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OBJECTIVE: In the German emergency medical system (EMS) psychiatric emergency situations (PES) are now responsible for up to 15% of all calls for the emergency physician (EP). A survey which was first conducted in 1996 to reveal knowledge about PES, reported a significant need for training. Seven years later it is interesting to investigate whether different conditions in the EMS may have changed assessments and attitudes. METHODS: The questionnaire of 1996 was modified to enable a comparison of PES and other frequent emergency situations with respect to the estimated number and the subjective stress. Open and multiple-choice questions or visual analogue scales were used to obtain the following data: demographic data, frequency of and stress by PES and other medical emergencies, own knowledge, and interest about training programs. RESULTS: Of the EPs 274 responded (male/female: 74/26%, mean age: 38 years, mean experience as an EP 6 years, anaesthesiologists 69%). The frequency of PES was estimated at 5% and 44% of EPs thought that there had been an increase in recent years. Personal knowledge was judged to be good by only 24%. The interest in training programs even increased slightly compared to the first survey; of particular interest was training in drug abuse disorders. Subsequent to internal, neurological and surgical emergencies, PES are considered to rank fourth in frequency, however the strain imposed by PES is significantly higher than for these other emergency situations. DISCUSSION: The results indicate an increase of relevance of PES in the German EMS, however, assessments made by the EP only changed marginally over the time period. The subjective awareness of the frequency of PES underestimates the reality in emergency medicine. The importance of training programs remains high to improve knowledge and to reduce feelings of incapability.
OBJECTIVES: We set out to study emergency department patient characteristics at a busy level-2 trauma center, to gain insight into the practise of emergency medicine, which is not yet recognized as a specialty in the Netherlands. METHODS: From May 27 to July 4 2001, the following data were recorded from the charts of all patients presenting to the emergency department: age, time and form of presentation, diagnostics, treatment, disposition and the single best diagnosis (International Classification of Disease-10 classification). RESULTS: The majority (84%) of the 5234 patients (134/day) patients seen were self-referred and treated by the emergency department physician. The remaining 16% were referred, usually by their general practitioner, directly to a specialty service, which saw them in the emergency department. Self-referred patients tended to be younger (average 33 years), with minor trauma, and infrequently required diagnostics (37%), treatment (49%) or admission (4%). The referred patients were older (average 50 years), with 41% needing admission. Only 16% of all patients were under 16 years of age. In all, there were five deaths (referred patients), 12 resuscitations, seven intubations, seven chest tube insertions and no lumbar punctures performed during the study period. CONCLUSION: The acuity of self-referred patients seen by the emergency physicians is low, with little diagnostic testing and few interventions and resuscitations, even in a busy center. This has both training and practise implications and it may be inappropriate to take an emergency medicine practise model or curriculum from another country based on its emergency department population.
BACKGROUND: To determine whether prehospital hypotension predicts the need for an emergent, therapeutic operation in trauma patients who present to the emergency department (ED) with normal systolic blood pressure (SBP). METHODS: An observational, cohort study was conducted at a Level I, urban, county trauma center. Consecutive trauma patients not in cardiopulmonary arrest and transported to the ED by emergency medical services during a one-year period were studied. Data on prehospital and ED vital signs, subsequent hospital course, and surgical procedures were collected. The occurrence of an emergent, therapeutic operation, which was defined based on the types of injuries found or repaired within 6 hours of arrival, was determined from operative and hospital records. RESULTS: Of the 1,227 total trauma patients, 160 were excluded because of cardiopulmonary arrest or inadequate documentation, leaving 1,067 study patients. Of those, 1,028 were normotensive on arrival to the ED. Seventy-one of the 1,028 patients (7%) were hypotensive in the field; 37% of these patients received an emergent, therapeutic operation and 6% died. Of the 1,028 patients, 957 (93%) were normotensive in the field; 11% of these patients received an emergent, therapeutic operation and 3% died. Thus, in trauma patients who were normotensive on arrival to the ED, the need for an emergent, therapeutic operation was more than three times more likely compared with those who had normal SBP in the field (odds ratio 4.5, 95% confidence interval 2.7-7.6). Mortality was also higher in the prehospital hypotension group (odds ratio 2.3, 95% confidence interval 0.8-6.9). CONCLUSION: Prehospital hypotension is a strong predictor of the need for an emergent, therapeutic operation in trauma patients with normal SBP on arrival to the ED.
OBJECTIVES: To describe the types of discrepancies in radiograph interpretation between emergency physicians and radiologists in a pediatric emergency department, and to determine the impact of discrepant interpretations on patient care. METHODS: Prospective cohort study of discordant radiographs from the period beginning March 1, 1995 and ending March 31, 1996. During this period, 2083 radiographs were coded by the radiologist as concordant or discordant. Three hundred forty-nine were coded as discordant, and 324 were eligible for the study. Charts were reviewed for relevant physical examination findings and emergency department management. Discrepancies that affected patient care were deemed clinically significant. RESULTS: Twenty-three (1.1%) of 2083 radiographs were interpreted differently by the emergency physician and the radiologist in a way that might have changed patient management. This represents 7% (23/324) of the radiographs originally coded by a radiologist as discrepant. The most common discrepancy was a patient with a normal chest examination and a radiograph interpreted as having an infiltrate by the emergency physician, but subsequently read as having no infiltrate by a radiologist (12/324). These patients may have received antibiotics unnecessarily. Two discrepant interpretations had the potential to have serious consequences to the patient if not identified. One patient with cardiomegaly and another patient with free air on abdominal radiograph were not noted by the emergency physician. CONCLUSIONS: Emergency physicians would benefit from more rigorous interpretation of chest x-rays to avoid unnecessary treatment with antibiotics. Emergency physicians do a good job interpreting plain radiographs, but occasionally miss significant findings that could lead to adverse outcomes. The presence of radiologists to immediately read radiographs 24 hours a day could prevent missed findings, but, given the small number of significant misinterpretations, is unlikely to be cost effective.
The population presenting at emergency rooms is increasing in Belgium. What is emergency in 1983 and why do people come? From a study of the emergency room population in a relatively new university hospital it emerges that more than 30% of those patients are in critical conditions or require in hospital treatment and about 50% are in acute discomfort. Our results confirm the impression that inappropriate use of emergency rooms is more an impression than a real problem. For socio-economic and cultural reasons, people go to emergency rooms when they need or think they should have medical help. Some emergency rooms are well able to cope with this situation. Others, less well-equipped in staff and facilities are dangerous and should be improved or closed. Unfortunately education and training programs for emergency physicians are still unknown in many parts of the French-speaking Belgium.
To assess the efficacy of emergency thoracotomy performed for thoracic trauma in the accident and emergency department, a retrospective analysis of patients who underwent this procedure and were brought to hospital by the Helicopter Emergency Medical Service was carried out. Between 1991 and 1994, 16 patients had emergency thoracotomy performed in the accident department. Twelve patients had sustained blunt trauma and four patients had sustained penetrating injuries. Three patients first assessed at the scene and 11 patients on arrival at the emergency department had Glasgow Coma Scores < 3. Eight thoracotomies were performed by the cardiothoracic team and eight by the trauma team. There was one survivor in this group; he had been stabbed at multiple sites and emergency thoracotomy was required to control bleeding from an intercostal vessel. Our results demonstrate experience of one of the first phase Level One trauma centres in the United Kingdom. From our small series, we believe that selection criteria for emergency thoracotomy in trauma patients need to be revised. From this series and a review of the literature, patients with penetrating injuries, vital signs at the scene and those with a high index of suspicion for tamponade seem to benefit most from thoracotomy in the emergency setting.
It is well known the high attendance frequency of the hospital emergency services (HES). In order to know the reason and justification of this demand, the emergency visits to the reference HES from a paediatrician population of our Health Center are studied. The results of a questionnaire of 304 emergencies are analyzed and compared with the level of frequency of the children to the HES. The follow-up of the emergency in the health center is also assessed. 82% of the emergencies attend the HES by themselves and the main reason to justify this behaviour were (up to two arguments): the paediatrician schedule unfit their requirements (55.5%), the likelihood to perform complementary tests (42.3%), rather than the severity of the process of the child (28.3%). The lower is the mean of brothers and sisters and the social class of the father, the higher is the frequency to the HES. 4.5% of the emergencies ended inpatient, and in 33% a complementary tests was performed. The lesser complementary tests are conducted the higher is the frequency to the HES (p = 0.001). Bases on the medical assessment, the emergency is justified in 28.1% of the cases, but it raised up to 44.4% when social arguments are also considered by the doctor who attended the emergency. 50% observe the advised to follow up in the Health Center, accomplishing better those with higher frequency. We consider that social and psychological elements of the children family, and the need to resolve the health problem as soon as possible, are two considerations more important than the severity of the process in the genesis of over-utilization of the HES.
STUDY OBJECTIVE: The American Board of Emergency Medicine (ABEM) Longitudinal Study of Emergency Physicians (LSEP) was initiated to describe the development of a new medical specialty through the continuing study of the lives of representative emergency physicians. The study is designed to gather data periodically over many years to come. The primary purpose of this article is to provide a baseline for the information obtained and the methods used to develop the ABEM LSEP. METHODS: Stratified, random sampling was used to select emergency physicians who represent different stages in the development of the specialty. Major data collections are conducted using a comprehensive questionnaire in 5-year intervals. Practice profiles were developed and analyzed. Homogeneous scales were created in 9 survey categories and analyzed. RESULTS: The survey was returned by 95% (958/1,008) of the emergency physicians. They are primarily middle-aged, family- and community-oriented, satisfied with their careers, and find that work stress is not a serious problem. Those who are trained in emergency medicine are the most likely to be involved in academic emergency medicine. CONCLUSION: The LSEP is a broad-reaching investigation of emergency physicians. Over time the study will describe (1) the individuals who move the specialty forward at different stages in the growth of the specialty, (2) the realities of practice in the specialty, (3) the relationship of the specialty to the personal lives and well-being of the specialty physicians, and (4) the changes seen in these factors over time.
OBJECTIVE: Environmental emergencies and disasters are becoming more frequent in developing nations. Between 1992 and 1996, disasters affected an annual average of 4.5 million Oceania residents. Unfortunately, public health planners in the region and responders throughout the world have little evidence on which to base measures of emergency preparedness. Indicators of preparedness must be identified, implemented and evaluated before the effectiveness of emergency planning interventions can be measured accurately. The aim of this study was to perform an objective evaluation of emergency preparedness among five nations in Oceania. METHODS: A standardized retrospective review of national-level public health and institutional-level hospital emergency operations plans from a convenience sample of five Pacific nations or territories was performed. In addition, in-country interviews, observation of operations and review of documentation were conducted. The rates of affirmative responses to 957 yes/no queries in the questionnaire were tabulated according to major emergency operational planning concepts and categories of emergency support functions. RESULTS: The study revealed remarkably low levels of emergency planning and preparedness among health and medical sectors of five Pacific islands. CONCLUSION: These data suggest a very low level of host national capacity for development of preparedness. Further investigation is necessary to define this need throughout this region of Oceania.
OBJECTIVE: To develop and evaluate an evidence-based tool for predicting the likelihood of emergency admission to hospital of older people aged 75 years and over in the UK. METHODS: Prospective cohort study of older people registered with 17 general practices within Halton Primary Care Trust in the north-west of England. A questionnaire with 20 items was sent to older people aged>or=75 years. Items for inclusion in the questionnaire were selected from information gleaned from published literature and a pilot study. The primary outcome measurement was an emergency admission to hospital within 12 months of completing the questionnaire. A logistic regression analysis was carried out to identify those items which predicted emergency admission to hospital. A scoring system was devised to identify those at low, moderate, high and very high risk of admission, using the items identified in the predictive modelling process. RESULTS: In total, 83% (3032) returned the questionnaire. A simple, six-item tool was developed and validated-the Emergency Admission Risk Likelihood Index (EARLI). The items included in the tool are as follows: do you have heart problems? [odds ratio (OR) 1.40, 95% confidence interval (CI) 1.15-1.72]; do you have leg ulcers? (OR 1.46, 95% CI 1.04-2.04); can you go out of the house without help? (OR 0.60, 95% CI 0.47-0.75); do you have problems with your memory and get confused? (OR 1.46, 95% CI 1.19-1.81); have you been admitted to hospital as an emergency in the last 12 months? (OR 2.16, CI 1.72-2.72); and would you say the general state of your health is good? (OR 0.66, 95% CI 0.53-0.82). The tool had high negative predictive value (>79%) and identified over 50% of those at high or very high risk of emergency admission. A very high score (>20) identified 6% of older people, 55% of whom had an emergency admission in the following 12 months. A low score (<or=10) identified 74% of the older population of whom 17% were admitted. CONCLUSIONS: In this study, we have developed and validated a simple-to-apply tool for identifying older people in the UK who are at risk of having an emergency admission within the following 12 months. EARLI can be used as a simple triage-screening tool to help identify the most vulnerable older people, either to target interventions and support to reduce demand on hospital services or for inclusion in testing the effectiveness of different preventive interventions.
In late 1993, 562 questionnaires were sent to members of the Emergency Medicine Section of the American Academy of Pediatrics; of the questionnaires sent, 65% (365) were returned. Data were collected on 280 full-time practicing pediatric emergency physicians (PEPs). Eighty-two percent of these full-time PEPs have been practicing pediatric emergency medicine for less than 10 years, and two thirds of them are males. The majority work in pediatric emergency departments, devoting 28.1 clinical hours per week to their specialty. Ninety-nine percent of these full-time PEPs are board certified in pediatrics, and 61.5% are board certified in pediatric emergency medicine, whereas less than one quarter are fellowship trained. Approximately two thirds of these physicians feel that board certification in pediatric emergency medicine is a prerequisite for practicing; only one quarter feel that a fellowship in pediatric emergency medicine is required at this time. Average annual gross income for full-time PEPs was $111,000 per year; 62.8% of these physicians make more than $100,000 per year. PEPs indicated that diversity of their clinical practice and the medical acuity of their patients were the most desirable aspects of pediatric emergency medicine, whereas scheduling and the shift work nature of the profession, along with lack of follow-up in hospital practice, were seen as the least desirable aspects of the subspecialty.
HYPOTHESIS: The public health system has a specialized body of knowledge and expertise in bioterrorism and public health emergency management that can assist in the development and delivery of continuing medical education programs to meet the needs of emergency medical service providers. METHODS: A nationally representative sample of the basic and paramedic emergency medical service providers in the United States was surveyed to assess whether they had received training in weapons of mass destruction, bioterrorism, chemical terrorism, radiological terrorism, and/or public health emergencies, and how the training was provided. RESULTS: Local health departments provided little in the way of training in biologic, chemical, or radiological terrorism to responders (7.4%-14.9%). State health departments provided even less training (6.3%-17.3%) on all topics to emergency medical services providers. Training that was provided by the health department in bioterrorism and public health emergency response was associated with responder comfort in responding to a bioterrorism event (OR = 2.74, 95% CI = 2.68, 2.81). CONCLUSIONS: Local and state public health agencies should work with the emergency medical services systems to develop and deliver training with an all-hazards approach to disasters and other public health emergencies.