 procedures (95% CI = 6.81 to 9.84). Univariate analysis showed EM‐bound students saw more patients than non‐EM‐bound students, performed more surgical procedures, and saw higher‐acuity patients (p = 0.004; 0.009; 0.016). Multivariate analyses controlled for EM specialty, gender, and month. Significant effects for EM specialty were found (ordinary least squares) for number of patients, procedures, and surgical procedures (p = 0.013; 0.048; 0.011). Logistic regression explaining acuity level showed EM specialty and gender were significant (p = 0.010; 0.038). Conclusions: In an EM subinternship, experience was variable between EM‐bound and non‐EM‐bound students. Male students saw lower‐acuity patients. The EM‐bound students saw more patients, higher‐acuity patients, and performed more procedures than non‐EM‐bound cohorts. Emergency medicine educators responsible for medical education should be aware of these differences.
Effect of Ethnicity on Denial of Authorization for Emergency Department Care by Managed Care Gatekeepers
Authors: Lowe Robert A. , Chhaya Sheetal , Nasci Kathleen , Gavin Laurence J. , Shaw Kathy , Zwanger Mark L. , Zeccardi Joseph A. , Dalsey William C. , Abbuhl Stephanie B. , Feldman Harold , Berlin Jesse A.
Published: January 2008

Abstract. Objective: After a pilot study suggested that African American patients enrolled in managed care organizations (MCOs) were more likely than whites to be denied authorization for emergency department (ED) care through gatekeeping, the authors sought to determine the association between ethnicity and denial of authorization in a second, larger study at another hospital. Methods: A retrospective cohort design was used, with adjustment for triage score, age, gender, day and time of arrival at the ED, and type of MCO. Results: African Americans were more likely to be denied authorization for ED visits by the gatekeepers representing their MCOs even after adjusting for confounders, with an odds ratio of 1.52 (95% CI = 1.18 to 1.94). Conclusions: African Americans were more likely than whites to be denied authorization for ED visits. The observational study design raises the possibility that incomplete control of confounding contributed to or accounted for the association between ethnicity and gatekeeping decisions. Nevertheless, the questions that these findings raise about equity of gatekeeping indicate a need for additional research in this area.
Emergency Determination of Decision‐making Capacity: Balancing Autonomy and Beneficence in the Emergency Department
Authors: Larkin Gregory L. , Marco Catherine A. , Abbott Jean T.
Published: January 2008

Abstract.The determination of decision‐making capacity (DMC) is an essential component of securing voluntary informed consent, for either treatment or refusal of care. Decision‐making capacity should be determined on some level during each patient encounter. Decision‐making capacity includes the ability to receive, process, and understand information, the ability to deliberate, the ability to make choices, and the ability to communicate those preferences. For patients in whom DMC may be uncertain, a more explicit approach to determination of DMC is recommended. However, DMC determination must neither compromise patient safety nor delay needed care. When DMC determination is challenging, or when the ramifications of a decision are serious, the assistance of a third party (such as a surrogate, a consultant, or another clinician) may be valuable in discerning the most appropriate action. In addition to the obvious clinical utility of DMC assessment, the steps taken in the very establishment of DMC may promote patient trust, professionalism, and humanistic clinical practice. While DMC may be conditional, the compassion and respect we have for our patients must be unconditional.
Magnetically Guided Orotracheal Intubation
Authors: Gaspari Romolo J. , Singer Adam J. , Thode Henry C.
Published: January 2008

Abstract. Objective: To describe a novel endotracheal intubation technique, magnetically guided intubation (MGI), and its rate of success in inexperienced medical students and interns using an airway mannequin model. Methods: This was a prospective, descriptive study of 25 medical students and interns participating in an introductory course on emergency medicine without prior experience in human orotracheal intubation. Magnetically guided intubation consists of a strong external magnet placed over the cricothyroid membrane to guide the introduction of a standard endotracheal tube containing a stylet with a magnetized tip. An airway mannequin was placed in a rigid cervical spinal collar to increase the difficulty of the intubation, and each student performed two sequential intubation attempts using MGI. The proportions of successful intubations and the time to complete intubation were determined. Descriptive statistics were used to describe point estimates and 95% confidence intervals for means and proportions of continuous and categorical data, respectively. Results: Of 25 participants, 19 were students and six were interns. Their mean age was 27 years, and 76% were male. The overall proportion of successful intubations using MGI was 80% (95% CI = 69% to 91%). Of 24 intubations, 48% were attempted without visualization of the vocal cords; 67% were successful (95% CI = 46% to 87%). The mean time required to complete intubation was 17.0 seconds (95% CI = 14.5 to 19.5 seconds). Conclusions: A novel method of orotracheal intubation using magnetic guidance is described as achieving a high rate of successful intubations when performed by inexperienced intubators.
Routine Carbon Monoxide Screening by Emergency Medical Technicians
Authors: Jaslow David , Ukasik Joseph , Sananman Peter
Published: January 2008

Abstract. Residential carbon monoxide (CO) poisoning represents a significant cause of unintentional morbidity and mortality in the United States. Screening by fire departments and utility companies is usually limited to instances in which there are symptoms of CO poisoning or there is activation of a home CO detector. Objectives: To determine whether emergency medical services (EMS) personnel can perform routine CO screening during 911 calls. Methods: A prospective observational study was conducted in an urban EMS system using emergency medical technicians (EMTs) to screen for elevated CO levels during emergency responses. The EMTs carried hand‐held CO meters that detect as little as one part per million of CO. Readings were taken at the patient's side during indoor patient contacts. If time allowed, a brief questionnaire was then administered to patients or by‐standers concerning knowledge about CO poisoning, type of household heating system, and presence of home CO detectors. Results: In a three‐month convenience sample of emergency responses, there were 264 residential CO readings obtained. There were nine (3.4%) positive residential readings, all with chief complaints believed to be unrelated to CO toxicity. Two hundred twelve surveys were completed during these emergency responses, with 145 of 212 (68%) participants familiar with the term “carbon monoxide poisoning.” Only 54 of 145 (37%) participants could name any signs or symptoms of CO poisoning. Of those surveyed, 133 of 212 (63%) participants reported an oil‐ or gaspowered heating system in their residence. Carbon monoxide detectors were absent in 185 of 212 (87%) residences, including all domiciles in which a positive CO reading was obtained. Conclusions: Emergency medical services personnel can perform routine CO screening and detect occult elevations in CO levels during 911 responses. Public knowledge of CO poisoning is limited and the use of home CO detectors is rare in this study population.
Ability of Patients to Accurately Recall the Severity of Acute Painful Events
Authors: Singer Adam J. , Kowalska Agnes , Thode Henry C.
Published: January 2008

Abstract. Objective: Pain studies require prospective patient enrollment to ensure accurate pain assessment. The authors correlated pain assessments of an acute painful episode over a one‐week period and determined the accuracy of patient pain severity recall over time. Methods: This was a prospective, descriptive, longitudinal study. Participants were a convenience sample of 50 emergency department patients with acute pain resulting from injuries or painful invasive procedures. A trained research assistant administered a structured pain survey containing demographic and historical features to all patients. Patients sequentially assessed their pain severity using a vertical 100‐mm visual analog scale marked “most pain” at the top, a verbal numeric rating scale ranging from 0 to 100 from none to worst (NRS100), and a verbal numeric rating scale ranging from 0 to 10 from none to worst (NRS10). Patients were contacted by phone and asked to reassess their initial pain severity one and seven days later using the two verbal numeric rating scales. Analysis of pain assessments using the various scales at the three time intervals was performed with Pearson's and Spearman's coefficients and repeated‐measures analysis of variance (ANOVA). Results: There were 50 patients with a mean age of 41 years. Correlation between initial pain assessments on the three scales ranged from 0.83 to 0.92. Correlations between the initial and 24‐hour assessments were NRS100‐0.98 and NRS10‐0.98. Correlations between the initial and one‐week assessments were NRS100‐0.96 and NRS10‐0.97. Repeated‐measures ANOVA showed no significant change in pain assessments over time for both verbal numeric scales. Conclusions: Pain severity assessments of acute painful events one and seven days later were similar and highly correlated with initial assessments using both verbal numeric scales. Patients accurately recall the severity of an acute painful episode for at least one week after its occurrence, which may allow retrospective pain assessments.
Concussive Convulsions: Emergency Department Assessment and Management of a Frequently Misunderstood Entity
Authors: Perron Andrew D. , Brady William J. , Huff J. Stephen
Published: January 2008

Abstract.Immediate concussive convulsions are an unusual but dramatic sequela to head injuries. Previously believed to be an epileptic phenomenon, they are now thought to be a brief traumatic functional decerebration that results from loss of cortical inhibition. With concussive convulsions generally occurring within seconds of head impact and lasting up to several minutes, patients are initially in a tonic phase, followed by a clonic convulsion. A postictal phase is generally brief if it occurs at all with these episodes. Patients with isolated concussive convulsions have no evidence of structural brain injury as assessed with neuroimaging studies or physical examination. Neuropsychological testing often demonstrates transient cortical dysfunction consistent with the concussive episode. The long‐term outcome for patients with isolated concussive convulsion is universally good, with no long‐term neurologic sequelae and no increased incidence of early or late posttraumatic epilepsy. Emergency department management should focus on evaluation of the associated concussive injury. The concussive convulsion requires no specific therapy, and antiepileptic medication is not indicated.
Limited Response to Cardiac Arrest by Police Equipped with Automated External Defibrillators: Lack of Survival Benefit in Suburban and Rural Indiana—The Police as Responder Automated Defibrillation Evaluation (PARADE)
Authors: Groh William J. , Newman Mary M. , Beal Paul E. , Fineberg Naomi S. , Zipes Douglas P.
Published: January 2008

Abstract. Objective: To assess the out‐of‐hospital cardiac arrest (OHCA) survival advantage after providing police with automated external defibrillators (AEDs) in rural and suburban Indiana. Methods: An observational evaluation was conducted in six Indiana counties (population: 464,741) before (retrospective) and after (prospective) training and equipping police with AEDs. The primary outcome evaluated was survival to hospital discharge for all cases of ventricular tachycardia/ventricular fibrillation (VT/VF) OHCA. Other factors evaluated include age, gender, race, arrest location, witnessed arrest, bystander cardiopulmonary resuscitation, response intervals, and survival to discharge for all OHCAs. Results are reported using chi‐square, Student's t‐test, and logistic regression. Results: Police were equipped with 112 AEDs, increasing total defibrillator capability by 43.2%. During the study period, AED‐equipped police responded prior to emergency medical services (EMS) in 26 of 388 cases (6.7%). The time intervals from 911 call‐to‐scene and 911 call‐to‐shock were shortened by 1.6 minutes (95% confidence interval [95% CI] = 0.0 to 3.1, p = 0.05) and 4.8 minutes (95% CI = 1.3 to 8.3, p = 0.008), respectively, with police response as compared with EMS response. Survival to hospital discharge for VT/VF OHCA was 15.0% (3/20) in cases in which police responded first and 10.0% (16/160) in cases in which EMS responded first (relative risk [RR] 0.63, 95% CI = 0.17 to 2.39, p = 0.45). Survival to hospital discharge for VT/VF OHCA did not improve from the prestudy period (16/204, 7.8%) to after police AED availability (19/180, 10.6%) (RR 0.72, 95% CI = 0.36 to 1.45, p = 0.38). Conclusions: Out‐of‐hospital cardiac arrest survival in suburban and rural Indiana did not improve after police were equipped with AEDs, likely related to poor police response.
Analysis of School Injuries Resulting in Emergency Department or Hospital Admission
Authors: Junkins Edward P. , Knight Stacey , Olson Lenora M. , Lightfoot Amy , Keller Patricia , Corneli Howard M.
Published: January 2008

Abstract. Objective: To describe the epidemiology of school injuries resulting in emergency department (ED) visits, hospital admission, or death. Methods: Utah statewide school injuries from 1992 to 1996 were probabilistically linked to statewide ED records (1996 only), inpatient hospital records (1992‐1996), and death certificate records (1992‐1996). Results: There were 43,881 school injuries for the years 1992 through 1996. In 1996, 1,534 of 6,354 total school injuries (17.5%) resulted in ED evaluation. Between 1992 and 1996, 354 school injuries (0.8%) necessitated hospital admission. The overall rates of school injuries (per 1,000 students) of primary (kindergarten—grade 6) and secondary (grades 7‐12) school students requiring ED evaluation were 3.29 and 3.28, respectively; for hospital admission, 0.165 and 0.139. Abbreviated Injury Scale‐1990 (AIS‐90) regions identified in ED patients were the upper extremity (39.2%), face (20.8%), and lower extremity (17.1%), while AIS regions among inpatients were lower extremity (29.1%), upper extremity (26.6%), and head (22.6%). There were a total of 1,123 hospital days, and total charges of $2.16 million. The ED charges totaled $545,000. Median length of hospital stay was 1 day, and median hospital charge was $3,080. There were four fatalities. Conclusions: This study emphasizes the significance of school injuries and the need for interventions to prevent these injuries
Targeted Musculoarticular Sonography in the Detection of Joint Effusions
Authors: Valley Verena T. , Stahmer Sarah A.
Published: January 2008

Abstract. This article describes an advanced application for an established technology, specifically the use of bedside sonography in the assessment of the acutely painful joint in the emergency department. The sonographic windows for each of the axial synovial joints are outlined, with a brief discussion of commonly encountered pathologic conditions.
Ethics Seminars: The Practice of Medical Procedures on Newly Dead Patients—Is Consent Warranted?
Authors: Moore Gregory P.
Published: January 2008

Abstract. The use of the newly dead to teach procedures is widely practiced in training institutions. This model allows a realistic opportunity both to become more familiar with lifesaving maneuvers before they are actually necessary and to maintain proficiency. Whether to notify the next of kin first has been an issue of ethical debate. Some argue a “don't ask, don't tell” policy is justified, while others mandate open consent by family members prior to the practice. Several medical studies have found that patients and families are likely to consent to the procedures but prefer to be asked permission first. Multiple legal cases have addressed the issue of usage of cadavers postmortem without expressed permission. Earlier cases emphasized the concept of “pseudo‐property” rights and declared that the next of kin do not have constitutional ownership of the deceased person's body. More recent legal cases are declaring that families do, in fact, possess these rights. In this day and age of increasing recognition of personal autonomy, it is probably prudent to approach the next of kin for permission before performing procedures on the newly deceased.