bluuebunny/crossref_metadata_2025_split huggingface dataset:
On‐line Telemetry: Prospective Assessment of Accuracy in an All‐volunteer Emergency Medical Service System
Authors: Hollander Judd E. , Delagi Robert , Sciammarella Joseph , Viccellio Peter , Ortiz Joe , Henry Mark C. 
Published: September 2008

ABSTRACTObjective: To evaluate the need for on‐line telemetry control in an all‐volunteer, predominantly advanced emergency medical technician (A‐EMT) ambulance system.Methods: Emergency medical service (EMS) advanced life support (ALS) providers were asked to transmit the ECG rhythms of monitored patients over a six‐month period in 1993. The ECG rhythm interpretations of volunteer EMS personnel were compared with those of the on‐line medical control physician. All discordant readings were reviewed by a panel of physicians to decide whether the misdiagnosis would have resulted in treatment aberrations had transmission been unavailable.Results: Patients were monitored and rhythms were transmitted in 1,825 cases. 1,642 of 1,825 rhythms were correctly interpreted by the EMS providers (90%; 95% CI 89–91%). The accuracy of the EMS providers was dependent on the patient's rhythm (chi‐square, p < 0.00001), the chief complaint (chi‐square, p = 0.0001), and the provider's level of training (chi‐square, p = 0.02). Correct ECG rhythm interpretations were more common when the out‐of‐hospital interpretation was sinus rhythm (95%), ventricular fibrillation (87%), paced rhythm (94%), or agonal rhythm (96%). The EMS providers were frequently incorrect when the out‐of‐hospital rhythm interpretation was atrial fibrillation/flutter (71%), supraventricular tachycardia (46%), ventricular tachycardia (59%), or atrioventricular block (50%). Of the 183 discordant cases, 124 (68%) involved missing a diagnosis of, or incorrectly diagnosing, atrial fibrillation/flutter. Review of the discordant readings identified 11 cases that could have resulted in treatment errors had the rhythms not been transmitted, one of which might have resulted in an adverse outcome.Conclusions: In this all‐volunteer, predominantly A‐EMT ALS system, patients with a field interpretation of a sinus rhythm do not require ECG rhythm transmission. Field interpretations of atrial fibrillation/flutter, supraventricular tachycardia, ventricular tachycardia, and atrioventricular blocks are frequently incorrect and should continue to be transmitted.
Effect of Nitrous Oxide Analgesia on Pneumothorax
Authors: Seaberg David C. , Yealy Donald M. , Ilkhanipour Kaveh 
Published: September 2008

ABSTRACTObjective: To address whether spontaneous inhalation of 50% nitrous oxide (N2O) for up to 30 minutes adversely affects swine with pneumothorax (PNTX).Methods: Five fasted, female swine (13–17 kg) were sedated with IV ketamine, intubated, and allowed to spontaneously inhale either 50% N2O or room air (RA) in a sequential crossover design in which each animal served as its own RA control. Small (group I, 150 mL), medium (group II, 300 mL), and large (group III, 500 mL) PNTXs were created by instilling air into the left pleural space via an 18‐Fr three‐way Foley catheter. Changes in PNTX volume, heart rate (HR), central venous pressure (CVP), blood pressure (BP), ECG, and arterial blood gas (ABG) parameters were recorded in separate 10‐and 30‐minute trials. A 15‐minute washout period was given between each trial. Data were analyzed using repeated‐measures analysis of variance with post‐hoc Tukey's tests.Results: No significant increase in PNTX size was seen during the 10‐minute trials. In the 30‐minute trials, a statistically significant increase in absolute PNTX size was seen with NzO compared with RA for group I (44 ± 17 vs 16 ± 5 mL, p = 0.02), group II (61 ± 21 vs 26 ± 4 mL, p = 0.01), and group III (62 ± 32 vs 40 ± 5 mL, p = 0.06). No difference in HR, CVP, MAP, ABGs, or ECG were observed between the N2O and RA trials for any size PNTX. No animal developed hemodynamic signs of tension pneumothorax.Conclusion: In this model, spontaneous inhalation of 50% N2O for up to 30 minutes is associated with little risk of hemodynamic or respiratory compromise. Although PNTX size increases with 50% N2O use, the magnitude observed in this animal model is less than previously reported.
The Extent and Effects of Abuse and Harassment of Emergency Medicine Residents
Authors: McNamara Robert M. , Whitley Theodore W. , Sanders Arthur B. , Andrew Louise B. , Force For the SAEM In‐service Survey Task 
Published: September 2008

ABSTRACTObjective: To determine the extent and effects of abuse and harassment, including sexual harassment and racial or ethnic discrimination, experienced by residents in emergency medicine (EM).Method: The study instrument was an anonymous, self‐report survey administered to a national sample of EM residents. The survey was timed to coordinate with the American Board of Emergency Medicine's annual In‐Service Examination in February 1993. The residents reported whether they had experienced nine types of abuse or harassment during their residency training, the sources of these incidents, the effects on the residents, and whether they chose to file a formal complaint regarding these events.Results: Surveys were returned by 1,774 (80%) of the 2,229 residents who sat for the examination—74.4% men and 24.6% women. Overall, 98% reported at least one occurrence of abuse or harassment, with patients being the most frequent source. More than half of the more senior residents reported having been physically hit or pushed. Other health care professionals were a frequent source of verbal abuse and sexual harassment. Women were significantly more likely than men to report unwanted sexual advances (63% vs 32%, p < 0.001), discomfort from sexual humor (66% vs 27%, p < 0.001), and unfair treatment because of gender (71% vs 15%, p < 0.001). Non‐Caucasians reported a higher rate of racial or ethnic discrimination than did Caucasians (51% vs 23%, p < 0.001). As a result of these episodes, 19% of the respondents had questioned their decision to become a physician, 20% had questioned entering the specialty of EM, 11% had experienced emotional effects lasting over one month, and 11% had experienced disruption of their family lives. Only 56 (3.2%) had filed formal complaints.Conclusions: Residents frequently encounter abuse or harassment, particularly from patients. They also report adverse consequences from these episodes.
Emergency Medicine Resident Moonlighting: A Survey of Program Directors
Authors: Langdorf Mark I. , Bearie Brian , Ritter Michael S. , Ferkich Anthony , Moonlighting For the CORD Task Force on Resident 
Published: September 2008

ABSTRACTObjectives: 1) To systematically describe emergency medicine (EM) program directors' perceptions of the benefits and risks of resident moonlighting. 2) To assess moonlighting policies of EM residencies, the degree of compliance with these policies, and the methods of dealing with residents who are out of compliance.Methods: A written survey was mailed or hand‐delivered to all allopathic and osteopathic EM residency directors in the United States in 1992–93. Incomplete and ambiguous surveys were completed by phone.Results: There was a 96% response rate (113/118). The average EM resident clinical workweek ranged from 38 to 50 hours while the resident was assigned to ED rotations. Most (90%) of the program directors believe moonlighting interferes with residency duties to some degree. Few (10%) programs prohibit moonlighting altogether, although 44% limit moonlighting to an average of 41.5 hours per month. Program directors believe residents moonlight primarily for financial reasons. Most (60%) of the program directors believe moonlighting offers experience not available in the residency, primarily related to autonomous practice. Fifteen programs reported residents who had been sued for malpractice while moonlighting, with one program director named along with the resident. One third of program directors have penalized residents for abuse of moonlighting privileges.Conclusions: EM residency directors are concerned about the effect of moonlighting on resident education. The directors' concerns regarding litigation, excessive work hours, and interference with residency duties are balanced by a general acceptance of the financial need to supplement residency income.
National Survey of Emergency Medicine Resident Moonlighting
Authors: Langdorf Mark I. , Ritter Michael S. , Bearie Brian , Ferkich Anthony , Bryan James , Force For the SAEM Inservice Examination Survey Task 
Published: September 2008

ABSTRACTObjectives: To survey emergency medicine (EM) residents regarding moonlighting practices and perceptions for clarifying: 1) resident moonlighting remuneration; 2) any association of perceived educational debt with moonlighting income and hours; and 3) perceptions related to moonlighting (including motivations, impact on resident training, and potential medicolegal difficulties).Methods: A confidential, voluntary survey was administered to all allopathic EM residents in the United States. This written survey was provided to residents at their in‐service examinations. Completed forms were anonymously returned by residents or local administrative staff to a central site where all identifiers were removed prior to mailing en mass to the investigators. Comparisons between groups were made using chi‐square tests and correlations were assessed using the Pearson correlation coefficient.Results: Seventy‐six percent (1,826/2,407) of the surveys were returned. There was a weak correlation (r = 0.11) between educational debt and moonlighting hours for residents in the second year and above, but no association of debt with moonlighting income. Most (88%) of the residents reported that their programs permitted moonlighting. Nearly half (49%) reported that they did moonlight in some way. Most (82%) thought moonlighting provided experience not available in the residency. Only 13 (2%) respondents stated they had been sued for malpractice while moonlighting. Most (66%) moonlighting respondents stated that they moonlighted for financial reasons, with educational debt the primary motivating factor. Of the moonlighting residents, 28% were unsure of their type of malpractice insurance coverage, and 9% had no coverage at all.Conclusions: Education about EM practice matters including the risks of moonlighting should begin early in residency, because moonlighting is widespread. Residents are vulnerable to medicolegal action while moonlighting and have insufficient knowledge of their malpractice insurance coverage. Although educational debt is perceived as a strong motivating factor for moonlighting, there is only a weak relationship between educational debt and moonlighting hours.
Impact of Interventions for Patients Refusing Emergency Medical Services Transport
Authors: Alicandro Jeanne , Hollander Judd E. , Henry Mark C. , Sciammarella Joseph , Stapleton Edward , Gentile David 
Published: September 2008

ABSTRACTObjective: To evaluate the effect of a documentation checklist and on–line medical control contact on ambulance transport of out–of–hospital patients refusing medical assistance.Methods: Consecutive patients served by four suburban ambulance services who initially refused emergency medical services (EMS) transport to the hospital were prospectively enrolled. In phase 1 (control phase), all patients who initially refused medical attention or transport had an identifying data card completed. In phase 2 (documentation phase), out–of–hospital providers completed a similar data card that contained a checklist of high–risk criteria for a poor outcome if not transported. In phase 3 (intervention phase), a data card similar to that used in phase 2 was completed, and on–line medical control was contacted for all patients with high–risk criteria who refused transport. The primary endpoint was the percentage of patients transported to the hospital.Results: A total of 361 patients were enrolled. Transport rate varied by phase: control, 17 of 144 (12%); documentation, 11 of 150 (7%); and intervention, 12 of 67 (18%) (chi–square, p = 0. 023). Transport of high–risk patients improved with each intervention: control, two of 60 (3%); documentation, seven of 70 (10%); and intervention, 12 of 34 (35%) (chi–square, p = 0. 00003). Transport of patients without high–risk criteria decreased with each intervention: control, 15 of 84 (18%); documentation, four of 80 (5%); and intervention, 0 of 33 (0%) (p = 0. 0025). Of the 28 patients for whom medical control was contacted, 12 (43%) were transported to the hospital, and only three of these 12 patients (25%) were released from the ED.Conclusion: Contact with on–line medical control increased the likelihood of transport of high–risk patients who initially refused medical assistance. The appropriateness of the decreased transport rate of patients not meeting high–risk criteria needs further evaluation.
Bystander vs EMS First–responder CPR: Initial Rhythm and Outcome in Witnessed Nonmonitored Out–of–hospital Cardiac Arrest
Authors: Swor Robert A. , Boji Bernice , Cynar Mark , Sadler Edward , Basse Eliezer , Dalbec Dean L. , Grubb William , Jacobson Ronald , Jackson Raymond E. , Maher Ann , Rivera–Rivera Edgardo J. 
Published: September 2008

ABSTRACTObjectives: To assess whether outcome and first–monitored rhythm for patients who sustain a witnessed, nonmonitored, out–of–hospital cardiac arrest are associated with on–scene CPR provider group.Methods: A retrospective, cohort analysis was conducted in a suburban, heterogeneous EMS system. Patients studied were ± 19 years of age, had had an arrest of presumed cardiac origin between July 1989 and January 1993, had gone into cardiac arrest prior to ALS arrival, and had received CPR on collapse. First–monitored rhythms and survival rates were compared for two patient groups who on collapse either: 1) had received CPR by nonprofessional bystanders (BCPR) or 2) had received CPR by on–scene EMS system first responders (FRCPR).Results: Of 217 cardiac arrest victims, 153 (71%) had received BCPR and 64 (29%) had received FRCPR. The BCPR patients were slightly younger (62. 4 vs 68. 4 years, p = 0. 01) and had slightly shorter ALS response intervals (6. 4 vs 7. 7 minutes, p = 0. 02). There was no difference in BLS response time intervals or automatic external defibrillator (AED) use rates. The percentage of patients with a first–monitored rhythm of pulseless ventricular tachycardia/ventricular fibrillation (VT/VF) and the percentage of patients grouped by CPR provider who survived to hospital admission or to hospital discharge were:Controlling for age, the odds ratio for VT/VF with BCPR was 5. 45 (95% CI 2. 8, 10. 3).Conclusion: Patients who receive BCPR more often have a first–monitored rhythm of VT/VF than do FRCPR patients, despite both CPR–provider groups' initiating CPR essentially immediately after patient collapse. Hence, BCPR and FRCPR groups have different first–monitored arrest rhythms, which may affect survival rate. These patient populations should not be considered to be homogeneous groups in CPR research.
Incidence, Source, and Nature of Complaints Received in a Large, Urban Emergency Medical Services System
Authors: Curka Peter A. , Pepe Paul E. , Zachariah Brian S. , Gray Don , Matsumoto Cory 
Published: September 2008

ABSTRACTObjective: To document the incidence, source, and reasons for all complaints received by a large municipal emergency medical services (EMS) program.Methods: A retrospective review of all complaints received during three consecutive years (1990–1992) in a centralized EMS system serving a large municipality (population 2 million). All cases were categorized by year, source, and nature of the complaint.Results: In the three study years, EMS responded to 416, 892 incidents with nearly a half–million patient contacts. Concurrently, 371 complaints were received (incidence of 1. 12 per thousand); 132 in 1990, 129 in 1991, and 110 in 1992. Most complaints involved either: 1) allegations of “rude or unprofessional conduct” (34%), 2) “didn't take patient to the hospital” (19%), or 3) “problems with medical treatment” (13%). Only 1. 6% (n = 6) were response–time complaints. Other complaints included “lost/damaged property,” “taken to the wrong hospital,” “inappropriate billing,” and “poor driving habits.” The most common sources were patient's families (39%) and the patients themselves (30%). Only 7. 8% were from health care providers.Conclusion: Reviews of complaints provide information regarding EMS system performance and reveal targets for quality improvement. For the EMS system examined, this study suggests a future training focus on interpersonal skills and heightened sensitivities, not only toward patients, but also toward bystanders and family members.
The Australian Capital Territory Injury Surveillance and Prevention Project
Authors: McClure Roderick J. , Burnside Joan 
Published: September 2008

ABSTRACTObjective: To identify the representativeness and sensitivity of the data collected by the Australian Capital Territory Injury Surveillance and Prevention Project (ACTISPP) for ED injury cases seen in the Australian Capital Territory (ACT).Methods: A retrospective descriptive study was conducted using a systematic sample of people injured in the ACT between January 20 and September 19, 1992, and who received their first treatment for this injury in an ACT ED. The ACTISPP surveillance system is dependent on ED patient or family completion and return of a comprehensive injury survey. The following population variables in the ACTISPP database were compared with those of the injured ED population, as determined by ED and hospital record review: age, gender, postal code of residence, nature of injury, body part injured, and whether the patient had been admitted to hospital.Results: The sensitivity of the surveillance system for injuries seen in the ED was 31% (95% CI = 30–32%). The distribution of the ACTISPP sample did not differ from the expected distribution for sex or socioeconomic status. The distributions differed by age only in the 5–14–year age group (p < 0.001). With respect to the nature of injury and body part injured, the difference was significant (p < 0.001) but was no greater than 7% for any of the categories. Two percent of the surveillance sample were admitted to hospital, compared with an estimated 4% of the target population (p < 0.001).Conclusions: Approximately one–third of all incident injuries managed in the EDs of the ACT are included in the ACTISPP database. Although some sampling bias is introduced in the surveillance process, it does not appear to be of sufficient magnitude to compromise the project's goals.
Out‐of‐hospital Provider Use of Epinephrine for Allergic Reactions: Pilot Program
Authors: Lindbeck George H. , Burns Donna M. , Rockwell Diana D. 
Published: September 2008

ABSTRACTObjective: To describe experience with an out‐of‐hospital provider program for the recognition and field management of allergic reactions by advanced life support (ALS) and basic life support (BLS) providers.Methods: Data sheets completed between June 1, 1988, and August 31, 1993, and records from receiving sites (physicians' offices or EDs) were reviewed for information regarding the presentation of the allergic reaction, the time course and treatment provided out of hospital, and the clinical outcome at the receiving health care facility.Results: Thirty‐seven data sheets were completed during the study period. Fourteen (38%) of the providers were BLS providers. The epinephrine was supplied from the emergency medical services (EMS) provider's personal kit in 35% of the cases, from an EMS vehicle in 57% of the cases, and by the patient in 8% of the cases. Availability of the kits allowed administration of epinephrine prior to the arrival of the first EMS vehicle in 41 % of the instances and prior to physician on‐line medical command in 65% of all the instances (predominantly by BLS providers). Overall, 77% of the patients experienced alleviation of their symptoms of respiratory difficulty, swelling, or rash after epinephrine administration, while 20% were unchanged and 3% worsened. All patients receiving epinephrine had an ED diagnosis of allergic reaction, and no adverse event was encountered on follow‐up of the patients treated.Conclusions: Severe allergic reactions can be reliably identified and safely managed by out‐of‐hospital providers, including BLS providers. Providing personal anaphylactic treatment kits and increasing the pool of providers trained to manage allergic reactions (including BLS providers) can often decrease the time to treatment.
Intravenous Chlorpromazine vs Intravenous Metoclopramide in Acute Migraine Headache
Authors: Cameron James D. , Lane Peter L. , Speechley Mark 
Published: September 2008

ABSTRACTObjective: To compare the efficacy of IV chlorpromazine with that of IV metoclopramide in the treatment for acute migraine headache in the ED.Methods: A prospective randomized double‐blind trial was undertaken at two university‐affiliated urban EDs with a combined annual census of more than 85,000 patients. Included in the study were patients presenting to the ED with a diagnosis of migraine headache. The subjects were randomized to receive 0.1 mg/kg/dose IV of either chlorpromazine (CPZ) or metoclopramide (MC), up to a total of three doses.Results: Ninety‐one patients completed the protocol; 44 received MC and 47 received CPZ. The demographics of the two groups were similar. Both drugs provided, for the majority of patients, adequate pain relief as measured on a visual analog scale (VAS) completed every 15 minutes from T = 0 minutes to T = 45 minutes. The average pain relief over 45 minutes (ΔVAS) for CPZ was 4.87 cm, vs 4.34 cm for MC (p = 0.35). There also was no statistically significant difference in blood pressure (BP) changes (ΔBP < 2 mm Hg for both systolic and diastolic BPs, p = 0.47 and 0.33) or numbers of patients reporting adverse effects (AEs) (CPZ: 16 of 35; MC: 13 of 29, p = 0.43). There was no severe AE with either study drug.Conclusions: Metoclopramide and chlorpromazine administered IV are both effective in the management of acute migraine headache. They are associated with similar minor side‐effect profiles.
Ultrasonography to Evaluate Adults for Appendicitis: Decision Making Based on Meta‐analysis and Probabilistic Reasoning
Authors: Orr Richard K. , Porter Deborah , Hartman Daniel 
Published: September 2008

ABSTRACTObjectives: To review ultrasonography (US) test performance and to develop recommendations for the use of US to aid in the evaluation of potential appendicitis.Methods: A meta‐analysis was conducted using all English‐language articles published since 1986 (17 studies; 3,358 patients) to ascertain sensitivity and specificity of US for diagnosing appendicitis in adults and teenagers. Calculation of the predictive value of US was performed for three groups of patients: group I—usually operated on (prevalence of appendicitis = 80%); group II—usually observed in hospital (prevalence = 40%); and group III—usually released home (prevalence 2%).Results: Overall sensitivity was 84.7% (95% CI: 81.0–87.8%), and specificity 92.1% (88.0–95.2). The accuracy and usefulness of US were related to the likelihood of appendicitis. In group I, a positive test was accurate [positive predictive value (PPV) = 97.6%], but a negative study could not rule out appendicitis [negative predictive value (NPV) = 59.5%]. The converse was true for group III patients (PPV = 19.5%, NPV = 99.7%). Test performance accuracy was balanced only for group II patients (PPV = 87.3%, NPV = 89.9%).Conclusions: 1) US should not be used to exclude appendicitis for patients who have “classic” signs/symptoms, due to the underlying high false‐negative rate. 2) US is most useful for patients who have an indeterminate probability of disease after the initial evaluation—if US is positive, the patient should have an operation; otherwise, he or she should be observed. 3) US is not recommended for screening patients who have a low probability of appendicitis, due to the low prevalence of disease and high false‐positive rate in this group.