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In a quality and cost-conscious health care environment, the pediatrician and emergency physician must work as a team. This statement clarifies important issues of this relationship, including coordination of patient care, communication between clinicians, provision of continuity care, and responsibility for quality emergency care.
This rule sets forth a description of the FEMA training and education assistance program to the States. The program functions through State Cooperative Agreements and is designed to further comprehensive emergency management training including emergency preparedness planning, hazard mitigation, and disaster response and recovery. In response to State and local expressed needs, FEMA was formed to coordinate and manage all disaster planning and response in one Agency. The combined training responsibilities of predecessor agencies are now being administered by the Training and Education Office of FEMA using the State Cooperative Agreements and Regional Support Contracts as the vehicle to meet individual State training needs. This rule defines the objectives and elements of the program, the funding approach, and the State application/proposal.
Mortality for emergency abdominal aortic aneurysm (AAA) repair remains high but results of specialist vascular surgeons are superior to those of general surgeons. A retrospective audit was performed on all patients undergoing emergency AAA repair over 53 months at one hospital to determine the necessity for a vascular specialist on-call rota. Patients were stratified into two groups, those treated by specialist vascular surgeons and those treated by general surgeons. There were 37 patients in the vascular surgeon group and 36 in the general surgeon group. There was no significant difference between the two groups when age, sex distribution, APACHE II score on admission, pre-operative delay and type of rupture were considered. The average operating time was 114.7 min in the vascular surgeon group and 111.9 min in the general surgeon group. Total blood transfusion requirements, and postoperative duration of ventilation, inotrope therapy and intensive treatment unit stay were similar in the two groups. Intra-operative, 30-day and cumulative hospital mortalities were 10.8% versus 8.3%, 32.4% versus 38.9% and 40.5% versus 38.9% in the vascular surgeon and general surgeon groups, respectively. The mortality figures compare favourably with other published series. As the results of the two groups were similar, there is currently no need for vascular surgeons to be routinely available for acute AAA surgery at our hospital.
Ask for and believe the patient's report of pain, use a preventive approach, combine opioids and nonopioids when possible, and consider adjuvant drugs for neuropathic pain not relieved by an adequate trial of opioids and NSAID. Remain a patient advocate through careful assessment and reassessment of the patient and informative collaboration with the physician and other colleagues. Anticipate and treat side effects, and identify and address pain myths held by patients and families that interfere with sound pain management practices. Establish mutually set goals and direct the patient to necessary follow up. Emergency nurses can do much to alleviate unnecessary suffering and improve quality of life for patients with cancer who come to the emergency department for help.
The review updates knowledge on the taxonomy, bacteriology and genetics of Bartonella as well as pathogenesis of bartonellosis. The role of Bartonella in human pathology, formerly considered to be rather modest, causes now growing anxiety. In this connection Bartonella are now believed to be the causative agents of so-called emerging and re-emerging diseases, i.e. diseases, formerly unknown to man, and diseases, believed to be eradicated and playing at present no important role in human pathology. These microorganisms are a bright example of successes of molecular biology in the detection of microorganisms, as well as in their phylogenetics and systematics.
The outcome of multiple injures freqently depends on the priority of treatments, and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma whounderwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients, the vital signs on arrival, interval between injury and intravascular surgery, type of brain injury, type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival, and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture, and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients, there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage, emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.
Kentucky continues to lag in development of a statewide trauma care system, and objections to implementation have arisen from hospital emergency departments. In order to clarify these issues, the Kentucky Hospital Association conducted a statewide survey. Respondents represented 95% of the state's general acute care hospitals. A large majority (78%) reported that they could not meet the American College of Surgeons' (ACS) standards for verification as a trauma care facility at any level, and a similar number (81%) opposed requiring verification for facilities providing trauma care. Staffing deficiencies (particularly surgical specialists) were the primary reason cited for facilities' inability to meet ACS standards, while objections to requiring ACS verification were based on concerns about the ability of EMS to transport patients to definitive care in a timely enough manner. Recommendations included improvements in emergency department (ED) facilities and staffing as well as EMS capacity and training. Improvements in Kentucky trauma care will require additional funding to increase the number of verified facilities and enhance coordination among providers and facilities.
The treatment of emergencies in a hospital or in private practice is subject to a common set of rules, but each setting presents its own particularities. These specificities include the prevalence of different pathologies, the possibility of hospitalisation and the length of the observation period, and these are illustrated by pertinent case histories. The effect of different prevalence is well illustrated by the thrombolytic treatment of myocardial infarction. The cost/benefit ratio of this treatment is entirely different when administered to a population seen in private consultation, in which myocardial infarction makes up only 5% of patients presenting with thoracic pain, as opposed to a hospital setting in which the prevalence of myocardial infarction is much higher. The possibility of hospitalizing patients is illustrated by community-based pneumonia, in which knowledge of the epidemiology and prognostic factors are guides in choosing appropriate antibiotics and in rapidly selecting the patients requiring admission to hospital. Finally, the length of observation is illustrated by patients presenting with abdominal pain. Certain symptoms and signs can indicate a surgical affection, but often a certain period of observation is required before the correct diagnosis can be made. To improve physicians' performance in emergency medicine will require better knowledge of areas up till now often ignored, such as epidemiology, decision analysis, a probabilistic approach to different pathologies, unfavourable prognostic factors of known illnesses, and simple clinical and paraclinical factors which serve to discriminate between those cases requiring hospitalisation and those which may be followed on an ambulatory basis.
This article discusses the elements of the legal system that impact emergency physicians and their legal responsibilities. It addresses the specific responsibilities of the emergency physician providing on-line direction to EMS units in the field, and the legal principles that control. Special emphasis is placed on compliance with new federal legislation and addressing medical-legal issues presented by field personnel during patient care situations.
The objective expression of the state of knowledge of 6th year students of the Faculty of General Medicine in the field of emergency care is an important factor in the evaluation of their preparation for the medical profession, regardless of the specialty they choose. Knowledge of these data is essential for improvement of undergraduate teaching of emergency care. Suitable application of computer technique can supplement the possibilities how to achieve this. The application of so-called model situations on personal computers makes it possible to extend training of decision taking to all spheres of medical training.
Dental pain and disfigurements cause patients to seek care from the Emergency Department of hospitals. It is important for physicians to understand dental disease and trauma in order to diagnose, treat, and refer patients with dental emergencies efficiently. Many common dental problems have been discussed in clinical terms. Treatment and referral options were offered. Techniques for local dental anesthesia and avulsed tooth splinting were described.
From January through December 1988 the causative factor of each case of childhood seizure seen in the Children's Emergency Room of the University of Calabar Teaching Hospital, Calabar, Nigeria, was prospectively studied with a focus on the relative importance of malaria-related seizures. Of the 134 seizure cases seen, febrile convulsion (FC) formed the majority (55%) with cerebral malaria (CM) as the only major (33%) rival. Other conditions such as meningitis, epilepsy, hypoglycaemia and drug poisoning together (12%) played a minor role. Malaria was the dominant cause (73%) of FC; 81% of these cases did not respond to chloroquine. On comparing the number of cases of CM accumulated in the same unit from 1986, there was a significant increase (P < 0.001) in the proportion of yearly CM admissions from 1986 through 1988. The study confirms the premier position of malaria in the causation of childhood seizures and also suggests a possible upsurge in the prevalence of CM in the environment. This upsurge probably derives from the emergence of chloroquine-resistant Plasmodium falciparum (CRPF) reported in Nigeria which appeared to have been identified in the present study. While more studies are needed to confirm this hypothesis, clinicians in areas of CRPF are alerted about a possible upsurge in CM in their locality.
We analyze the result of using a pneumological rapid-attention facility for diagnosis and immediate treatment of patients with respiratory symptoms arriving at the emergency room of University Hospital Virgen del Rocío in Seville (Spain). In the first six months the outpatient service saw 321 patients (male/female ratio 2.6), most of whom were between 55 and 75 years of age and had never before seen a pneumologist (83.4%). Dyspnea was the most common respiratory symptom named (by 35% of patients), and acute exacerbation of chronic obstructive pulmonary disease was the most usual diagnosis (in 19.1%). Only 21 (7%) were admitted to the hospital. We that creating the outpatient unit effectively met a societal need for rapid diagnosis and treatment of patients with respiratory complaints in the area served by our hospital emergency service.
STUDY OBJECTIVE: The National Highway Traffic Safety Administration developed the EMS (emergency medical services) Technical Assessment Program to assist states in developing and improving their EMS systems. The main goals of this evaluation were to document the level of improvement in EMS system development following completion of the Technical Assessment Program and to identify necessary program improvements at the National Highway Traffic Safety Administration. DESIGN: Independent investigators retrospectively reviewed the information in Technical Assessment Program reports from 35 states that participated in the program during a 5-year period. RESULTS: Training and certification programs for prehospital personnel were the most well-developed elements of EMS systems. Conversely, comprehensive quality management and EMS system evaluation programs were almost uniformly absent (89% of states). Areas of need targeted for improvement included enabling legislation for EMS (60%) or trauma system development (69%), an improved mechanism to assess system resources (71%), an established or updated state EMS plan (80%), aging and unreliable communications equipment (89%), fully operational prehospital data collection systems (89%), and consistent medical oversight for all prehospital providers (92%). CONCLUSION: Program evaluation revealed that significant recommendation-based changes occurred in all components of EMS systems. The Technical Assessment Program is one tool that states can use to promote EMS system improvements.
The Lothian Emergency Contraception Project (LECP)--a primary care-based intervention to offer advance supplies of emergency contraception (EC) to women aged 16-29 was not associated with a reduction in abortion rates. We undertook case studies, utilizing qualitative and quantitative methods, to evaluate the intervention. In this article we present findings from qualitative interviews with 44 primary care professionals working at case study sites and 22 women who had received advance supplies to explain this failure. Professionals reported that women rarely asked for advance supplies of EC and they were reluctant to offer supplies to women because of concerns about contradictory sexual health messages implied by the offer, a perceived association of EC use with chaotic behavior by women, views about the sort of women suitable for advance supplies and practical difficulties making the offer. Women were reluctant to ask for advance supplies because of misgivings about the appropriateness of offering advance supplies to everybody and concerns about being judged by health professionals as morally inadequate. If advance provision of EC is to be successful in reducing abortion rates, professionals must address their concerns about EC and develop imaginative ways of encouraging women most at risk of unwanted pregnancy to take supplies home.
The aim of this review is a critical discussion of factors actually or potentially contributing to persistence or emergence of echinococcosis in humans. Alveolar echinococcosis (AE), a life-threatening infection of humans, is caused by a larval stage of Echinococcus multilocularis. The adult parasite inhabits the intestine of foxes and other carnivores and has a wide distribution in the northern hemisphere (North America and northern and central Eurasia). Recent surveys in central Europe have extended the known geographical occurrence of E. multilocularis in foxes from four countries at the end of the 1980s to at least 11 countries in 1999. Cases of human AE previously regularly reported from only four countries are now recorded from seven countries, but the annual incidences are low. Since adequate information from earlier surveys is not available, it is not possible to conclude if the new findings reflect a recent extension of the parasite's range or just the first identification of hitherto unnoticed endemic areas. Evidence of parasite spreading has been reported from North America and Japan. Factors with the potential of enhancing the infection risk for humans in the future include increasing fox populations and parasite prevalences, progressing invasion of cities by foxes, the establishment of urban cycles of the parasite, and the spill-over of the E. multilocularis infection from wild carnivores to domestic dogs and cats. In view of the potential severity and fatality of AE in humans health authorities should initiate internationally coordinated countermeasures. Although control programmes against human cystic echinococcosis (CE), caused by E. granulosus, have been established in some countries and effective control strategies are available, the parasite has still a wide geographical distribution affecting many countries of all continents. Thus, human CE is persisting in many parts of the world with high incidences, and in some areas it is a re-emerging problem. For example, alarming increases of the number of human cases have been reported from Bulgaria and Kazakhstan, and the People's Republic of China. Progress in control can only be expected if health authorities attribute a higher priority to this disease and if all modern diagnostic and control options (for example vaccination of intermediate host animals) can be used.
Osmotic dehydration produced by systemic hypertonic NaCl (HS) inhibits gastric motility and emptying and also inhibits feeding in adult rats. Conversely, in neonatal rats, dehydration does not inhibit feeding. The present study examined whether the postnatal emergence of dehydration anorexia is temporally associated with the emergence of dehydration-induced inhibition of gastric emptying. Rat pups 4 to 19 days old were injected subcutaneously with HS (0.75 M NaCl; 200 microL/10 g body weight). Control rats were injected with isotonic saline (0.15 M NaCl). Thirty minutes later, rats were given access to milk that could be lapped from paper towels on the floor of a warm testing chamber. Other HS-treated and control rats were given an intragastric load of 0.15 M NaCl (2% body weight) and then killed after 30 min to determine how much of the load had emptied from the stomach. Consistent with previous reports, HS-treated rats consumed significantly more milk than control rats from postnatal Day 4 (P4) through P11 but consumed significantly less milk than controls at P19. HS treatment did not affect gastric emptying of 0.15 M NaCl at P4 or P11. Conversely, HS treatment significantly inhibited gastric emptying at P19. These findings suggest that the hypophagic effects of dehydration develop in tandem with inhibitory effects on gastric motility and are consistent with the view that the full complement of mature homeostatic responses to plasma hyperosmolality requires coordinated activation of forebrain and hindbrain neural circuits that are only partially formed in neonatal rats.
In September 1994, in response to a reported epidemic of plague in India, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States for imported pneumonic plague. Plague information materials were rapidly developed and distributed to U.S. public health officials by electronic mail, facsimile, and expedited publication. Information was also provided to medical practitioners and the public by recorded telephone messages and facsimile transmission. Existing quarantine protocols were modified to effect active surveillance for imported plague cases at U.S. airports. Private physicians and state and local health departments were relied on in a passive surveillance system to identify travelers with suspected plague not detected at airports. From September 27 to October 27, the surveillance system identified 13 persons with suspected plague; no case was confirmed. This coordinated response to an international health emergency may serve as a model for detecting other emerging diseases and preventing their importation.