bluuebunny/crossref_metadata_2025_split huggingface dataset:
Emergency Physician Use of Ultrasonography in Blunt Abdominal Trauma
Authors: Ingeman Jeffrey E. , Plewa Michael C. , Okasinski Robert E. , King Randall W. , Knotts F. Barry 
Published: September 2008

ABSTRACTObjective: To evaluate the diagnostic utility of abdominal diagnostic ultrasonography (DUS) performed by emergency physicians for intraperitoneal fluid caused by blunt abdominal trauma (BAT).Methods: The design was a prospective, blind, observational study. During a 15‐month period, a convenience sample of patients presenting to the ED with BAT necessitating CT scan of the abdomen, diagnostic peritoneal lavage (DPL), or laparotomy was studied. Scans were performed by an emergency medicine (EM) attending, or a resident supervised by an attending, using a real‐time sector ultrasound scanner with a 3.5‐MHz probe. Training in DUS included a 1‐hour didactic session and 1 hour of practice on human volunteers. Free intraperitoneal fluid was defined as an anechoic stripe in the hepatorenal, bladder‐rectal, or splenorenal space, and constituted a positive DUS study. Free intraperitoneal fluid detected on abdominal CT scan, DPL, and/or laparotomy was the criterion standard.Results: Of 110 patients scanned, 13 were excluded secondary to technical difficulty or lack of diagnostic follow‐up modalities. Of the remaining 97 patients, there were 24 females and 73 males, ranging from ages 2 to 78 years. DUS detected intraperitoneal fluid in 21 subjects, including 3 false positives. There were 6 false‐negative DUS examinations. DUS had a sensitivity of 75% (95% CI 53–90%), a specificity 96% of (95% CI 89–99%), and an accuracy of 91% (95% CI 83–96%). No false‐positive or false‐negative DUS study occurred after the first 67 cases. The mean interval for a DUS scan was 4.9 ± 2.9 minutes, ranging from 0.5 to 16 minutes, and the mean intervals were not different between the positive and the negative studies. The accuracies of DUS were similar in the pediatric patients, 97% (95% CI 83–100%), and in the adults, 88% (95% CI 78–95%). The hepatorenal view provided the highest sensitivity as well as the least number of uninterpretable scans of the 3 DUS views.Conclusion: Emergency physicians with minimal training can use DUS with fair sensitivity and good specificity and accuracy to detect free intraperitoneal fluid in both pediatric and adult BAT victims. The hepatorenal view provides the highest sensitivity for intraperitoneal fluid, although the 3‐view series (with hepatorenal, bladder‐rectal, and splenorenal spaces) can typically be performed within 5 minutes and may increase the specificity and accuracy.
Patient Refusal of Care in the Out‐of‐hospital Setting
Authors: Adams James , Verdile Vince , Arnold Robert , JK R. Jack Ayres , Kosowsky Joshua 
Published: September 2008

ABSTRACTA case vignette of out‐of‐hospital refusal of emergency care is reported with accompanying discussion. This case illustrates the challenges faced by out‐of‐hospital emergency care personnel in these scenarios and provides guidance to the emergency physician and emergency medical technician. Recommendations are provided for preparing the emergency medical services system to handle these cases.
Use of Practice Tracks in the Medical Specialties
Authors: Melanson Scott W. , Sexton Joseph D. , Heller Michael B. 
Published: September 2008

ABSTRACTObjectives: To evaluate the use of practice tracks by each of the 24 medical specialty boards and to compare this with the experience in emergency medicine (EM).Methods: Scripted telephone surveys were conducted with representatives of each of the specialty boards.Results: Of 24 specialties currently recognized by the American Board of Medical Specialties (ABMS), 14 (58%) reported a history of a practice track. Eight boards reported never having a practice track and 2 were unsure. All practice tracks have been limited in duration, most commonly closing after a specified period. The mean duration of the practice tracks was 9.8 years, the median was 7.5 years, and the range was 3–27 years. The practice track in EM was open for 9 years.Conclusions: Practice tracks were common in the early years of most specialties and most were limited by duration. The history of the practice track in EM is not dissimilar to those of other specialties.
Topical Tetracaine Attenuates the Pain of Infiltration of Buffered Lidocaine
Authors: Bartfield Joel M. , Lee Fayzel S. , Raccio‐Robak Nancy , Salluzzo Richard F. , Asher Shellie L. 
Published: September 2008

ABSTRACTObjective: To determine whether topical tetracaine attenuates the pain of buffered lidocaine infiltration.Methods: A prospective, randomized, double‐blind trial was conducted involving adults with lacerations being repaired following local anesthesia. Two 0.5‐mL injections of buffered lidocaine were given in a standardized manner. Injection 1 was given prior to application of topical study solution. Injection 2 was given on the opposite side of the laceration after topical application of a study solution that was 4 mL of either tetracaine or normal saline. Pain of each infiltration was measured using a visual analog pain scale. Pain score differences (injection 1 ‐ injection 2) were compared for the 2 study solutions using a Wilcoxon 2‐sample signed‐rank test.Results: Of 57 subjects studied, 29 received tetracaine and 28 received saline. The groups were similar in age, gender, wound length, wound location, and initial pain score. Pain scores decreased significantly in the tetracaine group as compared with the saline group. The median pain score difference for tetracaine was 12.0 mm, with an interquartile range (IQR) of 2 to 43 mm, as compared with 2 mm, with an IQR of —17 to 21 mm for saline (p = 0.048).Conclusion: Topical tetracaine attenuates the pain of infiltration of buffered lidocaine.
Evidence for and Impact of Selective Reporting of Trauma Triage Mechanism Criteria
Authors: Burstein Jonathan L. , Henry Mark C. , Alicandro Jeanne M. , McFadden Kim , Jr. Henry C. Thode , Hollander Judd E. 
Published: September 2008

ABSTRACTObjective: To determine whether out‐of‐hospital care charts selectively report trauma triage criteria, and the impact of such documentation on triage guideline development.Methods: A special structured data instrument that requested the presence or absence of the American College of Surgeons (ACS) trauma triage criteria was completed by emergency medical services (EMS) personnel transporting victims of motor vehicle crashes. The standard written EMS report forms for a subset of 199 patients with at least 1 ACS trauma triage mechanism criterion were reviewed by the investigators. Outcome data were obtained from medical record review. The structured data instrument and the standard EMS report were compared for concordance. The impact of method of data collection on the ability of the ACS criteria to predict patient outcome was determined.Results: EMS reports and structured data instruments similarly noted the presence of anatomic, physiologic, and “other” trauma triage criteria (p > 0.07 for all individual comparisons). Most mechanism‐of‐injury criteria noted on the data instrument (pedestrian struck >20 mph; crash speed >20 mph; vehicle deformity; compartment intrusion; rollover; and ejection) were infrequently documented on the standard EMS report (median 28.5% noted, range 0–100%). Patients who had mechanism criteria noted on the EMS report were more likely to be admitted to the hospital (44% vs 13%; p = 0.006). to require major operative procedures (10% vs 0%; p = 0.005), and to have prolonged lengths of stay (26% vs 9%; p = 0.02) and injury severity scores ±16 (15% vs 3%; p = 0.03) than were patients who had mechanism criteria documented only on the structured data instrument.Conclusions: In the authors' EMS system, standard EMS report documentation underreports ACS trauma triage mechanism criteria. This underreporting appears to bias outcome analysis in the direction of a worse outcome and more resource utilization. Reporting of mechanism‐of‐injury criteria improves with use of a structured data instrument.
Computed Tomography Screens Stable Patients at Risk for Penetrating Cardiac Injury
Authors: Nagy Kimberly K. , Gilkey Susan H. , Roberts Roxanne R. , Fildes John J. , Barrett John 
Published: September 2008

ABSTRACTObjective: To determine the accuracy of CT of the chest in diagnosing the presence of cardiac injury in stable pitients with penetrating chest injuries.Methods: A retrospective chart review of a convenience sample of stable patients with penetrating thoracic wounds evaluated for hemopericardium using chest CT at an urban level I trauma center.Results: 60 stable patients with penetrating wounds in proximity to the heart underwent CT. Three patients had radiographic evidence of pericardial fluid, and 1 had an equivocal study. These 4 patients underwent subxiphoid pericardial window exploration: 2 had only clear fluid present, the other 2 had hemopericardium. The latter patients had a total of 3 cardiac and 1 diaphragmatic injuries, which were repaired at subsequent sternotomy. None of the 56 patients who had negative CTs had further clinical evidence of cardiac injury. The sensitivity, specificity, and accuracy of CT in this setting for hemopericardium are 100% (95% CI 18–100%). 96.6% (95% CI 88–100%). and 96.7% (95% CI 89–100%), respectively.Conclusion: Chest CT may be a useful test for diagnosing the presence of hemopericardium in the setting of penetrating thoracic injury. With the caveat that the patient must be removed from a closely monitored environment, the authors advocate the use of CT in stable patients with penetrating chest wounds whenever echocardiography is unavailable.
Agreement between Emergency Physicians and Psychiatrists Regarding Admission Decisions
Authors: Garbrick Lisa , Levitt M. Andrew , Barrett Michelle , Graham Leslie 
Published: September 2008

ABSTRACTObjective: To determine the level of agreement between emergency physicians (EPs) and psychiatrists regarding the need for acute psychiatric hospitalization and treatment for patients presenting with alleged psychiatric complaints.Methods: A prospective, cross‐sectional assessment of concordance between EPs and psychiatrists in psychiatric admission decisions was performed at an urban county, teaching hospital ED. The participants had been brought to the ED for psychiatric evaluation. The patients were interviewed by an attending EP or a senior‐level resident, and a tentative impression and disposition were determined pfior to an independent examination and final disposition by a psychiatrist. Strength of physician group agrement was determined using the k statistic.Results: The patient mean age was 37.5 ± 15 years; 51% were men. The most common reasons for evaluation were disruptive behavior (28%), overdose (24%), and danger to self (23%). Of the 156 patients, 47 (28.7%) were sent home without treatment, 10 (6.3%) were determined to need only medical treatment, and 6 (3.7%) were released with outpatient psychiatric treatment. There were 84 (55.7%) patients admitted for psychiatric treatment. The EPs and psychiatrists had only moderate agreement regarding danger to self (k = 0.44), danger to others (k = 0.40). substance abuse as the primary problem (k = 0.50), and need for psychiatric hospitalization (k = 0.54).Conclusion: Moderate agreement between EPs and psychiatrists in key impressions and admission decisions suggests that shared training in psychiatric decision making, especially during residency training, is desired in this setting.
Acute Bilateral Blindness
Authors: Hoover Bradley W. , Stack Lawrence B. 
Published: September 2008

ABSTRACTAcute bilateral blindness is an emergent condition that may signal life‐threatening disease. This article details an emergency medicine approach to the patient with acute bilateral blindness, and reports a case of an elderly woman whose sole presenting complaint was acute loss of vision. She was ultimately diagnosed as having pulmonary embolism. The approach focuses on identification of life‐threatening disease processes, while differentiating between ocular. psychogenic, and cortical etiologies.
Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain
Authors: Pace Steven , Burke Thomas E 
Published: September 2008

ABSTRACTObjective: To determine whether morphine affects evaluation or outcome for patients with acute abdominal pain.Methods: Prospective, double‐blind, placebo‐controlled administration of morphine sulfate (MS) or normal saline (NS) in the setting of acute abdominal pain. The study was performed at a military ED with an annual census of 60, 000 visits. Patients ±18 years old who had abdominal pain for ± 48 hours were included. Patients who were allergic to MS or who had systolic blood pressures < 90 mm Hg were excluded. The physicians indicated a provisional diagnosis, a differential diagnosis, and a provisional disposition. Study solution was titrated to the patient's assessment of adequate analgesia (up to a volume equivalent of 20 mg of MS); pain response was monitored using a visual analog scale (VAS). The patients were followed until diagnosis occurred or symptoms resolved.Results: Of 75 patients enrolled, 71 completed the study; 35 patients received MS and 36 received NS. More than half (44; 62%) of the patients were admitted from the ED: 28 patients underwent surgery. The VAS pain level improved more for the MS group, 3.9 2 2.8 cm, than it did for the NS group, 0.8 ± 1.5 cm (p < 0.01). Study solution dose was less in the MS group than it was in the NS group, 1.5 ± 0.5 mL vs 1.8 ± 0.4 mL (p <0.01). There was no difference between the groups when comparing accuracy of provisional or differential diagnosis with that of final diagnosis. Differences between provisional and actual dispositions were the same in all groups. There were 3 diagnostic or management errors in each group.Conclusions: When compared with saline placebo, the administration of MS to patients with acute abdominal pain effectively relieved pain and did not alter the ability of physicians to accurately evaluate and treat patients. Key words: abdominal pain; analgesia; analgesics; emergency department; morphine; opiates; pain.
Nitric Oxide Metabolite Levels in Acute Vaso‐occlusive Sickle‐cell Crisis
Authors: Lopez Bernard L. , Barnett Jordan , Ballas Samir K. , Christopher Theodore A. , Davis‐Moon Linda , Ma Xin‐liang 
Published: September 2008

ABSTRACTObjectives: 1) To measure nitric oxide (NO) metabolite levels in patients presenting to the ED in acute vasoocclusive sickle‐cell crisis (SCC), and 2) to determine whether a relationship exists between NO metabolite levels and pain.Methods: A prospective, observational study of patients with documented sickle‐cell anemia (SCA), aged ±18 years, presenting in typical, acute SCC was conducted in an urban, university teaching hospital. Excluded were those with atypical pain or acute, coexistent disease (as evidenced by fever, tachycardia, tachyon, or hypotension). Pain scores were measured by a 10‐cm visual analog scale (VAS). Blood NO metabolite levels for SCC patients and control subjects (healthy volunteers, n = 9; SCA control subjects not in SCC, n = 10) were determined using an NO‐specific chemiluminescence technique that measured plasma nitrite and nitrate, the stable end‐products of NO. The acute SCC patients were divided into 3 groups, with the range for the SCC‐normal (n = 5) group defined as within 2 SD of the healthy volunteer control patients. The SCC‐low patients (n = 21) had NO metabolite levels below this range and the SCC‐high (n = 21) patients had levels above this range.Results: The SCA and healthy volunteer control groups had similar NO metabolite levels (25.3 vs 22.6 μmol; p = 0.10). The 3 acute SCC groups had the following mean NO levels: 1) SCC‐normal = 21.3 ± 1.6 μmol; 2) SCC‐low = 7.2 ± 1.1 μmol; and 3) SCC‐high = 43.7 ± 3.5 μmol. The SCC‐high NO‐level group had significantly lower VAS pain scores when compared with the SCC‐low and SCC‐normal NO‐level groups (6.52 ± 1.85 cm vs 8.76 ± 0.83 cm, and 8.62 ± 1.29 cm, p = 0.02).Conclusion: NO metabolite levels vary in SCC patients. Elevated levels are associated with lower pain scores, while lower levels are associated with higher pain scores, indicating that NO metabolites may potentially represent a marker for compensatory mechanisms in SCC tissue ischemia. Further work is needed to delineate the usefulness of NO metabolites in assessing the seventy of SCC.
Tetrodotoxin Infusion: Nonventilatory Effects and Role in Toxicity Models
Authors: Mackenzie Colin E , Smalley Arthur J. , Barnas George M. , Park Sun G. 
Published: September 2008

ABSTRACTObjectives: To determine the cardiovascular, autonomic, and neuromuscular effects of an IV infusion of tetrodotoxin (TTX) when ventilation is supporte'd.Methods:TTX was infused in 18 anesthetized beagles during conventional mechanical ventilation. TTX infusion continued at a rate of 9.3 μg/kg/hr until apnea occurred with 1 minute of ventilator disconnection. Measurements included intravascular pressures, heart rate (HR), cardiac output, blood gases, displacements of the rib cage and abdomen, O2delivery, and responses to train‐of‐four and tetanic peripheral nerve stimulation. Results are expressed as mean ± SD.Results:During TTX infusion, all the dogs had discoordinate movements of the rib cage, abdomen, and limbs. Vomiting, urination, defecation, and increased salivation occurred. Nicotinic and muscarinic effects, neuromuscular blockade, and cardiovascular depression were produced by TTX. Apnea occurred in 72.0 ± 17.0 minutes when a total of 119.0 ± 17.4 μg of TTX was infused. At apnea, decreases in arterial pressure, cardiac index, HR, O2delivery, and systemic vascular resistance occurred, while pulmonary artery pressure and pulmonary vascular resistance increased. Loss of response to titanic stimulation was closely correlated with the dose of TTX that produced apnea.Conclusion:The clinical symptoms and signs of TTX poisoning are similar to those of anticholinesterase poisons, and TTX dosing as described by this model may serve as a surrogate for organophosphorus poisoning. The model may be useful to determine optimum therapies for TTX poisoning and, since TTX prevents sodium influx into cells, to investigate enhanced survival in animals suffering from ischemia.
Do Admitted Patients Held in the Emergency Department Impact the Throughput of Treat‐and‐release Patients?
Authors: Bazarian Jeffrey J. , Schneider Sandra M. , Newman Valerie J. , Chodosh Joshua 
Published: September 2008

ABSTRACTObjective: To examine the impact of reducing ED “boarders” (through the use of a short‐stay inpatient medicine unit) on the amount of time that treat‐and‐release patients spend in the ED.Methods: A retrospective analysis of hours spent in the ED was made at a university hospital teaching ED for treat‐and‐release patients in 4 clinical categories: chest pain, asthma exacerbation, sickle‐cell crisis, and seizure. The average hours per patient spent in the ED during the 4‐month intervals before (August‐November 1993) and after (August‐November 1994) the establishment of the short‐stay medicine unit were compared. Data were analyzed using the 2‐tailed, unpaired t‐test.Results: This short‐stay inpatient medicine unit received on average 135 patients per month from the ED, with an average length of stay of 2.4 days. The mean (±SD) number of admitted patients per day waiting in the ED >8 hours for an inpatient bed dropped from 9.6 ± 4.2, before the institution of this unit, to 2.3 ± 2.6. There was a significant reduction in the average number of hours spent in the ED by treat‐and‐release patients with chest pain (from 7.3 ± 6.0 to 5.5 ± 4.8 hr/patient, p c 0.001) and asthma exacerbation (from 5.0 ± 3.6 to 4.2 ± 2.9 hdpatient, p < 0.05), but not with sickle‐cell crisis or seizure, after the implementation of the short‐stay unit.Conclusion: Reducing the number of admitted patients waiting in the ED for inpatient beds, in this case by establishment of a short‐stay medicine unit, is associated with a decrease in the interval that treat‐and‐release patients spend in the ED.
Reliability of Performance‐based Clinical Skill Assessment of Emergency Medicine Residents
Authors: Burdick William P. , Ben‐David Miriam Friedman , Swishel Loice , Bechel John , Magee Douglas , McNamara Robert , Zwanger Mark 
Published: September 2008

ABSTRACTObjective: To test the overall reliability of a performance‐based clinical skill assessment for entering emergency medicine (EM) residents. Also, to investigate the reliability of separate reporting of diagnostic and management scores for a standardized patient case, subjective scoring of patient notes, and interstation exercise scores.Methods: Thirty‐four first‐year EM residents were tested using a 10‐station standardized patient (SP) examination. Following each 10‐minute encounter, the residents completed a patient note that included differential diagnosis and management. The residents also were asked to read an ECG or chest x‐ray (CXR) associated with each case. History, physical examination, and interpersonal skills were scored by the SPs. The patient note, CXR, and ECG readings were scored by faculty emergency physicians. Intercase reliability was determined for the residents.Results: Global score reliability, Cronbach's α = 0.85. Reliabilities for the other components were: history, 0.77; physical examination, 0.83; and interpersonal skills, 0.80. Differential diagnosis and management reliabilities were 0.61 and 0.66, respectively. Subjective scoring of the patient note resulted in acceptable reliability for legibility (0.80), history completeness (0.80), and history organization (0.81). Physical examination completeness and organization reliabilities were 0.74 and 0.73. For ECG and CXR readings, α = 0.74 and 0.34, respectively.Conclusions: SPs can be used to reliably assess bedside clinical skills of EM residents. While component reliability levels are slightly lower than the global clinical skill reliability coefficient, they are still high enough to use for identification of individual strengths and weaknesses.
The Psychological Effects of a Four‐week Emergency Medicine Rotation on Residents in Training
Authors: Alagappan Kumar , Steinberg Maurice , Mancherje Noel , Pollack Simcha , Carpentel Kenneth 
Published: September 2008

ABSTRACTObjective: To prospectively evaluate psychological stress reactions among residents in an emergency medicine (EM) rotation during a 4‐week period.Methods: Pre‐ and postrotation psychological distress levels were assessed over a 4‐week EM rotation. Subjects were evaluated by several psychometric measures. These included the assessment of anxiety, depressive, and other psychological symptoms by the Brief Symptom Inventory (BSI), and the occurrence of traumatic anxiety via the Dissociative Experience Scale (DES). Also assessed were the Impact of Events Scale and the Holmes Social Readjustment Ratings Scale (Holmes), a baseline life‐change measure. Demographic data were obtained. The study occurred in a university‐affiliated teaching hospital ED. The 45 EM residents and 27 non‐EM residents were analyzed as a group, followed by subgroup analysis comparing EM vs non‐EM residents.Results: An increase in psychological distress over the 4‐week rotation was found in the non‐EM group, but not in the EM group. For the non‐EM residents, all 10 BSI scales worsened and 3 of 4 DES scales worsened (p = 0.002), indicative of increased psychological distress. In contrast, analysis of the 45 EM residents showed improvement in 8 of 10 BSI scales and 3 of 4 DES scales (p = 0.057).Conclusion: A significant increase in psychologic distress was found among the non‐EM residents during an EM rotation. The EM residents showed a trend for a decrease in psychological distress over the same 4‐week period.