SAEM (UAEMS) 1975 Annual Meeting Program

Program Fifth Annual Meeting

May 20-24, 1975 University Association for Emergency Medical Services

Welcome to our Fifth Annual Meeting This year's program is designed to provide continuing education of medical students, house staff, midcareer physicians and allied health personnel who provide emergency medical service. If you a r e a member of University Association for Emergency Medical Services, this is your opportunity to exchange ideas with colleagues and assist in shaping the future of t h e organization. If you a r e not yet a member, we invite you to this meeting to learn more about t h e role of UAIERIS and how you can help. We look forward to having you join us in Vancouver.

Peter C. Canizaro, M.D. Chairman

Contents Welco~nc . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IFC General Information . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Executive Council Agenda . . . . . . . . . . . . . . . . . . . . 3 General Session Agenda . . . . . . . . . . . . . . . . . . . . . . :3 E r n e r g e n c Medicine Residency Forum . . . . . . . . . 7 Scientific Presentation A b s t r a c t s . . . . . . . . . . . . . . . 8 Floor Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2

General lnformation

I

I

Registration 'I'hc I J A E h l S Rc~gistrntionl)c,sk will hc, located in t h ( >Thompson Foyc,t of'thcx Rayshore I n n . Registrntion will begin W e t l n e s d ; ~ May .

21 a t 2:00 p . m . 'Th(b Rcxgistl.:~tion Desk n ~ i l lhe open ;ill d n 'l'hursday, May 22 and Fritiay, M : I ~2 3 , anti liom 8:30-9:30 a.rn. on S u t u r t i ; ~ y ,May 24. Everyone a t t e n d i n g t h e .Ann u a l Meeting is rc>cluiredto register. Pre-registrants have been 111;1iled;I copy of'this printed program and should h r i n g i t t o t h e hleet ing. Ll'alk-in registr;ltiuns will be processed at. t h e Rrgistriltion Desk. 'l'he registration kc, c.ovc.rs all p1annc.d activities c1u1,ing t h e A n n u a l Mec,ting, inclutiing t h e l u n c h c ~ sa n d hoat, cruise.

Information Desk l'hcs 1nfi)rmntion I)c,sk will he locateti i n the 'l'llompson Foyer along with t h e liegistration Desk.

1

Name Badges N a m e badges a r c rccluiretl for admission to all activities d u r i n g t h e -4nnual hleeting. Name badges will t ~ issuetl e upon c h e c k i n g i n a t t h e R c g ~ s t ~ . a t i o1)csk. n

Social Activities ,,

I hursday evening. Mav 2 2 , registrants a r e invited o n ;I boat cruise aboard the klalibu Princess. The cruise will hoard a t t h e B ~ s h o r rInn a n d d e p a r t a t 6:30 p.m. Registrants will enjoy a salmon t)nrbeque a n d live i n ~ ~ s i-4 c . cash b a r will he avail;~blc.,tldditional tickets !nay he ~)u~.chascsti a t t h e Regist.r;~tion Ilesk fbr spouses a n d g ~ r c s t sof'registrunts a t t h e cost of' $20 each.

Placement lnformation A I>ullctin ho:irtl to list positions i ~ n dp l i y s ~ c i a n s available nrill t)c locateti in t h e 'I'ho~npson Foyer, near t h e Kcgistration 1)esk.

Message Center Phone messages will he postcvi on a bullct in hoarci i n t h e Thompson Foyer. Registrants may also post messages in t h i s a r c a .

Proceedings Proceedings of'thc .4nnunl Mccting will not be prepareti ah a sc1par;ltc>puhlication. Selected presentotions a n d scientific papers will bc printed I ~ J A C E P

the J o u r n a l of the American College of Emergency Physicians and the University Association for Emergency Medical Services.

Annual Business Meeting Friday, May 83: immediately following the luncheon. t h e A n n u a l Business Meeting will be conducted. Agenda items include: reports from committees, review a n d voting on proposed revised constitution a n d bylaws and election of officers. Members are requested to bring t h e copy of the proposed revised constitution a n d bylaws previously mailed to the membership. This year candidates for t h e offices of vice president, secretary a n d treasurer (secretary1 treasurer as a combined office if revised constitution a n d bylaws a r e approved) will be proposed a n d elected. Members a r e encouraged to attend t h i s irnportant meeting.

About Vancouver The city a n d t h e communities which adjoin i t offer every facility for enjoyment, from superb restaur a n t s a n d s p a r k l i n g n i g h t spots to a n excellent range of modern accommodations. The area also includes some of t h e most scenic parks a n d golfcourses anywhere, miles of clean sandy beaches a n d t h e opportunity for every sort ofoutdoor activity, from sailing to skiing.

Perhaps most rewarding of all is the sheer physical beauty of t h e place, from t h e glistening h a r b o r rimmed by towering mountains to rolling green pasturelands. And near at hand a r e such richly varied scenic areas a s the Fraser Valley a n d t h e Sunshine Coast.

The city, the sea a n d t h e rich, green land: it's a n irresistible combination . . . a s you'll discover during t h e UAIEMS Fifth Annual Meeting.

A multitude of activies can complement your journey to Vancouver for t h e UAIEMS a n n u a l meeting.

Perhaps a salmon fishing trip, a cruise, camping i n the mountains. a n island tour or a skiing, golf or tennis excursion is w h a t you a r e considering.

Arrangements have been made with Venue West Executive Services to assist you a n d your family with planning your pre- or post-convention trip.

They can be contacted before your arrival a n d they will have a booth to assist you during the convention In the Bayshore Inn.

Annual Business and Committee Meetings Bayshore Inn, Vancouver

All members of UAIEMS are cordially invited to attend and participate in all sessions

Executive Council Tuesday, 20 May 1975 1:30 5 3 0 p.m.

Executive Session

7:00 p.m.

Dinner for Executive Committee

Discovery Room Chairman's Room

Wednesday, 21 May 1975 8:00 a.m.

8:30 a.m.

12 noon

Breakfast for Executive Committee

-

Executive Session

10 a.m.

Coffee Break

12 noon

Lunch for Executive Committee

1:00 -

Comnlittee Meetings

4:00

Economics of Emergency Medicine E.D. Organization & Planning Medical Education Paramedical Education Publications Resources and Public Infornlation Publicity Traditional Specialists

Chairman's Room Discovery Room

Chairman's Room

President's Room Board Room Director's Cowichan Stanley Park

Room Room Room Room

Chairman's Room Discovery Room

4:OO 6:00 p.m.

Continuation of Executive Session

7:OO 8:30 p.m.

Cocktail Reception Discovery Room Sponsored by Vancouver General Hospital

2:OO 6:00 p.m.

Registration

Discovery Room

Thompson Foyer

General Session Thursday, 22 May 1975 ThompsonlMackenzie Rooms MORNING SESSION: 7:30 8:15 a.m.

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General Session Thursday, 22 May (continued) 6

Damage to Tissue Defenses by Vasoconstrictors 'I'HOMAS R STE\ ENSON. S1.n GEORGER ~ L I W H E A VPH.D. ER. RICHARL) F EoI.I(.H.h1.l). h11l.I'ON T. EDCERTON.M.D.

3:30 p.m.

Coffee Break

4:00 p.m.

SCIENTIFIC PAPERS SESSION I1 Kenneth L. Mattox. M.D., Moderator 7 EMT Proficiency Test 'I'ou .ABERCROMBIE. 31 A. 8 Development of Selection Criteria for Advanced EMT Trainees LEWISFLINT.M.D. ROBERTBROWN.P H D .

CAROLI,ATIMER.R.N MAX S RITTENBURY,$1 D.

9

10

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Use of The Immediate Double Spica Cast in Multiple Trauma Patients RICHMD .4.ZORN,M.D. SICT. HANSEN,J R . , M.D. Platelet Reponse to Acute Blood Loss in the Dog and Baboon ROBERTLIM. M D. JAMES HOU'ROF-T, h1.D. DONALDT R U N K E YM. D.

Esophageal Obturator Airway; Its Use a n d Complications. Two Case Reports of Pharyngoesophageal Perforation KENNETHR. JOHNSON,JR.,hl.D MICHAELG. GENOVESI.M . D KENNETHH . LASSER.B.A.

12

"Call for Help" - An Algorithm for Emergency Care of Burns JOEC. RI(:KINLEY, B.S.N., R.N. CAHLJEI.ENKO, 111. M.D.

5:30 p.m.

Adjourn

6:30 p.m. Midnight

Boat Trip (Cash B a r ) Outdoor Barbecue

Friday, 23 May 1975 ThompsoniMackenzie Rooms MORNING SESSION: 7:30 a.m.

Breakfast fhr Regional Directors

8:30 a.m.

Status o f Emergency Medicine Residency Programs ( P a n e l discussion^ David K. Wagner, M.D., Moderator J a m e s W. Haviland, M.D. H. Thomas Blum, M.D. Joseph F . Waeckerle. M.D. Robert H. Dailey, M.D.

Coquitlam Room

General Session Friday, 23 May (continued) 10:30 a.m.

Coffee Break

11:00 a.m.

SCIENTIFIC P A P E R S SE:SSION 111 E n v ~ n'Thai. R1.D.. Moderator

13 The Use and Abuse of Echoencephalography in the Emergency Room FRLOEHICK W .(:I..Ass. 11 1) F:RI(' B1.Al'KWELL. M . D .

J . 'r. 11('R4K,kl.1). ~ V I L I . I A M17. % ~ ( . K I N %11.1).

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14 Clinical Comparison of Syrup of Ipccac and Apomorphine in Adults J ~ u o ~ fSCH~FFEK\I\. i: hl I ) .

Nl IRb14S J . ~)IAZIC)NII. 11 r).

15 Monitoring Resuscitation of Primates from Hemorrhagic and Septic Shock DOUALL) ' I ' R I . N K ~51.I) :Y. , J a ~ t ;HOLI'ROFT, s hll) ~ I A R.ANN Y C'AI{P~~:NI'EK, R S

16 Pneumomediastinum in Heroin and Marijuana Users KENNETH I>hlxrrox. 11 1).

17 Cleansing t h e Traumatic Wound hy High Pressure Syringe Irrigation Klc I I A K I ) F. K ~ L I I . I51.1) I . . PHI).

TIICIMAS STEV~~:NSOU. 51.1). %III.TON T. ED(;ERTON. M.1).

18 Auditing the Quality of Care in Emergency Departments IJNDACo1.~.M .A. GENEC.AYTEN. 1 l . n . . 11 t' H .

KI.I)OL.F ST~ROSCIK. 11 1).

('.

1230 p.m.

Luncheon A n n u a l Business Meeting

Fraser Room

AFTERNOON SESSION: 2 0 0 p.m.

British Colrrn~hin'sISirrc,rgrrrcy Krfei-rnl Sercire - .4 ('orrcrpt C h a p i n Key. M.1).

2:30 p.m.

Procirrcicrl 1rrrhulnrrc.c Srr[?icoo f Hrilish C'oluiit hin P e t e r M Rnnsford, RI D

3:15 p.m.

Cof'f'etx B r e a k

p.m.

I'nrrcocr~'rrnird I)istrirt Mospilnls I.,'iirrrgeicc,t/ I.'nrilities ( A n Audiovibual P r e s e n t a t i o n I Royal Columhian Hospit;tl H e r b e r t P a r k i n , M.1).

Lion's G a t e Hospital G e r h a r d Helmel, lf.1).

S t . P a u l ' s Hospital Albrrt Schulz. M.D. Vancouver G e n r r a l Hospital K e n n e t h K r i s l j ; ~ n s o ~M i,I).

General Session Friday, 23 May (continued) 4:00 Organi~ational lccting Ferguson Room 6:00 p.m. o f ' t h e Society of' Teachers of E mergency M e d ~ c i n e David K . W a g n r r . l1.D. 4:30 p.m.

4ir-Sen Rescue z i t h I'ortuhle Hyperhnric ('hnrnher ~Moviei W l l l ~ a n iT r a p p , M 1)

Saturday, 24 May 1975

Thompson Room

Emergency M e d ~ c i n eResidency F o r u m 9:00 a . m .

R e s ~ d e n c yDirectors' Panel How do you s t a r t one? l l a k i n g i t a positive learning e x p e r i e n c e for h o u s e staff h o w t o t a k e t h e p a l n o u t of learning Administrative hassles a n d how to deal w ~ t ht h e m

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Mackenzie Room

12:30 p.m

Lunch

1:OO p.n1.

Residents P a n e l U p t h e u p staircase through efftctive teaching formats T r a i n i n g Inside vsOutside t h e E D P r o g r a m G r ~ p e sa n d Solutions

Panels will consist of residents, p a s t residents a n d directors.

E v e r y o r ~ eis welcome to a t t e n d all sessions a n d questions from t h e floor a r e invited.

Scientific Presentation Abstracts

The Assets and Liabilities of Helicopter Evacuation in Support of Emergency Medical Services Herbert J. Proctor, A1.D. D e p a r t m e n t of S u r g e r y U n i v e r s i t y of N o r t h C a r o l i l i a School of' 1 I e d i c i n e Chapel Hill, North C a ~ , c ~ l i n a

Stephen A. Acai, J r .

Office of' E m e r g e n c y XIedical S e r v i c e s R a l e i g h , N o r t h Carolitla

Introduction Physician participation in the North Carolina MAST program offers an opportunity to assess the helicopter's effect on patient morbidity and morral~ty.One hundred arid ten patients provlde the basis of thls report. Referral data, flight logs, and receiving hospital charts were reviewed.

Complete data were available for 91C; of the patients.

Results

category Trauma Cardiovascular Newborn Misc Average

distribution ofcases -

rh mor-

talitj

--

50%

2 7'& 24'1

23''

qmorbiditj reduced

-

29' < 71'r

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R morbidity increased

r/r morbidity indefinite

Trauma Cardlovascular Newborn kll sc

45

404

0' /

5'6

Average

1'4

category

-

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The total time from mission request to patient of'f-loading l119+43 minutes) was less ( p < .001) than the driving time to the receiving hospital l163c43 minutes). Patients were accurately diagnosed 83% and adequately prepared for evacuation 55% of the time. Three patients were probably saved and four patients probably expired a s a result of using the helicopter.

Conclusion T h e overall mortality of 2 8 ' i , of which 52"; were as. sociatcd with C N S Irkjury. 1.cflects t h e severity of cases evacuated end t h e fatal n a t u r e of man: C N S problems No net efli,ct on mortality w a s nuted. T h e 38'; reduction i n n ~ o r b i d ~ tisy encouraging but riot a s spectacular a s some have c l a ~ m e d .T h e 71'; decrease in morbidity in cardiovascular cases enlphnsizes t h e value of t h e helicopter in these cases. In all cases in ~ v h i c ha n effect on morbidity o r mortality could be determined, evacuation time w a s t h e sole o r major factor.

T h e c~vcrallc~ffectof t h e program i s felt to be favorable.

The d a t a will be presented w ~ t ha description o f t h e North made fur improvCarolina program a n d recornn~end;~tions i n g t h e deficiencie:: noted above in t e r m s of physician t r a i n ing. helicopter dispersal, a n d equipment.

A Review of 55 Operations in the Emergency Room - ~ p k r a t i nRoom: ~ A Three Year Study Kirk K. Kazarian, M.U. .Jegadees D.Devanesan, M.D. Walter L. Mersheimer, M.D. D e p a r t m e n t of Surgery. New York Rledical College - Metropolitan Hospital Center, New York, New York.

T h e survival of'a patient t h a t a r r i v e s in the Emergency Room in extremis o r m o r ~ h u n dd u e to t r a u m a or whose condition is c r ~ t i c a la n d r e q u i r e s lznmediate operative intervention i s often a function of time. R e s u s c ~ t a t i o nand rapid e s t a h l ~ s h m e n tof t h e corrective operation is essential to sustain life. Xlovement of this type of patient m a y be ecluivalent to administering t h e coup de grace.

Sincc March 197:'. the New York Medical College \letropolit:rn Hospital C e n t e r h a s incorporated a new operatingroorn s u i t e in t h e Emergency Department. A fully trained surgeon i s present for 24 h o u r s a day. In over three years, t h e operating room s u i t e w a s used 55 times and t h e r e were 24 survivors. 143.7'% survival r a t e , T h e vital signs of all patlents were unobtainable a t t h e t i m e o f a d n l ~ s s i o no r shortly thereafter. T h e r e \rere 2 3 s t a b \rounds. 20 gunshot wounds. 10 multiple t r a u m a cases ( d u e to fallsor automobile rlcc~dentsi,a n d 2 ruptured aneurysms.

Resuscitzrtion. initial evaluation a n d oper;itive intervention were carried o u t in t h e Emergency I l e p a r t m e n t operati n g room suite.

T h e results of surgery o n 55 patients a r r i v i n g in the Emergency Room too c r i t ~ c a to l he transported to t h e main operating room suite a r e analyzed a n d factors related to survival ;ire discussed.

Health Services Research as an Emergency Department Management Tool Donald S. G a n n , h1.D. Geoffrey Gibson, P h . D .

Division of' E ~ n e r g e n c ySledicine.

The J o h n s Hopkins University School of'hledicine and Hospital, Baltituore, Maryland Health S e r ~ ~ c Research es is a n elt'ect~ver n ~ < n a g e m e n l . t r c i i n ~ n ga n d service tool in t h e hospital emergency d c p a r t rnent a n d t h i s report ind~cat'h t h e ;lctivities untlerwt~ya t t h e Health Servicch Reat1arc.h unit 01'The J o h n s H o p k ~ n s tiospital Ernergencv D r p a r t m e n t . T h e unit represent.; ;In empirical 'lpproach to clu;il~tyof'meclical c a w a > s e s s ~ n c nats well 11s rigoroil:, ~ t l ~ p i levaluation ct of'scver;~l s e n icr Int?r.ventions introduced in t h e erner.:,.t.nc.y depurt!nent S p e c ~ l i call?. clinical p r o h l e r n ~Lire identitiedon t h e hasi.;ol'clinic~~l importance. incidencc, Seasihility of s h o r t tern1 outcome results lending to rnarragernent tlecihions. a n d t h e uvnil;lh~lity of a n i l ~ t e r v e n t i i ~ r~procetlure l or protocol chanjic~lto address the prohlcin. T h e following clinical p r o h l e m ~a r e heing inve3tigated: chest pnlns. rninor \vound infectlons. pneumonia, "short thrm" a d i n i s s i ~ ~ headaches, n. ankle i l i ~ juries. a n d p a t i e n t s \\ ho leave before t1,rictment Service intervention> heing e\clluatrd ~ n c l u d e :triage nursing. ;t nun-urgent w;ilk-in clinic, nursing audit. patient exlt interviews, p a t i e n t advocilcy a n d chronic p i ~ t i e n t e d u c a t l ~ ~ n group;. For each of' these t h e generic mcthod~,logicformat is first. 3 r e v ~ e wo f e n l e r g e n q dcparttnent rnedlcal records to identif- t h e patient population study group a n d its c l ~ n ~ c a l a n d demographic characteristics: second. t h e delineation from records o l ' t ~ v opatient groups which did did not receive t h e intervention under s t u d y and I;,llow-up interviews \vith patients to determine different~illrnortlidity; t h i r d , a pr11spectlve research design I where feasible a n d e t h i c a l ) which randomly allocates eligible patienth to a n txxperirncnt;ll o r ~ t hi n t e r v e n t i o n ) q o u p o r a control g r o u p with patitlr~t fuIlo\v-up through personal intervie\vs to assess patient health s t a t u s outcomes. 'rhe-;e d a t a a r e ilsed in redesigning the emergency departlnent, for presentation a t clinical rounds, In protocol development a n d t h e assessment or innovative manpower roles, in clinical a u d i t ~ t ' c a r eprocesses a n d outcomes, in e n h a n c i n g resident a n d a t t e n d i n g staffs clinical a n d research skills, i n t h e acceptance o r ~.ejection or existing interventions, a n d in t h improvement ~ or patlent care standards.

Extending the Art - Portable Cardiopulmonary Bypass Kenneth L. Mattnx, M.D. A r t h u r C . Beall, J r . , M.D. C o r a a n d W e b b M a d i n g D e p a r t m e n t of Surgery, Raylor College of Medicine and t h e Ben T a u b General Hospital, Houston, Texas.

T h e advancements i n extracorporeal cardiopulmonary support t h r o u g h oxygenation a n d p u m p i n g units h a s permitted t h e explosive develupment of h e a r t surgery. \lost

\yell e q u ~ p l ~ eoperating ti room.. h a \ e n rnc~d~ji.n cnrdlopulmonary hypass d e v ~ c ecomplete \ v ~ t h~ n u l t ~ ppir~lip lr heads ant1 heat exchange

A battery po\\ered poi.tahlc c ; i ~ . d ~ o p u l ~ n r ~ n ; i ~par. .> has been ut11izc.d In iC5patient.. \\ho,e ~ l ~ l l d i t l ~~l~nr e c l u d e d nlo\elilcnt to t h r operating rljrlm. Seventeen patlcnts \vith inassl\e p u i ~ i i o n n rrinholi ~ and eight ~ ~ i i t i e n\t \>~ t texteri~ s l \ r c ; ~ l . t i ~ o l ~ u l r n otriiu~rl~c ~ ~ a ~ ~ y\\,ere i~iccesstullyplziccd on e fifteen mlcardiopulmonary l ~ y p a ;si t ~t11t.11. t ~ e d h ~ d\\.1t1111i nutc..: of cardlac a r r e s t i ~ t ~ l ~ fze~~ n tg~ r iiirter) il a n d femoral r l n c : i n n u l ; ~ l ~ r jTI\ n o o t h e r patlent., \\ ~ t mas3i\.c h Ilc>n~opt > 51sh ; ~ dthe poi.tat]le pulilp s t a ~ i d b yc ~ ~ ~ c o r n ~\ \t,a~nt h suct crs.;f'i~lc c ~ n t i . o~ f~tlh e i r air\\ a y . T h e portable u n l t allo\\s f i ~ r ~ r d ~ ' r ltl.;inhf.r. y e \ i ~ l u i l t ~ oal ~ l i dt h e r a p y .

Elc,\en i ) t t h e patients \ \ i t 1 1 ~-r~assi\-e pul~iionar,v? ~ ~ l l ~ l J i l \\el.r hal\ aged. S I Xof'tllc c ~ g h patients t \\-ho required portwhie c ~ l l ' d i c ~ p ~ l f l l i ~h>-pass n a r > for maqslve, traulnatic thorac-~c ~ q c i r i e -t~ird : control ol'theil. liemorrhage a n d repalr allo\\lrig tor tl~,(,c~~itiriuance of'by[~ass. \ Y ~ t h c u n t ~ n u e da d v a n c e m e n t of m e d ~ c a ld e \ i r r i . t ) r o a d e ~ i ~ nilf'thc g c l ~ n ~ cappl~catloris al of'an i n s t r u m e n t \\ 111 hecome more \v~dcspreatl Adript~\.einnovations allo\v f l ~ r extension of' t e c t i n ~ q u e r~ ~ r e v i o i ~ hl I~>r .n ~ t e tod a local or . I J ~ cialtv

Evaluation of an Emergency Department Observation Ward N o r m a n J. Diamond. 1I.D. f J e r o i ~ A. ~ e S c h o f k r i n a n , h1.D. John W. Elliott Receiving-Emergency Division, D e p a r t m e n t of Medicine. H a r b o r G e n e r a l Hospital, TorYance, C a l i f o r n i a a n d U C L A S c h o o l of Medicine, Los Angeles. California. k ; l ~ ~ e r g e n cLlepartments > IE;.I). I a r e repeatc.dl> f;iccd \ \ ~ t l i p w t ~ e n t s111 \\ h o ~ i i~ m m e d ~ a tdc~. a g ~ i o s itherapy s, or d1spc151tlon I S not a\~a~l;lt)l'O b s e r v a t ~ o nLV;lrds a r e \vldel> used tu hold rt:it1ie patlent.; p e n d ~ n ga d m i s s ~ o nto , trcwt ;elf l ~ r i ~ ~ t r d [lrohlcln? or to a \ \ a l t c o n h l ~ l t a t ~ oorn further te<tq. In 0111. 8 hetl \\;ird, patlent5 l n , ~he obher\.ed f i ~ r;l nl;ixlrnuin I J 2.1 ~ h o u ~ sunder t h e <Lire of' a f u l l - t ~ i l i ehouie stiiff. n u r s r ant1 ;ittcndant I1;itlents n ~ t hpomihlc m o c ~ l r d ~ iazlc h r m ~ a .or post t r i i u n ~ a t i cn b d o m ~ n a lpain a r e n e \ e r held and h o l d ~ n g p a t ~ c n t st l u r ~ n gt h e d a y t i m e I > d ~ s c o u r a g e d U'c. rev1e\4rd 0111. c,xperlcncc. ~ ~ 166 t p,itlenti h ,idni~tted to our O l , i e ~ . \ ; i t ~\V;lrd r ~ ~ ~ d i ~ r ~ nSepten-rber. g 1971. 'This grou11 of'H.1 fernaI~.s;inti 8 2 r11;ilesr;inged In a g e from 16 to 92 ~ ~ 12'rt I h~ r i n gundc,r 35. The ;I\rr;lge s t a y n a s 14 3 hours.

T h e e l ' , \z ho \zerc, l~c~l(l vvernight stayc'ti an average of 19 hours. 'l'how lJt~\L'I'\t'dd u r ~ n gt t ~ vclay 1:39'i I s t a J e d a n a \ e r a g r of' 6'2 h o u r i . Furt\-t\kc~prrcent of' t h e p a t ~ e n t sheld uvcrnight \zc.re ; i t l m ~ t t r dt h r f o l l o \ \ ~ n gmorning.

Comlnr111 diagnoses ~rlcludetldrug overdose 125.9'r I alcohol~-rn 12(I.,i'; I. and l l u ~ dand electrolyte a b n o r n l a l ~ t l e s

.spuno.n p.nr:ulrireluo> ur pap!o.\n a q plnoqs put? i . a ~ u , ? l . ~apn s s ~ l s.r~r:ciri~~ ~ u ~ ~ q d . > u !ain31pu! d., qarpnls a s q l J O "Ilns".I aiij,

spun0.H ~ I . > ~ ~ : L I I L L I ~ !U~ IL Ini.n ~ ~ J ~ aJ . 1 nq ~ ~ o l s.~r?ntldnpurl s a s u ? ~ -211 .xlss11 ~ ~ r ? t l liouu~ prp iau!nsopl[i l u a 3 ~s ! l a q l s a u e [ u s -01 a i [ ~lsaj,~.' J r l r l s o t l J a q /rir~.~!jrri,Yis~ii uu a.\r?q 1000'()0~'1 '(~oo'~)o~:Ia I u ! . ~ q d a u ! t I a ,lo s u o ! l n [ o s aln[!p ~ r ? q l p . ~ l t : . ~ l ~ u o i u os up e i u n q n! s a ! p n i s [r?s1111~s.uo!l!ppn 111

EMT Proficiency Test 'Torn Abercrontbie, M.A. 'Test Psychologist Regional Technical Institute (JAB, LTniversity Station Birmingham, Alabama '~h?~~t,jeclivc~ev;llu;o ~ ft ti ho en b:mcrgency Xlrtliccll Technician i i ;\TI essentiill s t e p In the refinement of ;In eniergcncy mcdic;ll delivery s y s t c ~ n Pro\ .

I ~ I O Lfor I recogrlitioi~of' ~)er.fi)rrrr;~nce ~ ~ b i l inot t . n e c e s s ~ ~ r i acquired ly through tradltioncrl ~tlediurnsis desirnhle In t h e emergency rnedical sysI r n l Hoth ol'these e n d s a r c obtninuhle with t h e EXUT Prof'ciency 'Test rlev~yloped a t t h e Llnrversity of Alabama 111 H~rirrir~gt~~~rn.

jirl~upot'xut)jcct ~ l l a t t e experts r were 1)rought together and thc? drvtalopcd ctn a r r n c h n ~ rt,isk . inventory of the EXIT [~rol'essiorr.T h e inventory was put intv a f b r m ~ l tcapahlc of' colrlputer ; ~ n i l l y s i i .It \va> invested ~ ~ four t dir~lerlsion h q u c > t i o r ~for s each task. I'rt.~luency.criticality. rreecl a n d tlejirc~eo f s u p e i ' v i ~ i o nT. h c tklsks \vCre then rnniletl to 'LOO f'unctioninji EXIT'.; In every s l a t e of'the 1.nitctl S t a t e s .

Over 170 EMT's ~.rsponded.Based on their rating. the t a s k s were r a n k ordered in cncli category. Test items were developed to measure t h e indivitiual significant t a s k . 'The items were carefully screened a n d compiled into a YO0 questiun cxumin;ltion. T h e t r s t \ < a s norrucrl In Nr\v Yt1r.k City. r u r a l Illirlois. rnetropolitan Los Angeles County a n d rur;rl X l a h a m a . Estcnsive a n a l y s ~ of s thc results h a s heen accorrlplibhed. T h e test is c o n ~ p l e t ea n d i.eadv Ibr use. 'l'l~e test ia currently being useti a s s t a t e 11censure nlet i i u n ~ s .e t ~ d11f hasic course einrninations, equivalency of erllergency t r a i n i n g In pri~jirnnlsother t h a n EXl'l'. objective clvaluation ol'spstem component>. pri~t'iciencyfor milit a r ~ l yt r ; ~ i n c d veterans, e v n l u a t i o r ~of instl.uctionnl pro&Tarns ant1 instructors. a n d ;is e n t r ? p r e - r e q u i s ~ t e sfhr a d ~ r ~ i s s i oto n advanced E l I T t r a i n ~ n g

Development of Selection Criteria for Advanced EMT Trainees Lewls Flint, M.D. Robert Brown. Ph.D. Carol Latimer, R.N. hlax S. Rittenbury, M.D. Department of Surgery, Medical University of South Carolina a n d South Carolina Association, Charleston. South Carolina.

Advanced E r l ~ r r g e n c yMedical Technicians I . ~ D V - E M T I a r e presently utilired in marly a r e a s . T h e i r t r a i n i n g varlcs according to t h e definition of t h e role o f t h r ADV-EMT's i n each nledical c o m r n u n ~ t yADV-EAlT . courses uniformly require subst;irrtial investnlents on t h e part of physicians. nurses a n d t r a l n r e s as well a s s ~ g n i f i c a n tfinancial Input from Sunding agencies. Development of' methods for accurately selecting t r a i n e e s who c a n a n d will complete ADV-

EIllT courses with acceptable levels of long t e r m performance ctruId produce s a v i n g s i n t ~ r n ea n d money. T h e purpose of o u r study via;. to explore t h e use of pre-course testi n g to predict perfbrrnance.

A s t a n d a r d psychological profile 116 P F I w a s used in conjunction with a test of a w a r e n e s s t o provide o b j e c t ~ v ed a t a on 142 candidates. Usual biographic d a t a were gathered a n d personal interviews supplemented the s e l e c t ~ o nprocess. Acceptable s t a n d a r d s for .L\DV-EMT's were fhrmulated using projections of desirable behavior a n d comparisons with psychologic profiles associated with satisf'actory performance i n other. s i m i l a r jot)s.

Twenty-one candidates deemed moat suitable were selected. Comparisons with nun-selected candidates revealed significant difrerences in ps>chologic test scores tP<O.011.

All candidates successfully completed t h e 280 h o u r course a n d examination. T h e validity of t h i s finding w a s e x a ~ n ined when a second group of 21 s t u d e n t s w a s selected from a candidate group with less d e s ~ r a b l etest scores. E ~ g h of t 21 s t u d e n t s failed t o complete course requirements T h e d a t a suggest t h a t s t a n d a r d psychological tests m a y be valuable adjuncts to biographical d a t a a n d interviewing for selection of t h e ADV-EMT s t u d e n t . T h e role of such testi n g in predicting long t e r m success i n t h e ADV-EMT role is t h e subject of a n ongoing study.

Use of the Immediate Double Spica Cast in Multiple Trauma Patients Richard A. Zorn, M.D. Sig T. Hansen, J r . . M.D. Department of Orthopaedics. University of Washington School of Medicine, Seattle, Washington.

Harborview Medical C e n t e r i s a university hospital in downtown Seattle n e a r t h e confluence of' freeways, a n Industrial complex a n d a n active waterfront. It is, therefore, a major c e n t e r for massive t r a u m a a n d receive> m a n y patients with multiple injuries with severe ti-actures r ~ ft h e low back, pelvis a n d lower e x t r e m i t ~ e s .

In t h e past four years, we have adopted a n approach in which a specially-designed double spica cast i used tbr patients whose injuries ~ n c l u d eunstable fi-actures of t h e pelvis o r lumho-sacral region with o r without o t h e r lower extremity fractures. It is applied immediately after initial resuscitation a n d p r i m a r y surgical care which m a y include thoracotomy. laparotom. a n d i n t e r n a l fixation of long bone fractures in lower extremities. T h e cast stabilizes t h e low back a n d extremities for control of bleeding, support of t h e fractures a n d e a s e of nursing care. Modifications c a n be m a d e to t h e cast f i ~ rf u r t h e r surgical procedures a s necess a r y to alloir. monitoring of t h e chest a n d abdomen.

This paper presents t h e details of t h e application a n d modifications of t h e cast. T h e results of fifteen cases where t h e i n ~ r n e d i a t eapplication of t h e dout>lespica cast w a s used a r e reported with t h e specifics of fb111.cases which display its advantages.

Platelet Response to Acute Blood Loss in the Dog and Baboon Robert Lim, M.D J a m e s Holcroft. M.D. Donald Trunkey. M.D. D e p a r t m e n t of Surgery, T r a u m a Center, University of California a t S a n Francisco General Hospital, San Francisco, California.

Defects In primary hemostasis have been shown to occur with massive blood replacement in the treatment of hemorrhagic shock in man. These defects, in part, are attributed to abnormalities of platelets in blood transfusions. To further evaluate this defect, platelet f u n c t ~ o nwas studied in acute blood loss only.

Platelet studies consisting of platelet counts, platelet aggregation induced by ADP and Epinephrine, measurements of intrinsic platelet ATP & ADP and electron mlcroscop~c( E M )studies of circulating platelets were performed a t diflerent times before and after hemorrhage in 13 dogs arid 13 baboons.

The table summarizes the results (mean significant platelet function.

i S.D.I

BABOON

DOG -

Time*

P1 Count**

Before

319 i 122

P1 k i z g PI (ADP)*** Count** 53 +_ 13

Irnmed

15

250 i 64 70 5 23 ( ~ ( 0 0 5 ~( p < 0 0 1 )

30

2 3 9 ~ 5 7 67221 ( p < 0 01, t p 4 0 021

60

of the

P1 A g g .

(ADP)*"*

376 i 203

35 2 17

364 t 222

50 i 24 ( p < 0 01)

351 2 209 ( p < 0 051

40

mln after bleed~ng No x l o J cumnl, ' mlsslon

-'c

+_ 17

of llght trans-

There were no significant changes in platelet aggregation to Epinephrine in the intrinsic ATP & ADP content. nor in the EX1 studies of the circulating platelet.

With acute blood loss a n immediate change in platelet aggregation occurs. This increased aggregability is associated with a fall in the platelet count. This is in keeping w ~ t hfindings in patients after hemorrhagic shock whose platelets a r e lessresponsive to aggregating agents. Inadequate resuscitation in the emergency room after acute blood loss, continued hemorrhage and multiple transfusions will aggravate this bleeding diathesis. Description of our resuscitative program includ~ngwhole blood and platelet replacement will be described.

Esophageal Obturator Airway; Its Use and Complications. Two Case Reports of Pharyngoesophageal Perforation.

Kenneth R. Johnson, J r . , h4.D. Michael G. Genovesi, h4.D. Kenneth H. Lasser, B.A. UCLA School of Medicine, Los Angeles, California.

The esophageal o b t u r a t o r airway i s a device designed fbr assisting artificial ventilation i n lieu of' placement of a n e n dotracheal tube. T h e airway is hllndly hut easily introduced through t h e oropharynx a n d advanced into t h e esophagus. A cuff a t t h e distal e n d i s inflated, a n d t h e esophagus is occluded. A mask is t h e n placed occluding t h e nose a n d mouth, a n d a resuscitation h a g or mechanical ventilator 1s attached to t h e tube. Air holes proximal to t h e cuff allow a i r to flow from t h e ventilator bag into t h e p h a r y n x , larynx, t r a c h e a a n d lungs. T h e alrway h a s been found to be a n effective a n d reliably safe m e a n s of providing a n artificial airway. It preventsgastric dilitation a n d aspiration by esophageal occlusion. It i s not totally without hazard however.

Two cases of pharyngoesophageal t r a u m a a r e reported, t h e first being a high esophageal t e a r found a t post lnortem exa m i n a t i o n , a n d t h e second being a pyriform s i n u s laceration noted on admission to t h e hospital. A hrief discussion of t h e therapy of' pharyngoesophageal perforations is given. T h e t r e a t m e n t for cervical esophageal perforations is conservative a n d fbr thoracic esophageal perfbrations is surgical.

Despite these two complications. o u r experience with over 1,000 cases leads us to t h e conclusion t h a t t h e esophageal obturator airway is safe a n d effective. It should he used whenever persons unskilled in dlrect endotracheal i n t u b a tion a r e participating in cardiopulmonnr. resuscit;rtive efl forts.

"Call For Help": An Algorithm for Emergency Care of Burns.

J o e C. hlcKinley, B.S.N., R.N. Carl Jelenko, 111, M.D. Burn Investigation Laboratories, Medical College of Georgia, Augusta, Georgia We have been increasingly distressed a t t h e n u m b e r s of ~ n d i v i d u a l swith b u r n s of a variety of severities a n d a g e s transferred t o o u r B u r n Service a f t e r inappropriate - if a n y - resuscitation a n d care.

For example, d u r i n g October - November, 1974. \vc a d mitted 20 p a t i e n t s with b u r n s of' 141.8% BSA. Six, includi n g o n e 2-year-old with a 3% BSA scald lesion, h a d received inadequate, incorrect or n o fluld resuscitation. Four had clear evidence of post-burn pulmonary injury which h a d been ignored for a s long a s five days first identified a n d m a n aged on a r r i v a l a t o u r institution. Two were severely anemic, and four had received no topical antibacterial t h e r a p y .

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In gent,r,ul, t h e prlniat,! p h ? s ~ c i a n~ l i ; ~ l i ; ~ gtlie~ic. i ~ i g 1x1t ~ t a ~ i live-(I ts in ;I conltiiuli~tyof Ic,ss t h a n 9000 p ~ ~ p ~ i l ; i t ~ o n : l i ; ~ daccc,ss to ;I l i c ~ h p ~ t aI'ucil~ty l of' onl? 25-ZO heti;; a n d . \villi one3 e x c r l ~ ton. \\,is 15-20 ?cLat,sout of m c d ~ c a lschool. ;ind \ \ a h nilt a " ~ l x ~ c ~ . i I ~ s t . " I t \ \ a s o u r ;ihse-.>rnc,nt t h a t . In t h e s1iol.t tcsl.ln. rr-rtiucat ~ o t i01' p h > s l c ~ ; ~ n;in(] . : rlurses conccrnlng thv c3nir1-gt,nc> managt~liit~1it111' ie\c.l.v t)urii> \\,IS r i r ~ t Icahlhlc \Ve also ni;idtx tt1cjudg~~lnc.n t tliat ;I I ~ I ; I J I Ip~.c~l>lcrn ~ cern~pl.~sc.tl tht, In; l h i l ~ t ?of t h ~nursc. , o r p h > h ~ c i a nIn t l i ~coniniut1lty , liusp~tal to 111akc tin t~;irl? d c - t c , r ~ i ~ i ~ ~ ract g~aornd ~ l i g tllr u l t ~ m a t t ~ complrhity o l ' m a n a g l n g t h r p'ltlrnt \ \ I I ~tn:I]lli~11lirn I ~ J L I I . ? .

01.c l t ~ t r t c t t~t l. a u ~ n a 'l'hc~ .

Ii~ttet.\ \ e t ~ c . l ~ c \ . tl~i ;l~. dlittlc to do \ v ~ t ht h e [~.itic,nt'sc3conoti~ic s t , ~ t u zbut \ \ a h l'rlatc~timorc to tlic tt.catltlg g1.oup's ~ r ~ t i h ~to l ~;Iccesh ty :I 1,111.n cc3nter. ;lccortl~ngly.\ve tic,\eloprd ;In ;iIgu~.ithmw h ~ c htiet ti ti lie.; rIlus'jutlgm~.ntaI a r ~ dassessmc,nt steps ~ l p p r o p r ~ a for t r tiett.1.1111nlng\vl~etlierLI p a t i e n t ~ ~ t,I lrn:~j~it. i hurl^ o r c ~ l c c t r ~ c ; ~ l I ~ J L I I i. b? t1,earable in t h e local :il.c:i idc,~~tllic,s c c ~ ~ . t crlni~~ tc'r~;ic r ~ t ~ v iliil~ rt h ~ ds t , t e r m ~ n n t ~ odrtincss n: t h c kc,? t)mcsrgt1ticy ~ i > ; ~ ~ i ; ~ g ehtc>ps ~ i i c ~; In~ tP I . ~ I I I I . I ; I ~\\C tic,tlit~~. the ~ ; I I I C I I ~ I S rel:i~nt~cl a t thtx loc;~ll ~ \ell.~r t l,insporrt.rl \II,.~ ~mpot,t;lntIy. t11(, n l g o r ~ t h ~ pi ir r ~ \ ~ t i cas p l i o n ~ '~ i u l n l ) r t\.\ 1 t 1 1 \\.liicli ,I c c n t r a l hut.n scxl,vlceca11 11t. ;iccc,<-~,d.

Exl>tlrit~licc.to tiate. I S l i ~ i i i t c ~hur ~ i . I~rc:iuhc~ot'tIic crlnhtrl~ct ~ o t io l ' t l ~ it ~ l g ~ ~ r cc~rt;i111 ~ t l i ~ p~ ~~~, r ~ i ~ i i ;it.c, r t r r:I\s L I I I ; I ~ I I L ~ li11, c11!1c,~,t1\ca ca\aluatiot~ ol' i t s t>l'fbctivencnh. Froti1 t h c ~ ~ c~t~ . \\.,111I(1 1i1)I)Cat.[ h a t thih 1llt3t[lodot';lpprc~;lchIliis 1i;lti ;I I I O Z I t i \ v c.ftc~c~t a t Itlast I n t ( l l ' l l l h el1 gc1ttilig tlit'se s 0 1 . t ~01' pittlvnth inti1 ;in alJlx.ojx ~ ; i t ec.i~'c~t l ~ c ~ lt~spc~tlitiounl? ~t\ a ~ ~ d \ \ ~ t h1110rc ; I ~ I ) I . ~ J I 1111l1;1I ~I:I~V c;II.~.

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The Use and Abuse of Echoencephalography in the Emergency Setting Frederick W. Glass. M . U .

Eric Blackwell, IC2.D. J. T. McRac, h2.D. Willjam >I. McKinney, 51.1).

Bo\r.rnan Gray School of Xledicine, \VinstonSalem. North Carolina.

Tile ~ n t l . o c l u c t ~111' ~ ~t .nc l > c ~ c ~ n c ~ v ~ ~ l i i ~ II,>c ~ g[,c.k<c.ll t ~ : ~ ~ ~ 111 I~> 1955 ~ n i t ~ ; i t e e;I l I I L I I I ~ V~I 'W C I I III I.C ; I I ; I ~ I ~ I / I C ; I c~ iI ~~ ~I>c,t.~c-, ~t l~ o l ' ~ ~ ~ \ . e s t i g a t iuo h~ ~ i s~ di ~g a g n o s t i ci~ltr;rse~untl IOI. d c , r c , l . ~ n ~ n ~ a t i o n ol'spact, o ~ , c u p \ ~ l iIce: s ~ o n sa n d o t l i ~ , 11arI111loq> r ol'tll~, ~ler\.oiiss?.steli~.T h e 111itl;ll 11s~'01' t l i ~ s~ C Y ~ I I I I ~\ \I ; II <I ~ 111 ~ t2v;iluation o l ' h c a d ~njiiric>ha n d otlic,~.tii>r;~htx.:1 1 1 ' t l i t . nc.1.\ I I U S sy>te111 Fc1111)\\ i t ~ gt\\e,ri t \ vt1;lrs 01' rc)ht.;~rc,h.>t;i~i~i:~~.ci t t . c l ~ ~ i i q u chave, > hccolile ; ~ \ n i l ; ~ l )hl el use In t h e cslnc.t'gcllc.?

1.ootn srl t ~ n g ' r h r purpose3 of' t h ~ spapcxl. I S to I'?\ lr\v 11y tnentls of a n i o \ . ~ r ,t h e tcchniclue of s t a n d a r d rctioc~ncc~phalt~grnpliy.T h i s bvill include, a coordinnte h ? > t e l r ~lijr determ ~ n a t i o l ol'm~tilille i In tt1l.c.e s p e c ~ t i c;ircu~-.uI'tlic~ h i , a ~ n'I'llc . i n d ~ c ; ~ t l t ]fni s~ ec.ll11encrphalogr;i11t1> r in t tit.eme~.gency1.irorn s e t t i n g \ \ 1 1 1 be tiiscussrd w ~ t ht.\;~niples oi' t? ptcal ciihc.5

The results of consecutive cases over the past two years will be presented. The percentage abnormal~tyhas averaged approximately five percent, even with increased usage of the procedure, which falls within the range of major screening procedures using other techniques, such a s skull films.

CBC, urinalysis, and other chemical tests.

The use of echoencephalography in many emergency situations has been abused due to poor training, lack of a standardized technique, and more recently t h e use of automated midline instrumentation, which may lead to significant errors in Interpretation and reduced patient care.

In summary, echoencephalography using current techniques has been of significant value in the diagnostic crlterla necessary for the management of emergency patients with head injury and other pathology.

Clinical Comparison of Syrup of Ipecac and Apomorphine in Adults Jerome Schofferman. M.D. Receiving-Emergency Division, Department of Medicine, Harbor General Hospital, Torrance and UCLA School of Medicine, Los Angeles, California.

Induction of ernesis is often indicated to treat patients who have ingested dangerous q ~ ~ a n t i t i eofs poison(s1. Because the ernetic of choice has not been firmly established, a prospective, randomized study was performed to compare syrup of ipecac to apomorphine. Twenty-eight adults were studied. Fifteen received 30 cc of ipecac orally and 13 received 0.lmglkg apomorphine subcutaneously. The groups were similar in age, sex and poison(s) ingested.

Emesis was successfully induced with initial therapy in 13 of 15 (87%i ipecac-treated patients and 10 of 1 3 (77'2 apomorphine-treated patients. The mean latency period before onset of vomiting was 11.6 minutes (range 4 to 26 min.1 in the ipecac b ~ o u pand 5.3 minutes (range 2 to 1 3 min.) in the apomorphine group ( p < ,011. In the ipecac group, 1 patient suffered moderate central nervous system (CNS) depression, but no hypotension or respiratory depression was observed. In the apomorphine group significant CNS depression developed in 8 patients (62%'1,hypotension developed in 5 (38%i and respiratory depression in 1. There was no consistent relationship between type of poison ingested and occurrence of side effects. Intravenous naloxone was ineffective in reversing side effects 5 of the 7 times it was apomorphine e tabused. In addition, difficulty d i ~ s o l v i n g ~ h let occurred, thereby delaying initiation of therapy.

Although apomorphine has a rapid onset of action, the high incidence of potentially dangerous side effects with its use make syrup of ipecac the preferred emetic for routine use.

Monitoring Resuscitation of Primates From Hemorrhagic and Septic Shock Donald Trunkey, M.D. J a m e s Holcroft, M.D. Mary Ann Carpenter, B.S. The Department of Surgery and the T r a u m a Center, University of California, S a n Francisco General Hospital, S a n Francisco, Califbrnia.

Successful resuscitation of shock victims will In part depend on the type of fluids administered and monitoring techniques and interpretation. The purpose of this study was to evaluate the indices commonly used in monltorlng shock.

Twelve baboons were subjected to either hemorrhagic or septlc shock to a n endpoint of'a skeletal muscle membrane p o t r n t ~ a lof' 6 5 m v . All anim;ils were then ~esuscitated and the following parameters measured: gross urine output, cardiac output systemic blood pressure. pulmonary artery pressure, pulmonary artery wedge pressure IPAWI, central venous pressure tC\'P). blood gases (pH, POs, PCOsl, rnixed venous gas and extravascular lung water iEVLW) by a double-indicator dilution method: the thermodye technique.

fa),

Mean Art. Pres. cont. 2'12 hr.

Results:

EVLW cont. 2% hr.

Hemorrhagic shock resuscitated with Ringer's lactate, N = 4

128 12.9

91 5.6 i 1 0 . 3 k0.7

5.2 k1.6

Hemorrhagic shock resuscitat~onwith Plasmanate N = 4 Septic shock resuscitated with Ringer's lactate, N - 4

112 187

88 k10.4

4.9 11.4

6.2 21.9

112 28.5

65 i8.1

7.5 i1.9

10.6 k3.2

Q

cont. 2% hr.

123 i 6

114 241

PAW cont. 2% hr.

4.5 +3.0

1.2 k3.0

CVP cont. 2'2 hr.

-1.7 +1.5

-1.3 k1.5

All values expressed a s mean F SD. Cont. = control, 2% hr. = hours after resuscitation begun.

PAW was positively associated with Q ( r = .53, p>0.05) and CL'P ir = .51, p>0.025). EVLW was negatively associated with POs ( r = . 6 5 . p>0.01) and arterial pressure ( r = . 4 9 , p>0.05). Arterial pressure did not correlate with

(2.

21

Conclusions: Pulmonary artery wedge pressure is the most sensitive index of volume replacement but may be impractical in the emergency room. Urine output and CVP are relatively reliable indices of resuscitation and easiest to perform. A r t e r ~ a lpressure does not reflect cardiac output and is not a reliable index.

Pneumomediastinum i n Heroin and Marijuana Users Kenneth L. Mattox, M.D. Cora a n d Webb Mading D e p a r t m e n t of Surgery, Baylor College of Medicine and the Ben Taub General Hospital, Houston, Texas Patients with penetrating or blunt trauma who sustain tracheo-bronchial or esophageal pathology may present with pneumomediastinum and cervical subcutaneous emphysema. Most such lesions require operative repair. Occasionally, these findings may be associated with nonsurgical conditions.

During the past three years 38 patients were seen with mediastinal and cervical emphysema. In 15 there had been a n antecedent history of violent coughing. Four patients had penetration of major air or food passages. Ten patients had recently smoked several marijuana cigarettes and two were chronic users of intravenous heroin. All patients admitted to prolonged Valsalva maneuvers, either to steady the arms or to prolong t h e a l v e o l a r e x p o s u r e to m a r i j u a n a .

Esophagography, bronchoscopy and esophagoscopy were negative in all 12 patients with a history of drug misuse.

Conservative management of these patients consisted of antibiotics and close observation. All recovered without sequelae, with resolution of t h e pneumomediastinum within four to five days. Pathophysiologically, pertussive and traumatic pneumomediastinum would appear similar.

Cleansing the Traumatic Wound by High Pressure Syringe Irrigation Richard F. Edlich, M.D., Ph.D. Thomas Stevenson, M.D. Milton T. Edgerton, M.D. Department of Plastic Surgery, University of Virginia School of Medicine, Charlottesville, Virginia Emergency room physicians commonly employ irrigation to cleanse the contaminated wound. The success of this technique appears to be related to the pressure a t which the saline is delivered to the wound site. Utilizing the rabbit a s the experimental animal, standardized wounds were contaminated with a n infective dose of Staphylococcus nureus.

The wounds were irrigated with 150 ml of 0.9% saline delivered either from a 50 ml glass syringe or a 35 ml disposable plastic syringe with a 19 gauge needle. The glass sy-

ringe delivered fluid to the wound a t a pressure less than 1 p.s.i.. while t h e plastic syringe and needle irrigated t h e wound a t a pressure of 8 p.s.i.

Gentle irrigation of the wound did not significantly reduce the bacterial count or protect the wound against infection. High pressure irrigation with the 35 ml plastic syringe and 19 gauge needle resulted in a 10-fold decrease in wound contarnination and significantly lowered the incidence of infection.

On the basis of our study, we routinely use high pressure irrigation in the care of traumatic wounds seen in our emergency room.

Auditing the Quality of Care in Emergency Departments Linda Cole, M.A. C. Gene Cayten, M.D., M.P.H. Rudolf Staroscik, M.D. Center for the Study of Emergency Health S e r v i c e s , U n i v e r s i t y of P e n n s y l v a n i a , Philadelphia, Pennsylvania.

.

.

The ouroose is to develoo and test a . of this oroiect " methodology for evaluating the quality of emergency department care. The authors reviewed the literature on quality of care evaluation, summarizing the advantages and disadvantages of various techniques of structure, process and outcome evaluation. The pilot project described below was then initiated, focusing on process evaluation.

Frorn the twelve most common chiefcomplaints a t a large city hospital E.D., sixcomplaints were selected asrepresentative, and a panel of experts developed explicit criteria which were checked against current medical literature for clinical soundness. For each of the six categories, universal, administrative and diagnostic - specific criteria were developed. Following a pretest audit of records, criteria and standards were modified. Using these explicit criteria. non-physician personnel audited records retrospectively for a three-week period during May, 1974 until a sample size of 100 or 50 (depending upon the frequency of the condition) was reached. Those that failed the initial screening were submitted to the physician panel for review by implicit criteria.

The failure rate varied by diagnostic area and ranged from 35% to 90';;. Results of the audit are now being presented to the E.D. staff so that they may modify their patient care andlor record keeping activities in accordance with the standards for good care; the audit is thus tied to a continuing education program. A follow-up audit is planned to test the educational impact of the project on the staff. Subsequently, we plan to revise and standardize our methodology by testing it a t a variety of E.D.s.

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