SAEM (UAEMS) 1974 Annual Meeting Program

University Association for

Emergency Medical Services

PROGRAM Annual Meeting Dallas, Texas May 28 - June 1, 1974

Bring this program to the Annual M e e t i n g with you.

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Welcome To Dallas .

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. . . for the Annual Business and Committee Meetings of the University Association for Emergency Medical Services. It seems fitting, son~ehow,that we should be meeting in the Big Country to talk about the Big Challenge of improving emergency medical care through the development of more effective educational programs.

Our organization has made significant strides in defining areas of educational need in the field of Emergency Medical Services. At this, our Fourth Annual Meeting, the caliber of the presentations is indicative t h a t UA/EMS is zeroing in on the specifics of a n educational system responsive to the needs of emergency medicine.

We t r u s t t h a t you will find t h e sessions stimulating and worthwhile. More importantly, it is our hope t h a t when you leave Dallas you will take with you a better understanding of this dynamic field of medicine as well as a resolve to work in your area for the organization of a truly effective system of emergency medical service.

James R. Mackenzie, M D President, UA/EMS

About UNEMS The University Association for Emergency Medical Services had its inception in 1968 when a small group of physicians who served as Emergency Department directors in teaching hospitals decided that the problems of emergency medical care required a concerted approach if they were to be solved.

Since that time, U A E M S has grown to a thriving organization of over 300 members from the United States and Canada. The membership requirements are simple; a medical school faculty appointment and active participation in the delivery of emergency medical care.

The objectives of UAIEMS are defined in its constitution, which states that improvements in the quality and delivery of emergency medical care shall be pursued by: collecting and disseminating information regarding E M S problems; providing a n annual forum to discuss these problems; aiding and encouraging the university physician in his participation in the field of EMS; developing guidelines and consulting in matters of emergency department staffing, administration, design a n d performance; recommending appropriate changes in E M S legislation a t the local, regional and national levels; and encouraging academic recognition for work in this field by teaching physicians.

The University of Texas

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. . . Health Science Center a t Dallas was formed in 1972 to encompass Southwestern Medical School and its sister components for graudate and allied health education. Founded in 1943 as a private medical school, Southwestern became a part of the University of Texas system in 1949.

Its current enrollment of 516 medical students and 80 graduate students will be enlarged in the fall of 1974 when expansion plans call for a n entering class of 200 students. Long known for its academic excellence, Southwestern Medical School has the support of 16 clinical facilities for its broad-based program of medical education.

Leadership President Vice President Secretary Treasurer

James R. Mackenzie, George Johnson, William E. Matory, Ronald L. Krome.

MD MD MD MD

Executive Council Alan R. Dimick, MD Charles Frey, MD Carl Jelenko, MD

Gerald L. Looney, MD Leslie Rudolf, MD Robert Rutherford, MD

Committee Chairman STANDING COMMITTEES Nominating Membership Program Constitution and Bylaws Auditing

George Johnson, MD Carl Jelenko, MD Peter Canizaro, MD Tom Piemme, MD Frederic Platt, MD

SPECIAL COMMITTEES Economics of Emergency Medicine E D Organization and Planning Medical Education Paramedical Education Pit blic Information Public Information i n C'anada Publication,$ Publicity Regional Planning Resources

Karl Mangold, MD Paul James, Edmond Monaghan, Gerald Looney, William Carey, Allen Klippel, Trevor Sandy, William Ghent, Carl Jelenko, Christine Haycock, Fred Vogt, Harlan Root,

MD MD MD MD MD MD MD MD MD MD MD

Annual Business and Committee Meetings

Sheraton-Dallas Hotel All Members of UA/EMS a r e Cordially Invited to Attend and Participate Tuesday, M a y 2 8 , 1 9 7 4 1:30 p.m. to Executive Committee 5:30 p.m.

Meeting

Cafe D'Or

Wednesday, M a y 2 9 , 1 9 7 4

8:30 a.m. to 12:OO noon 12:OO noon to 1:00 p.m.

1:00 p.m. to 4:00 p.m.

Continuation of Executive Committee Meeting Luncheon

Cafe D'Or

Chaparral Club

lJA/EMS Committee Meetings Economics of London Room Emergency Medicine ED Organization State Room and Planning Medical Education S.F. Austin Room Paramedical Education Trinity Room Publications Pioneer Room Public Information Brazos Room Puhlicity S a n Jacinto Room Resources 0. Henry Room

Ballroom Lobby 2:00 p.m. to Registration 6:00 p.m.

4:00 p.m. to Continuation of Cafe D'Or 6:00 p.m.

Executive Committee Meeting 7:00 p.m.

Reception (Cash Bar) W.B. Travis Room

Thursday, M a y 3 0 , 1 9 7 4 - General Sessions

Ballroom Foyer 7:30 a.m.

8:25 a.m.

Registration

Ballroom Lobby

8:30 a.m.

The Rohert H . Kennedy Lectureship in Emergency Medical Care

Opening Remarks Ronald C. Jones, M D

Emergency Medicine as a Specialty Oscar P. Hampton. M D Panel Discussion George Johnson, J r . , MD, Moderator Oscar P. Hampton, M D James D. Mills, M D H. David Root, M D David K . Wagner, M D

10:30 a.m. Coffee Break 11:OO a.m. Emergency Department Design a n d Organization Paul M. James, Jr., MD, Moderator

P

Construction and Planning Robert B. Rutherford, M D Function ,James R. Mackenzie, MD Conlrnl~nicationsand Transportation David R. Boyd, MD

12:30 p.m. Luncheon

South Ballroom

Presidential Address 2:00 p.m.

James R. Mackenzie, MD SCIENTIFIC PAPERS SESSION I Peter C. Canizaro. MD, Moderator

1. Cause of Death in 425 Consecutive

Hospitalized and Non-Hospitalized Trauma Deaths Donald D. Trunkey. M D

2. Major Surgery i n the Emergency Center Kenneth L. Mattox, M D George L. Jordan, .Jr., M D

3. Amelioration of Prehospital and

Ambulance Death Rates from Coronary Artery Disease by Prehospital Emergency Cardiac Care (Sponsored hy Leslie E. Rudolf, MD) Richard S . Crampton, M D ,John R. Miles, Jr., M D Joseph A. Gascho, M D Robert F. Aldrich, M D Roy Stillerman, M D

4. Cardiac Arrest Outside the Hospital:

The Yield of a n EMS System Without Telemetry G. S. Gordon, M D Cleve Trimhle, M D

5. The Use of Peritoneal Lavage as a

Diagnostic Tool in the Emergency Department Christine E. Haycock, M D George Machiedo, M D

6. Potential Sources of Error in the Use

of Peritoneal l a v a g e as a Diagnostic Tool P . C. Breen, MD L. E. Rudolf, M D

3:30 p.m.

Coffee Break

3:45 p.m.

SCIENTIFIC PAPERS SESSION I1 Carl Jelenko, 111. MD, Moderator

7. A Burn Team Looks at Child Abuse Patricia S . Phillips, RN Elaine Pickrell, MSW Thomas S . Morse, MD

11. Accidental Hypothermia: Core Re-

warming with Partial Bypass Per Wickstrorn, M U Ernest Ruiz, MD G. Patrick Lilja. M D J . Peter Hinterkopf, M D John J . Haglin, MD, Ph.D.

9. Complications o f Subclavian Sticks William F. Mitty, Jr., MD Thomas Nealon, Jr., MD 10. Ambulance Critique Review David B. Pilcher, MD

I I . The Emergency Department Record George R. Schwartz, MD

12. Types o f Arterial Trauma William E. Evans, MD

5:15 p.m.

6:00 p.m.

Adjourn Busses depart Sheraton-Dallas Hotel (Live Oak Street Entrance) to Country Dinner Playhouse for Cocktails, Dinner and "No Hard Feelings," a three-act play.

Busses will return to Sheraton-Dallas Hotel a t conclusion of play.

Friday, M a y 31,1974 - General Sessions

Ballroom Foyer 7:30 a.m.

8:30 a.m.

State Room Telemetry and Advanced Care Regional Directors Breakfast

Panel Discussion Eugene L. Nagel, MD, Moderator Fred B. Vogt, MD Col. Gaylord Ailshie Donald S. Gann, MD

10:30 a.m. Coffee Break 11:OO a.m. SCIENTIFIC PAPERS SESSION 111 C. Richard Baker, MD, Moderator

13. Teaching Cardiovascular Physiology

i n the Emergency Room Rae R. Jacobs, MD James S. Carter, MD William Sosnow, MD David Cobb, MD 13. Focal Motor Seizures in Patients with

Alcoholism Howard S. Schwartz, MD Philip R. Yarnell, MD Gary Vander Ark, MD

15. Development of a New Surgical Tape

for Sutureless Wound Closure Richard F. Edlich, MD, PhD George Rodeheaver, PhD Milton T . Edgerton, MD

16. Value of the G Suit to Control

Hemorrhagic Shock in Patients with Severe Pelvic Fracture Daryl J . Batalden, MD Per H. Wickstrom, MD Ernest Ruiz, MD Ramon B. Gustilo, MD

I T . Emergency Treatment of High Pressure Injection Injuries of the Hand B. J. Parks, MD R. L. Horner, MD Cleve Trimble, MD

I

18. The Injured Diaphragm, A Diagnostic

Emergency Anatole Gourin, M D

12:30 p.m. Luncheon and Annual Business South Ballroom Meeting 2:00 p.m. Description of Parkland Memorial Hospital Emergency Facilities Erwin R . Thal, M D

Dallas Ambulance System Chief Bill Roberts Ambulance Division Dallas Fire Department

3:00 p.m.

5:00 p.m.

Busses depart Sheraton-Dallas Hotel (Live Oak Street Entrance) for tour of Parkland Memorial Hospital Busses depart Parkland Memorial Hospital to Dallas-Fort Worth International Airport and to Sheraton-Dallas Hotel

Third Annual Emergency Residency Workshop

Sheraton-Dallas Hotel Saturday, June 1 , 1 9 7 4 Cafe D'Or 9:15 a.m. Introduction - Robert H. Dailey, M D

9:30 a.m.

Problems and Solutions in Establishing the Residency Program Residency Directors Panel Gail V . Anderson, M D H . Thomas Blum, M D William J . Czrey, M D Albert J . Lauro, MI) W. tiendall McNahney, M D

H. Arnold Muller,MD Peter Hosen, MD C. C. Roussi, MD Ernest Ruiz, M D Donald M. Thomas, M 1)

11 :00 a.m. Questions and Answers 12:30 p.m. Lur~chrorl- Vaquero Room 1:30 p.m. Problems and Solutions in Resident Training - Present and Past Residents Panel James Alexander, James T. Lemay, M D MI) Pamela P . Bensen, MD Richard M . Goldberg.

MD

3:00 p.m. Questions and Answers 5:30 p.m. Adjourn

David M . Maxwell, MD Jeffrey Selevan, MD ti. L. Shapiro. M D Others t,o be named

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Patients arriving with pre-terminal respiratory cerehral anti resl'iratory patterns whose injuries were limited to in(rat horac,ic organs denionstrated a 6 7 ' ~survival. Cardiac injuries were successt'ully controlled in 23 p a t i e n t s .

I,;i[xirotoniy anti cardiopulmonary hypass were less ~~1ccc~hs1'ul in controlling extensive multiple organ injuries. ;2;l;rjor surgery in the emergency center environnlent may be rccluired Sor the lraumatizeti patient who is too critical to he (ransportrtl to the operating room. Autotransfusion, fine screen tillration t r f transfused blood and radiography intrinsic. t o I he resuscitation room have served as adjuncts to nialor cniergency surgery.

3. Amelioration of Prehospital and Ambulance Death Rates from Coronary Artery Disease by Prehospital Emergency Cardiac Care R I C H A R DCRAMPTON, S. M.D. .JOHN R. MILES,.JR., M.D. .JOSEPH A. GASCHO, M.D. ROAEKIF. ALDRICH, M.D. Roy S'I.II.I.ERMAN, M .D. Irniversity of V i r g ~ n i a Medical C e n t e r , C'harlottesville. Virginia 111 :r co~lirnunity of 80,000 people living in 745 square i~iil's, a survey (196G-1970) of' prehospital deaths from pure coron;iry artery disease (CAD) in people aged 30-69 years stiowc~cithat $4 of 282 (29.8l;) died in the presence of a m lnilance personnel before and during transport. A prehospilal c~lrdiopulmonary resuscitation (CPR) and emergency cardiac care (ECC) system was added to the extant rrnergency medical service in March 1971. Of 243 calls I'r.0111 the community managed from 1 March 1971 to 31 Occclnber 1972, 71 patients had acute myocardial infarction and 21; exlxrienced prehospital cardiac arrests. 23 with ventric,ulnr I'ihrillntic~n and 3 with asystole. Two additional I):rt icnts hat1 venrricular tachycartiia abolished by precordial thuml)~versionwith the fist. Fifteen of these 28, were treated Irss than 5 rninutes aft,er onset, and 10 (67' ; ) returned t o ac11j.elilb. 'l'wenty of25 (80'0 major CPK-ECC interventions w ~ r cnecehsary 1)efore and dnring ambulance transport. An ;rtiditional hut unqumitifiable number of fatalities may have been prevented by routine prehospital ECC: relief of pain and abolilicln of dysrhythmias. Chi square testing showed that average annual CAD death rate in ambulances, 0.5 per 1000 people aged :30-:3Y years (1966-1971). fell 6 0 5 to 0.2 ( 197" 11, = 0.007) in the first full vear of'F,(:C. Likewise CAD dewt ll in an arnhulnn<.eper 1000 nmhulances dispatched fell (il",I'rc)ni4.8 per 1000 people aged 30-69 years (1966-1971) to 1.8 (1972, p = 0.007). Prehospital CAD deaths per 1000 people aged 30-69 years declined 28.65 from 1.96 (1966-1971) to 1.40 (1972, p = 0.04). Data for 1973 will be added. The initiation o f ' a prehospital ECC system significantly reduced CAD death in ambulances and in the prehospital phase for the 3069 vear age group in this community.

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4. Cardiac Arrest Outside the Hospital; The

Yield of an EMS System Without Telemetry G. S. GOKIION, M.D. CLEVETKIMRLE. M.1).

Department of' En~ergenryMedical Services, T h e Denver G e n e r a l H o s p i t a l , Denver, ('olorado 'l'hr ('it? a n d ( ' i ~ u n t y I I ~Ilenver's Ambulance Division covrrs 117 hciuare rniles a n d over 700,000 consumers a t daily ri.k. 'l'kr~hsystern incllides: I . pat ienr access t11 a r n e d i ~ a emergency l response center ~ l i r o u g h '911' or other c o m m o n entries ('O', fire, ~)llllc~rl;

2, c l ~ ~ p a t c h i nwhich g fully integrates with fire a n d police; :i 11re-l)ositioriirig (dispersal i11'arnl)ulancesa t five points

to n l ~ n ~ m i zresponse c tirnes (1 m i n u t e s or less in over !)Orf 01 r~nergcsnclehl: I , i r ~ ~ e ~ ~training s i v t ~ ant1 1111gradit1gi ~ t ' w n ~ t ) r ~ l n an nc de fire

rt>hc~it* 1)t3rsorinrl (rricI~r(l~ng constant critique); .-I, returning c,r~tical~ ) ; ~ t i r n (t w > i t h radio torewarning) t o tlic, nt,tirt>st of l o u r highly-categorizec1 regional I l o h l ~ ~ t n lI ~h .r r r 01 which triangulate t h e centrallyI i ~ c , a ~ rOt311ver d (;ener;rl tiospital ( I ) ( ; H ) ; l i , r l ~ r r c t 5i1l)ervision

01 all activities t)y a t'ulltirne r a r -

~IlOIO~i~t I{c.~c,lir~)c.rsonnt>l ;ire t,cjr~ipprdonly with bag-valve-tnasks. ~ ) ~ r l ; t i ] l oxyyc.11. c [)i~rtal)lesuction, plastic airways.

I ~ ; i ( ~ k l ~ t ~ n:tnd r d h f. u r i d ; ~ r n t ~ r llife ~ a l support skills. Hiomedical tc~lc.nlc~~r.\ h;rh Iwen absent l'ror~l these resources although lic,ltl ~ullc~rvlslorl I? ~)hysic,i;rns15 always available by radio. ~ l ' h i srcl)orl rr\.icws our r s p r r i e n c e with cardiopulmonary ;Irrt3hth orilsidr ~ h t I)(;H , during 197:i. 01'2.1.511 a m b u l a n c e rc.>lxln>rs. .->!Mi cases w r r r srlrcted l'or s t u d y wherein t h e l,;illc,nr \v;r.; witlro~it bital signs \r.hen first seen in t h e field. l ' I ~ ~ ~ ( L r lirkc.ri iti to p i ~ r t i c i l ~ ~ t i rhiig~ s p i t a l sother t h a n the I ) ( ; H 1l;rt.t. ~ h r nI ~ c r nexcluded a s have those whose cardiac ;rr.rc,lh wc,rc2n11t d i ~ tr c ~~)rim;rrycardiopulrnirnary disease I . ? . t r ; ~ u r i i ;clnig ~ , ovrrtlose, ('0 poisl~nirlg,drowning, etc. 01' ~ h o i c ;lrrr>lh d u e t i , proven primary cardic~pulrnonary 11atIioIi~:'.. 27 1 were recrir.r(I iind ninnaged tiv I)(;H. Of tlii~ic1,;llic,llts. 17'( w r r r : ~ d m i l t e d111 Intensive r a r e lJnits \villi ;~ccc.l)tal)lr \ iial higns a n d I S ' < survived to tie discharge d . T h i s experience cornpares very favorably with t h a t of other systerns employing mobile coronary care units utilizing either telemetry and/or physicians. T h e s e d a t a suggest t h a t conipulsc~ry attention to t h e basic prehospital system is a t least a s important t o resuscitative endeavors a s is current technical sc~phiatication.

5. The Use of Peritoneal Lavage a s a Diag-

nostic Tool in the Emergency Department CHRISTINE E. HAYCOCK, M.D. GEORGEMACHIEDO, M.D. College of Medicine a n d Dentistry of New Jersey, Martland Hospital Unit, Newark, New Jersey With the introduction of peritoneal lavage to replace the oulrnotied I'our quadrant needle t a p of the abdominal cavity Ii)r diagnostic purposes, this procedure has heen found t o be a n iricreasinyly valuahle tool, hoth in diagnosis and in the f r i > a l l ~ ~01 ~ npatients t with conditions such as acute pancriv~tit~x.

I t i h I)articularly useful in the diagnosis of blunt tra11111aI O the ahdornen with internal injury, and in differenlist 111gbetween penetrating and non-penetrating wounds of the abdomen. Concurrent to the diagnostic use of the peritoneal dialysis catheter in the Emergency Department, peritoneal lavage has heen used in the treatment of acute pancreatilis based upon enzyme (lactic dehydrogenase, lacI ; I I ~ .1)e1;1gIuc.uro~~idase. and amylase) studies carried out in ~ h rchc.;ln.l~ c la1)oratory. Early results of this technique have I ) ~ U V C ' I II I I I I S ~tricouragir~g.'1'0 increase the routine use ofthis 111otl;rlity l)y resitlent staffs, a protocol defining the exact t e c h n ~ q u e to be used was circulated to all surgical and rl~cdicalresidents in the hospital. A request was made that thib procedure be carried out in acute abdominal cases, and that klwcirller~sbe obtained for both diagnosis and research.

1)iagnostic specimens are sent to the hospital laboratory, arid research specimens to the clinical research laboratory.

Statistics will he presented to show the results of using this procedure in the Emergency Department, and a s a continuoils treatment modality. (Slides illustrating the technique i l l performing the lavage will be shown).

6. Potential Sources of Error in the Use of Peritoneal Lavage as a Diagnostic Tool P. C. BHEEN,M.D. L. E. RUDOLF,M.D. Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia Peritoneal lavage has been of increasing value in the early diagnosis of' intraperitoneal injury. This modality has been particularly helpful in cases of multiple trauma, or when the patient is unahle to cooperate with the examining physician.

Notwithstanding the usef'ulness of this technique, there are hcavcral pu~rtitialsources of error in its application which I I I ; ~lead ~ 111 unriecehbary laparotorlly.,A report of a series c~f r r a u ~ ~[ ~~ aat i c ~who ~ t s were been in the llniversity of Virginia 1'nlrrgrnc.y 1too111is presented. In each case, peritoneal I;rv:~gc~ \vas i.n~l)luyetlas a diayrlostic routine. Also presented arc ~ ) u ~ e n (a ~n d; ~real l sources of' misinterpretation of this with regard to falsely positive results. test, partic~i~larl> ,Ilclliods ol' ;j\oiding this occurrence are discussed.

7. A Burn Team Looks at Child Abuse P A T H ~S. ~ IPHILLIPS, A R.N. ELAINE PICKRELL, M.S.W. S. MORSE,M.D. THOMAS Children's Hospital, Columbus, Ohio Intentional burning is a severe form of child abuse. T h e abusers need help, and the children need protection from fi~rtherabuse. Many physicians do not know the limits of' their responsibility, and because of ignorance or fear of hecoming entangled, fail to initiate the needed chain of events. 'l'he mortality from repeated abuse is high. Clues to recognition can be found in the history. physical and x-ray examination, and in the hehavior o f t h e parents and child. 'l'hese clues include evidence of old or recent injuries to soft tissues or I~ones,burns which do not fit the history, especially burns of'the I)uttocks, perineum, feet or hands, contact burns and deep scalds resulting from trapping in hot water.

I'arcnts may delay seeking hurn care and give conflicting stories. They rnay describe family strife, a lonely mother, in,juries to other children or to themselves when they were children. They may exhibit extremes of concern or indil'l'erence. Children are frequently fearful, withdrawn, and undernonstrati~e. Many exhibit delayed emotional or intellect.ual cievelopment. There is often a striking lack of tvarn~thbetween the child and one or both parents. Twentv recent cases of' intentional burning will be reviewed. All illustrative cases will be followed through identification and initial reporting. investigation by the hospital Department ol' S ~ ~ c i Service. al reporting to the Juvenile Bureau of the 1'olic.r I)epartment and to the Children's Services Board, the legal protection agency of the county, court proceedings. coun.ielIirlg ol'the parents and eventual returq of the child to the familv.

8. Accidental Hypothermia: Core Rewarming with Partial Bypass PERWICKSTROM, M.D. ERNESTHCIIZ. M.D. (;. PATRICK LIL.JA,M.D. ,I. PETERHINTEHKOPF, M.D. M.D., PH.D. JOHN.J. HAGLIN, Departments of Emergency Medicine and Surgery, Hennepin County General Hospital, Minneapolis, Minnesota Accidental hypotherrnia due t o exposure is not an uncommon pmhlem and it can result in a high mortality. Most alrtho1.s now agree that the chance of developing one of the detrimental systemic effects of' hypothermia increases with the duration ol' hypothermia. Three patients with profound 11y1)othermiawere treated by rewarming on partial bypass a t Hennepin County (;enera1 Hospital. Two survived and have norrnal mental and metabolic functions. This method of resuh(.~lationis effective and safe and i~ provides circulatory

\ul11~urt in t h e event of' ventricular fibrillation. T h e resuhcitatio~i of the hypothermic patient should be continued until the patient is completely rewarnled since the outct~meis olten niuch hetter than might be expected from initial vital signs and neurological examination. T o avoid ventricular fibrillation. the patient should be handled gently. Blood gases should be measured often and corrected for temperature. An effort should be made to keep the patient wcxll oxygenated and at a normal pH. l i + concentration and hydration status of the patient should also he monitored (.los(.ly. Altrr the resuscitation, pulmonary care should he ernl~hahized.

9. Complications of Subclavian Sticks WILLIAM F. MI'ITY,J R . ,M.D. THOMAS NEALON,JR., M.D. S t . Vincent's Hospital and Medical Center, New York, New York Important modalities in treating a n d resuscitating patienth in Emergency Depart ments have been the recording and monitoring of the central venous pressure and the subsequent administration of large volumes of fluids via a subclavian venotomy. These procedures, usually performed by the younger members of' the house staff under emergency conditions, have carried a significant morbidity at the St. Vincent's Htrspital and Medical ('enter of New York. The major complication recorded was pneurnothorax. In the past I'ive years, sixty cases 01' pneurnot horax have been diagnosed in the Emergencv r)epart rnent as a result of a percutaneous huhclavian puncture for caval cannulation. Another compliration seen has been the n~isdirectionof the subclavian catheter into areas other than t he superior vena cava. A series 01' radiographs will be denionstrated showing the various Iocat~crnsof the misdirected catheters. It is now the 1)u11(.. 01' the Emergency Ilepartment not to allow this ~ o r t h w h ~ lprocedure r to IJC done under emergencv contiitions .1, junior members ol' the house staff in the Emergency 1)epartrnent. Il'caval catheter~zationis thought necessary in the Eniergrncv Department, i t has to be performed via a ~reril~heral vein. Otherwise, it must he performed in an intr~isivecare unit of the hospital or in the ol~eratingroom under sterile conditions I)y more experienced menlhers of the ho~lsehtal'l'. This exller~enceis heing reported to show how a tile-saving tec,hnlcjue can quickly develop into a lifet hreaten~ngsituatic~n.

10. Ambulance Critique Review DAVIDB. PILCHER, M.D. Department of' Surgery. University of Vermont, Burlington, Vermont I'eer rcv~cw hy anlt~ulance personnel can be best acc~rn~l)liihed Iry ol)servation IIE actual performance by other mrr~llrerh01 the health team with immediate critique. 'l'his is ol)viorlhly rarely possit)le. On-scene supervision hy state

ellleryency service coordinators a s well as open exchange of critique and inli~rmationin the Emergency Department during the [)re-hospital phases of care are sometimes possible. A regularly schetiuled review with regional ambulance perhonnel and Emergency Department personnel can result in a n rilucational experience for the ambulance personnel and ruemt)ers of' the Emergency Department health team.

Prerequisite to such critique sessions is an ambulance report forni which lends itself to the critique. This type of report form will be presented. Critique review sessions have been carried out in one ambulance district three times a month lor I tlc past t w ~ years. ) 'l'he pre-hospital phase of care is prescntetl 11y the involved am0ulance personnel and followup I.; given hy Erneryencv 1)epartnient physicians and nurse>. (;ivr-antl-take discussion is rriutually beneficial to ; i l l I)rrsvnt and, in I he university hospital, is also educational tor metlical students and housestaff. Examples of recent cr~riclliesession>. a s sent to all ambulance personnel, will he ~)wirnteti.'I'his has heen a successl'ul forrn of peer review ;lncl has gained illcreasing acceptance hy all concerned. It hhoulti I)e applicable to rural, urban, and university cLliieryc,ncyservices.

1 1 . The Emergency Department Record GEORGE R. SCHWARTZ, M.D. Medical College of Pennsylvania, Philadelphia, Pennsylvania Emergency Uepartrnent records serve both medical and administrative needs. Analysis of fifty different Emergency Ilepartment records, frorn university as well as community hospitals. showed significant deficiencies in meeting the 1netlica1 needs. Each record was analyzed for how we11 the lollowing were met: 1 ) Initial triage information. 2) Space for history and physical examination. 3) Test results. 4) Diagnosis. 5) Physic i a n ' ~ orders. 6) Treatment. 7) Procedures performed.

HJ I'lans and li)llow-up. 9) Nurse's observation. 10) Consultation notes. 11) Space for monitoring patients with specific k ~ n d sof' pr~)t)lems.12) Patient instruction. 13) Ease of review. None of' the records proved to be satisfactory in meeting all the medical needs. In fact, in almost all cases, the roorn for ntlministrative data consumed a disproportionate arnc~untof available space. Based on this analysis, a rnodcl Emergency Department record was designed. t3ecause of' ~ t slrnplicity s it may have widespread applicabilit y . or iit least, serve to focus attentionon Emergency Departriicnt records which meet physician's as well as a d rninistrator's requirements.

12. Types of Arterial Trauma WILLIAM E. EVANS, M.D. Department of Surgery, T h e Ohio S t a t e University Hospital, Columbus, Ohio Vasculi~rinjury to the extremities can be quite variable in terms of' cause, resulting pathology, presentation, and mode

of therapy. In this nonstatistical study, vascular injury of the extremity has been classified as blunt, penetrating, or iatrogenic. 'l'he variations in pathology, presentation, and treatment will be discussed.

13. Teaching Cardiovascular Physiology in the Emergency Room RAER. .JACOBS, M.D. JAMESS. CARTER, M.D. WIILIAM SOSNOW, M.D. D ~ c l nCOBB,M.D. Ilniversity of' Kansas Medical Center, Kansas City, Kansas Proper resuscitation of the patient in hypovolemic shock. cardiogenic shock, or septic shock requires an understanding of cardiovascular physiology. Appropriate patients are interSaced with an eight-channel monitor and recorder equipped with an ECC. cardiotachometer, two pressure channels, and a cardiovascular analyzer which integrates, differentiates, ~nultil~lies, and divides. In addition a cardio-green computerized cardiac output unit a n d a n intravascular PO2 analyzer are used. This allows measurement of heart rate, pulsatile a n d mean arterial pressure, central venous pressure, pulsatile and mean pulmonary artery pressure, dP/dt, dP/dt + P, mean cardiac output, continuous arterial and venous PO,, oxygen delivery, and oxygen consumption. Using a transfemoral pressure-flow catheter and square wave electromagnetic flow meter, it is possible to monitor pul.;atile flow and instantaneo~isvascular impedance (P/Q) along with its integral. A detailed record of infusions, drugs, and clinical response allows an evaluation of the effects of therapy. A slow speed recorder provides a continuous hard copy of the entire resuscitation. A detailed analysis of' the resuscitations at a weekly conference provides a successful learning experience for the student. The patient also benefits from more intelligent therapy based on objective data.

Interested nurses, house staff, and 24-hour biomedical electronic technician support make this program possible.

14. Focal Motor Seizures in Patients With Alcoholism HOWARD S . SCHWARTZ, M.D. PHILIPR. YARNELL, M.D. GARYVANDER ARK, M.D. Department of Emergency Medical Services, T h e Denver G e n e r a l Hospital, Denver, Colorado Alcohol withdrawal seizures have been assumed to be of a generalized nature. Focal seizure activity in an alcoholic has Oeen considered an infrequent manifestation of withdrawal anti, when present, thought to represent significant underlyi n g organic pathology. While post-traumatic injuries have heen firund to cause Socal seizures in 15'; of a non-alcoholic

pol~ulation. previous studies of' focal seizures have not separated nl(~oholics.A focal r~iotorseizure is produced by a n electrical discharge in the fiontal lobe cortex. Clinically, this i> n~anil'estedby rnovement in the contralateral extremities, 11ustrrralal)n~)rnralities, or turning toward the opposite direction. 'l'he seizr~remay begin in one area of the motor system anrl trlarch (progressively involve other areas) and may then I~ccotnegeneralized. In the past two vears, a group of 24 alcr~holi(, patients who experienced one or more focal seizures were sturlied with cerebral arteriography. 0peral)le subdural I r r n ~ ~ ~ r r h or a g ernpyerna e was found in 1 7 ' ' ~In . 20'; there was tie~nonstrahle pathology which would not have been an~enableto hurgical correction. Arteric~gramswere normal in the remaining 6 3 ' 1 . Of this latter group (15 patients), 13 hat1 the onset ol' li~calseizures within 36 hours of their last drink (the same time frame a s for alcohol withdrawal seizrrres) and five had histories of either past head trauma or previor~sevac.uation of sut)dural hemorrhage. While it may he p o s t ~ ~ l a t ethat d these are simple alcohol withdrawal 5eizrrres. there were no clinical distinctions from idiopathic epilepsy or polentiation of a n underlying traumatic seizure t'oc.us. 'l'he alcoholic may have focal seizures as part of his withtlrawal complex 1,111 this is a diagnosis of exclusion ahlch requires c,erel~ralarteriography.

15. Development of a New Surgical Tape for Sutureless Wound Closure RICHARD F. EDI.ICH, M.D., PH.D. GEORGERODEHEAVER, PH.D. MILTONT. EDGERTON, M.D. Department of Plastic Surgery, University of Virginia Medical Center, Charlottesville, Virginia The superiority 01' tape for closure of contaminated wounds has been confirmed by experimental studies. Contaminated wounds closed by tape exhibit significantly less infection than sutured wounds. Despite this demonstrated advantage of tape closure, surgical tapes have not gained wide acceptance chiefly because of difl'iculties encountered in achieving and maintaining a secure closure. Heretofore, the comn~erciallyavailable surgical tapes were susceptible to t~reakageand did not adhere securely to the skin. For these reasons, a surgical tape has been designed specifically for closure c~f contaminated wounds. This tape has a microporous structure which limits bacterial growth (122 f 8 bacteria/in" such as is encountered under the cloth tape (1035 f 9 bacteria/in2). This new microporous tape has an aggressive adhesive t h a t ensures adhesion of the t,ape to the skin. The adhesion of this new tape to skin is twofold greater than adhesion of the cloth tape to skin. Reinforcing rayon I'ilaments have been added to the new tape t o prevent tape breakage. The development of the reinforced microporous tape should greatly facilitate sutureless worlnd closure and allow the merits o f t h i s technique to be realized by civilian and military surgeons in the care of' the injured patient.

16. Value of the G Suit to Control Hemorrhagic Shock in Patients with Severe Pelvic Fracture DAIIYI, .J. BATAI.IIEN,M.1).

PERH . W I C K S ~ R U MM.1). , ERNEST R I I I Z ,M . D .

RAMONB. GI.S,I.ILO,M.D. Emergency Medicine a n d Orthopedic Ser vices. H e n n e p i n C o u n t y G e n e r a l H o s p i t a l , Minneapolis, Minnesota Severe hemorrhage and snbsequent fatal shock frequently are present following a massive pelvic fracture. Uncontrolled Illeeding accounts for a significant mortality in this type of Iraunna. 1)uring the past nine rnonths six patients with severe (life t tircatrning) pelvic fracture have been treated a t the Hennc~l~in ('ounty (;enera1 Hospital with applicationof a (; suit shortly al'ter the patient arri~zedin the emergency stal~ilizationrr~c~nl hut tollowing initial evaluation. Clinical ohservution indicates a n inmediate improvement in blood pressure and c.;rrdiovascular slal~ilityas pressure in the inIl;ltal)le suit is increased to 20 mm of mercury. This simple ;ind inexl~ensivedevice has provided sustained and satisfacd in several patients where shock ensued, tory b l o ~ ~pressure i r i spite ol'rapiil infusion of blood, whenever the pressure was released. Five 111'theinitial six patients survived and the G suit W A S i n place for a nlinimum of 24 hours in each case.

Sevcariil patients were treated in this manner for 48 hours I'ollo~vi~rg irrJury. Irr a well controlled nretropolitan emergency care ~ ~ r o g r a ni t r is prclposed that the C; suit can he used at t 1 1 scene ~ 01 :in accident by properly trained people resulting in the s ; ~ l v ; l ~ofe lives. I'ossil~le physiologic and anatornic trrcchanislns resj~~rrrsil~le for the imr~rediateimprovement in the pat lent on nl)plication of the G suit will be discussed.

17. Emergency Treatment of High Pressure Injection Injuries of the Hand H. .I PARKS.M . D .

K 1,. H O R ~ R H M. D . ( ' I ~11.:TRIMHI,I.:,M.1).

1 ) r p a r t w e n t of E ~ n e r g e n c yM e d i c a l S e r v ~ c e s .

'I'hr I ) e n \ e r ( i e n e r a l H o s p ~ t a l , D e n v e r , ('olorado ( ; ~ E : I S: C ~ n dpaint g111rinject ions of' the hand may be extrt~irrely s e r i o ~ ~ s.Al~lrough . the chen~icalnature of the in,jec,tcd ~i~;rlerial Ira5 a n inlluerrce on the extent of damage, the cril ic,;11 1':1ctorill reducing disal~ilityand morbidity appears 1 1 1 1 1 Ilrc ~ ~ inlrrviil Irrlnr injury to perat at ion. 'l'he pertinent l'eature of' 1.1 c,;iscs 01' high pressure injection injuries of the hnnti will he presented to emphasize the need for prompt decompressioli 01' the injured part and removal of foreign substance. Only five 111' the 1 1 patients underwent operation within 24 hours o l ' i n j ~ ~ rSix y . patients endured between one

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UA' F

EMS

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