SAEM (UAEMS)1976 Annual Meeting Program

University Association for Emergency Medica.1Services

Sixth Annual Meeting

Program May 11-15, 1976 Philadelphia, Pennsylvania

MEMBERSHIP DIRECTORY including Constitution and By Laws

Welcome to our Sixth Annual Meeting Philadelphia is a n appropriate site for this, our sixth Annual Meeting. UAIEMS is in much the same position a s our nation was 200 years ago. The membership is ready to move out of the formative stages and into full recognition as a viable and agressive organization. The agenda is a full one, with many scientific papers, several provocative panels a n d a Business M e e t i n g t h a t will consider a n u m b e r of i m p o r t a n t new program proposals.

UAIEMS members have a n opportunity to influence and participate in shaping the future of the Association. If you are not yet a member, we encourage you to join us in organizing to meet the growing educational and research needs of the emergency medical services system.

K e n n e t h L. Mattox, M.D. Chairman

Contents Welcome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IFC General Information . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Executive Council and Committee Meeting Schedule . . . . . . . . . . . . . . . .4 General Session Agenda . . . . . . . . . . . . . . . . . . . . . . .4 STEM Residency Forum . . . . . . . . . . . . . . . . . . . . . . .7 Honorary Member List . . . . . . . . . . . . . . . . . . . . . . . .8 Scientific Paper Abstracts . . . . . . . . . . . . . . . . . . . .ll Constitution and Bylaws . . . . . . . . . . . . . . . . . . . . . .56 Membership Directory . . . . . . . . . . . . . . . . . . . . . . . .65 Leadership . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Please bring this program with you to the meeting.

I

General lnformation Registration The U N E M S Registration Desk will be located in the Assembly Room of the Hilton of Philadelphia.

Registration will begin Wednesday, May 12 a t 12:OO noon. The Registration Desk will be open all day Thursday, May 13 and until noon Friday, May 14. Everyone attending the Annual Meeting is required to register. Pre-registrants have been mailed a copy of this printed program and should bring it to the Meeting. Walk-in registrations will be processed a t the Registration Desk. The registration fee covers all planned activities during the Annual Meeting, including lunches, with the exception of the Dinner-Concert a t the Academy of Music and certain other functions a s indicated in the program.

lnformation Desk The Information Desk will be located in the Assembly Room along with the Registration Desk.

Name Badges Name badges are required for admission to all activities during the Annual Meeting. Name badges will be issued upon checking in a t the Registration Desk.

Social Activities C.W. Hanson, M.D., chairman of t h e Local Arrangements Committee has organized a special evening of entertainment to be held a t the historic Academy of Music. A reception and dinner will precede a n exceptional "pops" concert by t h e worldreknowned Philadelphia Orchestra. Under the baton of William Smith, the orchestra will present two symphonic pieces by George Gershwin, including the exciting "Rhapsody in Blue." The remainder of the program will feature medleys from Duke Ellington and Burt Bachrach, along with tunes from "Kiss Me Kate," and "West Side Story." To give a proper bicentennial flourish to the concert, the orchestra will perform a Sousa Overture.

Tickets for the concert must be ordered separ a t e l y a n d will include t r a n s p o r t a t i o n to t h e Academy. Meeting registrants may purchase tickets for $9.00; guests may attend the reception1 dinner and the concert for $25.00 per person.

Placement Information A bulletir, board to list positions and physicians available will be located in the Assembly Room near the Registration Desk.

Message Center Phone messages will be posted on a bulletin board in the Assembly Room. Registrants may also post messages in this area.

Proceedings Proceedings of the Annual Meeting will not be prepared as a separate publication. Selected presentations a n d scientific p a p e r s will be p r i n t e d i n JACEP, the Journal of the American College of Emergency Physicians and the University Association for Emergency Medical Services.

Annual Business Meeting Friday, May 14, immediately following the luncheon, the Annual Business Meeting will be conducted. Agenda items include: reports from committees, and election of officers.

About Philadelphia: Bicentennial City W.C. Fields to the contrary . . . Philadelphia is the place to be during this Bicentennial Celebration year. And UAIEMS is fortunate to be holding its annual meeting as the 200th birthday celebration is nearing its peak.

The 1976 Bicentennial Celebration will be centered in three areas of Philadelphia. Independence National Historical Park - site of Independence Hall and the Liberty Bell. The complete restoration of the Park will include such new buildings as Benjamin Franklin's house and printing plant; a new Orientation Center, and the Graff House, where Thomas Jefferson wrote the Declaration of Independence.

Along the Delaware River waterfront - Penn's Landing - an unusual development, featuring a marina, hotel, restaurants, docks with vessels from the 17th Century to the present open to the public; floating museums; landscaped recreation areas, harbor tours, nite spots and entertainment.

Benjamin Franklin Parkway and Fairmount Park - where an alliance of the city's cultural institut i o n s , including t h e P h i l a d e l p h i a O r c h e s t r a ,

Pennsylvania Ballet, Lyric Opera, Arthur Hall Afro Dance Ensemble and others plan a year-long series of premiere events, e n t e r t a i n m e n t , exhibitions, exhibits - turning this spacious and magnificent boulevard into a daily midway of excitement, fun and entertainment.

Philadelphia will be the hub of the 1976 Bicentennial Celebration, but surrounding communities and areas, such a s Valley Forge, Washington's Crossing, Old Fort Mifflin, and virtually every part of Pennsylvania also have major plans and celebrations tying in the Philadelphia program.

1977 UAIEMS Annual Meeting Crown Center Hotel in Kansas City, Missouri will be t h e locus for the 1977 UAIEMS Annual Meeting. This unique facility with its soaring lobby a r e a t h a t features a waterfall cascading over a three-story high natural limestone bluff, is particularly well-suited to our meeting needs. The hotel has a n excellent facility for the presentation of scientific materials. Dates for the Meeting are May 16-18, 1977.

Program Chairman Kenneth L. Mattox, MD has announced t h a t he will accept abstracts for scientific papers to be presented a t t h e 1977 Annual Meeting. Members are urged to submit original contributions relating to t h e field of emergency medicine.

Abstracts should be limited to 250 words and typed double spaced on 8 ! Y h 11" paper. Abstracts must be a u t h o r e d . co-authored o r sponsored by a IJAIEMS member and t h e names and address of each author should appear on the abstract. Deadline for submission is October 30, 1976. Mail three copies of the abstract to: Kenneth L. Mattox, MD, LTAJEMS. 3900 Capital City Boulevard, Lansing, Michigan 48906.

Presentations a t t h e Annual Meeting will be limited to t e n m i n u t e s followed by a five m i n u t e panel discussion period. A completed manuscript must be submitted no later t h a n the day of t h e meeting and will be considered for publication in J A C E P , J o u r n a l of t h e A m e r i c a n College of Emergency Physicians and the University Association for Emergency Medical Services.

Executive Council and Committee Meetings Tuesday, May 11, 1976 8:15 a.m.

Liaison Residency Endorsement Committee Meeting

Room 401

1 9 0 p.m.

Executive Council Meetlng (Scheduled to adjourn a t 5:30)

Salon A

Wednesday, May 12,1976 8:30 a.m.

Salon A

Executive C'ouncil Meeting

1200 noon Registration Desk opens lc1o~t:s - 5:00 p.m.)

Assembly Room Entrance

12:OO noon 1,uncheon 1:00 p.m.

Cornm~tteeMeetings E.D. Organization and Planning Traditional Specialists Nominating Committee Medical Education Committee Research Committee

Room 402 Room 404 Room 405 Room 403 Room 406

4 0 0 p.m.

Executive C o u n c ~ lReconvenes (Scheduled to adjourn a t 5:30)

7:00 p.m.

Reception & Cash Bar

Salon A

Assembly Room

General Session Thursday, May 13, 1976 7:30 a.m.

Registration (closes -- 5:00 p.m.

Assembly Room Entrance

8:15 a.m.

Welcoming Remarks Leslie E . Rudolf, MD

8:30 a.m.

Robert H. Kennedy Lectureship in Emergency Medicine Care J o h n G. Wiegenstein, MD

9:00 a.m.

SCIENTIFIC PAPER SESSION I Leslie E . Rudolf, MD. Moderator Joseph Waeckerle, MD, Recorder

Salon A & B

1 Public Relations in the Emergency Department (see page 12) 2 A Survey of Hospital Medical Infor-

mation Systems a n d the Implications for EMS Research and Planning (see page 14) 3 Cardiac Telemetry Exercise Program (see page 14) 4 Teaching Initial Management of Shock in Children (see page 46)

5 A Unique Academic Approach to Critical Care Emergency Medicine Training (see page 46) 6 Effectiveness of Nurse Triage in a n Urban County Hospital Emergency Department (see page 22) 10:30 a.m.

Coffee Break

11:00 a.m.

SCI L E:Nrl'IFIC PAPERS Salon A & B SESSION I1 David K. Wagner, MD, Moderator Herbert Proctor, MD, Recorder 7 R a p e Evidence Kit: Simplified P r o cedures for t h e Emergency Department (see page 32) 8 Interactional Approach to the Difficult Emergency Department Patient (see page 12) 9 Jimson Seed Poisoning - A New Hallucinogen o n the Horizon (see page 22) 10 Self-Instructional Emergency Mediicine Course for Emergency Students (see page 38) 11 An E v a l u a t i o n of P r o v i d e r Performance in t h e Recognition a n d Treatment of Telemetered Electrocardiogram Patterns (see page 20)

1230 p.m.

Luncheon Assembly Room David K. Wagner, MD, presiding Presidential Address Leslie E . Rudolf. M D Recognition of Honorary Members Eugene Nagel, MD Anita Dorr, R N

1:45 p.m.

PANEL Assembly Room Emergency Medicine in Colonial America: a Bicentennial Review Carl Jelenko, 111, MD John Carter Matthews, MD

3:00 p.m.

SCIENTIFIC PAPERS Salon A & B SESSION 111 George Johnson, MD. Moderator W. Kendall McNabney, MD, Recorder

12 Visual Examination for Blunt Ahdominal Trauma (see page 18)

13 Necrotizing Fasciitis: A Persistent Surgical Problem (see page 34) 14 Diagnosis a n d Treatment of Pelvic Inflammatory Disease a n d Gonorrhea in the Emergency Department (see page 44) 15 Laryngotracheal Trauma: Recognition a n d Management (see page 30) 16 Gunshot Wounds of the Mediastinum (see page 24)

5

17 I f o w t o M a n a g e t h e P r e c a d a v e r i c Kidn e y D o n o r i n t h e E D (see p a g e 24) 18 Algorithm-Directed T r i a g e i n a n E m e r g e n c y R o o m (sze p a g e 30) 5 0 0 p.m.

Adjournment

6:10 p.m.

Buses leave for the American Academy of Music

6:30 p.m.

Reception - Dinner Philadelphia Academy of Music Presentation of awards for scientific papers will be made a t this time

8:30 p.m.

Philadelphia Symphony "Pops" Concert (Tickets may be obtained a t Registration Desk, quantities are limited)

Friday, May 14, 1976 8:30 a.m.

SCIENTIFIC PAPERS Salon A & B SESSION 1V James Mackenzie. MD, Moderator Joseph Vander Veer, MD, Recorder 19 C a n t h e Well T r a i n e d E M T - P a r a m e d i c Maintain Skills a n d Knowledge? (see p a g e 28) 20 I m p a c t of Medical T r a i n i n g o n A m h u l a n c e D i s p a t c h i n g ( s e e p a g e 40) 21 F a c t o r s i n S u c c e s s f u l P a r a m e d i c Re-

suscitation (see p a g e 50) 22 C o m p r e h e n s i v e State-wide E m e r g e n c y Medical T r a i n i n g (see p a g e 18) 23 University

E m e r g e n c y R o o m Reorganization t o I m p r o v e P a t i e n t C a r e a n d T e a c h i n g (see p a g e 54)

24 P a r a m e t e r s of t h e E m e r g e n c y R o o m

Population: T h o s e Who L e a v e P r e m a t u r e l y (see p a g e 52) 9:45 a.m.

Coffee Break

10:OO a.m.

Emergency Medicine in Assembly R o o m the Medical School Panel composed of medical school deans Leslie E. Rudolf, MD, Moderator Joseph R. DiPalma, MD, Dean Hahnemann Medical College Roger W. Sevy, MD, PhD, Dean Temple University Edward J. Stemmler, J r . , MD, Dean University of Pennsylvania Alton I. Sutnick, MD, Dean Medical College of Pennsylvania Assembly R o o m

12:OO n o o n Luncheon and

Annual Business Meeting 12:00 n o o n Emergency Medicine

Residents Association Business Luncheon Meeting

6

Take One

2 0 0 p.m.

SClENTIFlC PAPERS Salon A & B SESSION V Alan Dimick, MD, Moderator Robert Dailey, MD, Recorder 25 The Crush Injury: A High Risk Wound (see page 36) 26 Complications of Calcium Infusion: Clinical Experience a n d Animal Studies (see page 44) 27 Abscess Formation a s a Complication of Parenteral Methylphenidate Abuse (see page 34) 28 Practical Application of a Portable Doppler in EMS C a r e (see page 42) 29 Disaster Preparedness - Combined Community-University Triage Approach (see page 48)

4 0 0 p.m.

5:30 p.m.

30 Use of Viscous Xylocaine in Differential Diagnosis of Substernal Pain (see page 16) 31 Emergency Room Staffing - A Revolution in Shifts and Numbers (see page 26) PANEL Assembly Room What's New In Academic Emergency Medicine Ronald L. Krome, MD, Moderator E D Organization and Planning H. Thomas Blum, MD Paramedical Education William J. Carey, MD Resources Allen P. Klippel, MD Economics and Academia George Schwartz, MD Graduate and Postgraduate Education David K. Wagner, MD Research Opportunities Peter Rosen, MD

Society of Teachers of Emergency Medicine Business Meeting (Scheduled to adjourn a t 7:00)

Take One

Society of Teachers of Emergency Medicine Emergency Medicine Residency Forum Saturday, May 15, 1976 Wharton Rooms - North and South 8:15 a.m.

Welcome and Introductions

7

8:30 a.m.

"Where and When to S t a r t a Residency Program" Robert H. Dailey, MD, Moderator H. Thornas Blum, MD Peter Rosen, MD C. C. Roussi, MD David K. Wagner, MD

1050 a.m. Coffee Break ll:00 a.m. "Emergency Medicine Residency Training Through the Retrospectoscope: Graduate Hindsight" Michael Tomlanovich, MD, Moderator Timothy Allen, MU Bruce D. Janiak, MD 1:00 p.m.

Lunch

2:00 p.m.

"Emergency Residency Teaching Conference Formats: Good and Bad" Harvey Meislin, MD, Moderator Michael Callaham, MU Albert Lauro, MD W. Kendall McNabney, MD James R. Roberts, MD

4:00 p.m.

Adjournment

HONORARY MEMBERSHIPS The University Association for Emergency Medical Services awards honorary lifetime memberships to persons who have made exemplary and significant contributions to the field of emergency medical services. This year, the honorees are the late Anita M. Dorr, RN, founder of the Emergency Department Nurses Association, anti Eugene I,. Nagel. MD, O F the nation's first EMS rescue service.

ANITA M. DORR, RN Mrs. Dorr, who died in 1972. organized a group of Erie County (N.Y.) emergency nurses in 1969 to provide much-needed in-service education and a method of communicating about common problems.

From this modest beginning the concept of a national organization grew. In October of 1971 the fledgling organization, now named the Emergency Department Nurses Association, held its first annual meeting in New York City. EDNA membership is now well over 10,000 and it has taken its place as one of the leading nursing organizations in the nation. In all EDNA'S

educational ahd member service programs the early organizational efforts of Anita M. Dorr, RN, have had a vital impact.

EUGENE L. NAGEL, MD, FACA The Miami Emergency Rescue Service, first of the nation's EMS systems, owes its preeminent position to the efforts of Eugene L. Nagel, MD. A native of Quincy, Illinois, Dr. Nagel earned a n electrical engineering degree from Cornell before entering medical school a t Washington University.

His involvement with the field of anesthesiology and his teaching responsibilities a t the University of Miami prepared the stage for his appointment as advisor to the Miami Fire Department Rescue Service. In 1965 he inaugurated a training program in cardiac massage for fire rescue squad members.

His efforts in this capacity and later a s Medical Director for the rescue service, have made him a nationally recognized figure in the field of emergency medical services. Dr. Nagel has served as CPR consultant for the American Heart Association, on two EMS related sub-committees of the National Research Council/National Academy of Sciences, and a s vice-chairman of the EMS Committee of the American Medical Association.

He currently is chairman of the Anesthesiology department a t Harhor General Hospital in California where, fittingly, he is associated with the nation's largest EMS System.

HONORARY UAIEMS MEMBERS 1973

Robert H. Kennedy, MD Fraser N. Gurd, MD C. Barber Mueller, MD

1974

John G. Wiegenstein, MD Alexander Walt, MD

1975

Oscar P. Hampton, MD N. H. McNally, MD Curtis P . Artz, MD

1976

Anita M. Dorr, RN Eugene L. Nagel, MD

KENNEDY LECTURER J o h n G. Wiegenstein, MD of Lansing, Michigan h a s been selected by t h e University Association for Emergency Medical Services to present t h e Robert H. Kennedy L e c t u r e s h ~ pin Emergency Medicine.

D r . W i e g e n s t e i n , o n e o f t h e f o u n d e r s of t h e American College of Emergency Physicians is well known for his pioneering efforts to establish standards of practice in t h e field of emergency medicine.

Dr. Wiegenstein is director of t h e emergency department a t Ingham Medical Hospital in Lansing, Michigan. H e also heads t h e emergency medicine residency program a t t h e hospital, one of 33 in t h e United States. A native of Fredericktown, Missouri, Dr. Wiegenstein received his medical degree from t h e University of Michigan School of Medicine, before serving his internship a t Tripler Army Hospital in Honolulu.

From its inception in 1968 until t h e fall of 1971, Dr. Wiegenstein served a s C h a i r m a n of t h e ACEP Board of Directors. H e h a s continued to serve a s a member of t h e Board until t h i s year when h e stepped down in order to devote more time to his residency program a t I n g h a m Medical Hospital.

Founder of t h e Tri-County Emergency Medical Services Council in t h e Lansing, Michigan a r e a , Dr. Wiegenstein h a s long been active in organizing E M S programs a t t h e s t a t e and national level. He h a s represented ACEP on various committees of t h e American Medical Association and h a s been chairman of t h e Task Force on Emergency Facilities of t h e Michigan Emergency Services Health Council.

1976 University Association for Emergency Medical Services Annual Meeting Scientific Paper Abstracts

(See agenda of General Session for time of presentation)

Public Relations in the Emergency Department Cyril T. M. Cameron, MD, FRCS, FACS Director. Emergency D r p a r t m r r ~ t S a r n a r ~ t a nHospital Troy, New York The greatest single weakness In the provision of'ernergency medical care ohserved by the writer in emergency departments in several states was in the field of public relations. In teaching hospitals, emergency care is often provided solely by the least experienced physicians. 'The personal attributes of a physician (appearance. manner and manners) are, to his patients, often equally a s important a s the care he provides and in some cases more important. Physicians do not spend enough time listening to their patients' histories and often do not tnkc time to rxplain their findings in simple untlerstandable terms. Suitcihly professional behavior on the part of the nursing and other staff, including ensuring privacy for the patient :is far a s possible. is essential: use of patients' first names is not recommended. Care should be taken to see that the ph.vaician's or nurse's attitude to ;r patient is not prejudiced by chance remarks. No matter how busy, a physician can and must take a brief moment to talk to the relatives of seriously ill patients. Better public relations will result from attention to simple things. two important consequences being better cart. fbr our patients and less potential trouble fbr ourselves.

Interactional Approach to the Difficult Emergency Department Patient Richard Levy, MD, NIPH Senlor Hes~dcnt,Emergrncy Mediclne

Melvin Gale. MD Director, Emergency Psycl~iatryScrvice University of Cincinnati h4edic;ll C e ~ ~ t e r C~ncinnati.Ohio An a r e a of emergency medicine often overlooked is the management of doctor-patient rc7lationshlps. This skill is especially important to emergency physicians because of' their frequent encounters with difficult p a t ~ e n t s We . have developed a method to facilitate difficult doctor-patient interactions in t h e rrnergency department setting. This method includes the prrsentntion of vignettes fbllowed by recommendations fbr preventing or ameliorating undesirahle internc'tions. This paper examines fivr of these vignettes ranging in subject material from patients who are dissatisfied with their diagnoses to alcoholics who are rowdy and disruptive. Commentary is supplied which is specific to the individual cases. and general principles are proposed which have broad-based applicability.

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O u r hlF.'l'l~Ol~u-;c.d i t ! [ . 'Arr-t~ytlrriiiartesusci Anne" (Laerdal Mrd~c:ql ( ' ~ ~ ~ p o r i l tWe ~ o nselected ~. and motlified some ot'its patterns. sent these through one of our nmhulance radios ( t o create a tonel, a n d recorded t h e signal on a s t a n d a r d t a p e recorder. L a t e r we d u h h e d i n t h e monologue.

An introductory message esplains the rxercist, 111 I h e physician who is answering the console. A .;crlc.s of nunibered r h y t h m s follow. 'The doctor is asked Lo give his 111tcrpretation of t h e p a t t e r n and wti:ir liis ~ n s t r u c t i o n st r ~ t h e amhulance att,endnnt w ~ ~ uhe. l ~ Thcl i an:;wers and 1.1,sponse times a r e recorded hy t h e t e c h n i c ~ n nr u n n i n g t h e taped exercise. At t h e end of' the, quiz. th(, rhythm- a r c replayed along wiill a tl~scussionof'cxach pattern.

The IMPLICATIONS of' t h r ?xt%rciseprograrn ;ire that wrs can now hcttcxr prt.pare phys~ci;lnsl o work with cardiac telemetry. Hy testing and comparing various medical personnel (EL) nurses. amhulancc. attendants. c,tc. . . I , we may decide to change o u r guidelines for d e t r r m ~ n i n gwho should diagnose and prescribe 1r1 ;I cardiac emergency.

Use of Viscous Xylocaine in Differential Diagnosis of Substernal Pain George Schwartz, MD West Jerscy H o s p ~ t a l Northern Division C;imden. Kew Jersey Use of' viscous Xylocaine: A simplc trchnlcluc to dif't'erentiate pain of cardlac from t h a t ol' gastric oresophagr~nl origin.

T h e ohservaticin t h a t swallowing vi.icoirs Xyloc;~ine completely relieved t h e pain from esopli:~gitis and gasm i n u t c period of time 1c.d to n clinical tritis withrn a .i trial to determine l f ~t had a n y effect upon pain of cardiac origin, or pain from t h e lung. 40 patients were given a viscous Xylocaine preparation anti t h e results \\sert3inipressi\.e in demonstrating t h e ustrf'ulness and accuracy o f this new rapid d i q n o s t i c test.

Blood levels of' Xvlocaine were determined. Results showed poor syqtemic absorption of Xyloc;\inc a n d hltrotl levels of a maximum of' 1'5 t h e usual therapeutic 1rvc.l maintained i n t r e a t i n g p r e m a t u r e ventricular contrnrtions or v e n t r ~ c u l a rtachycardias. T h u s fioin t h e r f k c t i v e dose employed there would appear to hi. little systcrnic danger.

Viscous Xylocai ne Use in dif't'erential diagnosis of Chest Pain -~

Rttsults of' s t u d y w h i c h h a s h e e n c o m p l e t e d cle;irly shows t h a t viscous Xylocaine can he h i ~ h l yuseful a s a r a p i d diagnostic t e s t i n disf'erentiating chest p a i n of' gastro-intestinal origin horn t h a t of cardiac o r i g ~ n .This

simple, safe test will produce results within 10 m ~ n u t e s and offers substantial benefit in avoidance of potentiallv serious clinical errors.

Comprehensive State-Wide Emergency Medical Training Norman E. McSwain, J r . , MI1 Betti Rieber, RN Larry Hatfield There a r e many difftsrent wa.s emergency rnedic:~l training can be approached, on a local basis, o n a rrgion;tl basis, or a state-wlde basis for control. Rec:i~~seof the unique laws in the state of'Kansas, a state-wide ;tpproach to the training of basic nml)ulance attendants, paramedics and law enforcement officers was devrloped. Tht: coordinator of this program, one head who is a ph3sician located in a University Hospital, has allowed for development of all progratns so t h a t they can interact with each other, so t h a t standards throughout the state a r e compnrable and that the training programs in the hasic curriculum is such that an advance from either ot'thc basic programs (crash injury management or EMTIAI into the advanced program IEMICIcan be accomplished. Since all programs are standardized, hospitals and medical staft' are familiar with the level of training and ability of' any attendant who brings a patient in or who t r n n s k r s ;l patient from another part of the state.

Law enforcement officers a r e familiar with the training and ability of the attendants and vice versa. This ~illows for easier development of ;i team at the emergency site even though the individuals do not know each other.

The programs developed have certified by May I976 approximately one half the necessary EMTlAs for two per run on each run in the state, crash injury management trained law enforcement officers for the highway patrol and several local units and Emergency Mobile Intensive Care Technicians IEMICIfor 7 communities i38')i of population of the state covered).

Using this system, programs of all three types are being presented in the institutions of' high learning in the state.

Most of the state institutions present a t least one type of' program. Agreements with the state junior college system enable an individual to obtain part or all of their training fbr a n Associate of Arts degree in Emergency Medical Services in their local area.

All of this in a rural state with some population drnsities less t h a n 2 people per square mile.

Visual Examination for Blunt Abdominal Trauma Norman E. McSwain. Jr., MD Department of Surgery Univers~tyof Kansas Medical Center Evaluation of' blunt abdominal trauma has always prcsented difficulties for t h e s u r g e o n . Many adjunctive

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A Iu?o ~ q s ~ u - q u ! ou 'pau!elqo s! p!nU jo u~n1a.1ou ,j! quq? U! paq!ur![ qeqMaiuos a.la l n q ?!.law aAuq spoqlam asaqq 1 1 ' ~ a q a q ? ~ ' . ~ s!s.i[e!p 1cduol!.ratl ~o 'alpaou Buol 1: ~ { Y n o ~ qaBenul q 'deq luc.rpr?nb-~noj# u ~ p n ~ n' pu o~d o l a ~ o puaaq aAeq spoqqaw

CRTs in the B;rltimore art3n.The results ot't1ir.s~tclsts are examined and compared tvith the outcon~esof the physicians' tests.

The findings are viewed in terms of their implications for education of EMS providers and hc~althpl:inning.

Effectiveness of Nurse Triage in an Urban, County Hospital Emergency Department J o h n Mills, MD Anna L. Webster, MD Constance B. Wofsy, MD Phyllis Harding, RN Donna D'Acuti. RN Mission E m e r g e n c y Hospital a n d t h e Emergency Medicine Unit, Medical Service. S a n Francisco General Ilospital. and the Department of Medicine and Microhiology, University of Califbrnia, San Francisco.

The efficiency of patient triage by ); registertd nurse was evaluated over a three month period a t a n urban. county hospital emergency department. Adult patients presenting to the emergency deptrrtment thr care were seen first by a specially trained registered nurse. Ambulatory patients thought to have non-emergent illnt~ss were directed to the walk-in service for physiclan evaluation and t r e a t m e n t ; t h e r e n i n ~ n d e rwere seen i n t h e emergency service. In three months. ll,:129 patients came for care, and 4150 137'.; I of those were referred to the walk-in service for evaluation. Only 77 (1.9'); 1 o f the walk-in service patients \yere admitted to t h r hospital after physician evaluation, a s contrasted with 31% of patients seen in the cmergency service. Of'tlie 77 admitted patients, six were thought to require treatment within a few hours, 67 within hours to days, and four were considered elective admissions. There were no deaths. Error in triage was about equally divided between mistaken diagnosis and under-estimated severity of illness. A prevcntable triage error was cc~nsideredto have occurred in only 17 patients. All of these were mistaken severity of illness, and two of them required urgent care. Trained nurses can separate non-acutely ill patients from those that require urgent care with ;I 98'; accuracy, and they contribute significantly to the smooth functioning of ;r large cJrnt.rgency department.

Jimson Seed Poisoning A New Hallucinogen On the Horizon Richard Levy, MD, MPH Department of Emergency Medicine Cincinnati General Hospital Jimson weed, a plant containing bclladona alkaloids. is being used increasingly f'c~rits hallucinogenic effects.

Twenty-seven Jimson seed poisonings, recently treated i n the University of' Cincinnati Medical Center, a r e summarized. The salient features of this series are described.

A management protocol based on physiologic criteria is offered.

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am 'aaq y 3 o ~2uns sJaqurnN p u e s q j q s u~uo!qnIoilaH v - S u ~ j j e q sq u a u r q ~ e d a ab 3 u a S ~ a u r 3 ' p a s s n a s ~ ps! uo~lnq!.~l -s!b~ ur:Y.lo IIUR L I O ! ~ V , \ . I J S J J ~ jo ?son a q ) put? uo!l~s!nhae A J L I ~.1a1\t:1)t:.) !~ 01 Xu!jt?la~snB.~t?qo.i?j lualuds.inqw!a.i jo p o q ? ~ r uv ( j a a q s M O ) ~.paluasa.ld S I ~ o u o pbaup!y [e!lualod J q ) ,I" UOl?El!~SllS~3.7 JOJ [~qj!.l#[t! U v ' h l l f l ! ~ ,?I{) .LO/ ~ ) O O > sl ) ~ r , ~ l ) r.)y) ~ t l .I(!/ poo# S I )Z)YM.pa,1"1aap uaaq suri vlu.?p anuo .lo pnu!w.ialal) uaaq suq v + s a p a ~ o j a q.lavl!a u@aq ut:n uo!?nl!nsnsd.i K a u p ! ~(uo!luut:[dx31 .Kl!l!q!s.ia~a.i.i! j o lu!otl I: s! a.1~v7+11q' s ~ Y t ? l U s I s,,rp ut?,q .alqlssod st? uoos s c nnulti nyt?? ut:n sut?Y.~oj o ~ t ? \ o w aa~q l l t ? q j os qlvap jo lu.jtnoul au!jap 01 ~u~:j.u)(Iur! s! 11 .luarna3pnf [ua!l)aur e s! uo!)!rr!,jap at{) l t ? r { + a.\o!laq s u u ~ n ~ s b qbut?^ d (saldruli'x~l .~[lt:dpI I I C . Io? ~ i{lt:ap ~ ~ ! p . n ?u10.q a uo!~!u!,jap Zu! -Xrlnq~a?l:oo,tpt: sa!ll.~oq)nc.>rnos .saat?ld L u ~ r uu! palnd ,C[loi{ 2u!,?q ~ o s!u rllt?np,jo uo!l!ugap d q ~ (saldurt?x:*l , '(1:g ail4 u! J(!J +.in[" nq ol lua!lt?d j o addl l t ? q . "oj ~ '.'!~a]!.~n ? U . I . I ~ J Ja.\cq ! ~ ) s.talucrn SarIp!y lua.ra,II!([ 'ax a[[? s! l u a u -.?.~n.?o.ldut:Y.ro ,lo a.).Inos JLIO ..ra.\a ut?ql u ~ d [ q o ~~alna.13 d I: .\IOU 61 s~oi101). I , ? A O ~ ~ a[qn+!lis :J ,jo .inqlunu lua~n!jjnsu!

Can the Well Trained EMT-Paramedic Maintain Skills and Knowledge?

William F. McManus, MD Associate Professor of Surgery

Joseph C. Darin, MD Professor of Surgery The Institute of Trauma and Emergency Medicine, The Division of Surgery, The Medical College of Wisconsin and Milwaukee County Medical Complex. 8700 West Wisconsin Avenue, Milwaukee, Wisc-onsin.

The emergency medical technician !EMTi-paramedic m u s t m a i n t a i n his skill and knowledge. Supervising physicians and certifying bodies need reliable criteria to ensure safe, effective treatment.

Twenty-one esperienced fire-rescue men received 1000 hours of training; 550 hours ( 1 3 weeks) in-hospital and 450 hours (9 weeks) supervised field experience, to provide sufficient EMT-paramedics for two mobile emergency department !MED) units.

The measure of competence is the effectiveness of prehospital care. We have selected t h e pulseless, nonbreathing patient a s a tracer to assist in paramedic team evaluation. Resuscitation w a s a t t e m p t e d i n 2 4 1 pulseless. nonbreathing patients. Seventy-five (.'11%.i patients a r rived a t the hospital with a spontaneous pulse and effective cardiac rhythm and 34 ( 1 3 % )were discharged from the hospital alive.

As evidence of team competence in the area of mechanical skills, t h e ability to establish a peripheral intravenous infusion or successfully intubate the trachea in pulseless, nonbreathing p a t i e n t s is presented. Successful endotracheal intubation was accomplished in 214 of 228 (94Si.i and a p e r ~ p h e r a intravenous l infusion was successfully established in 216 of 238 ( 9 0 % ) patients. In t h e last six months, a peripheral intravenous infusion was established in 52 of 53 pulseless, nonbreathing patients !98<Z) and a n endotracheal tuhe was successfully placed in 42 of 42 attempts !lOOi;i J. The effectiveness of care in this tracer is more meaningful and a base for comparison of results is established if results are equated upon total population served per unit of time. The squads have been in service for 818 days in West Allis ( p o p u l a t i o n 71.649) a n d 6 6 7 d a y s i n Wauwatosa (population 58,676) therefore, 818 ~ 7 1 , 6 4 9+ 667 ~ 5 8 , 6 7 ~750 , = equivalent days 130,325 service

The competence of the EMT-paramedic must be measured in terms of patient end results, not by artificially contrived testing methods.

Algorithm-Directed Triage in an Emergency Department MAJ Larry E. Slay, MC, USA MAJ Wayne G. Riskin, MC, USA The Emergency Services Section Department of Medicine Brooke Army Medical Center Fort S a m Houston, Texas Sponsored by MAJ Barry W. Wolcott, MC, USA We present our experience with a triage system in the emergency services section of a 700-bed teaching hosl~ital.

On arrival all patients except those arriving by ambulance a r e seen in a screening section where trained corpsmen record the patients' chief complaints and the answers to physician-written triage algorithm questions specific for the chief complaint. The algorithms direct patients to one of four areas: l ) trauma room; 21 emergency medical area; 31 Acute Minor Illness Clinic IAMIC), staffed by physicians and physician extenders, 01. 4 ) other clinics o u t s i d e t h e e m e r g e n c y services s e c t i o n . An emergency physician may be consulted to advise disposition of p a t i e n t s whose c o m p l a i n t s a n d s p e c i f ~ cc i r cumstances ilre not covered by triage algorithms.

From 1 J a n u a r y 1975 to 31 December 1975, 78,822 p;ltients were triaged, 75,5513 during hours that the AMIC and other outpatient clinics were open. Referral without physician consultation was possible in 72,599 of these cases (96.1%1, a s follows: 13,777 (18.9%I to the the trauma room; 7,658 (10.5%I to t h e emergency medical a r e a ; 43,770 t60.3Q ) to the AMIC, and 7,393 t 10.2'; to the outpatient clinics. Of patients referred to the AMIC, 32,219 (73.6';) were triaged to physician extenders. The AMIC total accounted for X5.1f, of all patients presenting with medical illnesses, with physician extenders providing primary care for 67.25 of nonsurgical patients and 49.4% of all patier~tstreated within the emergency services section. When 1111 other primary care fac~litiesare closed, all patients are referred to the trauma or emergency lnedlcal areas. Triage during these times, initiated 1 August 1975, aids in identifying seriously-ill patients and cstahllshing prioritv of treatment for less-seriously ill patients. We feel t h a t an algorithm-directed triage system administered by paramedical personnel is a n effective method for the initial evaluation of large numbers of'ambulatory patients in an emergency department setting.

Laryngotracheal Trauma: Recognition and Management Glenn E. Lambert, J r . , MD Gorden T. McMurry, MD Department of Surgery Universitv of' Louisville Health Sciences Center Louisville, Kentucky Sponsored hy Lewis M. Flint, MD Prompt recognition and management of 1;lryngotrncheal trauma and associated injuries are essential Sor preven-

30

tion of immediate threat to life and future disahility. The severest injury can be quite subtle in its i n ~ t ~ presentaal tion.

Twenty-three cases of trauma to the larynx and trachea were treated by the trauma service of n city-county hospital during the period 1966 to 1975. Ten were the result of b l u n t t r a u m a a n d t h i r t e e n secondary to p e n e t r a t i n g wounds. There were nineteen survivors and four deaths.

Only one death was directly related to laryngotracheal ill,jury. There was significant delay in diagnosis and ~ n i t i n tion of treatment in four patients. Immediate co~itrolof the airway was obtained by endotracheal intubation in seventeen patients and emergency tracheostomy in six.

Primary repair with tracheostomy was the optimal operat ~ v emanagement. Significant voice impairment occurred in nine patients. Three of these improved significantly during follow-up. One patient required further reconstruction d u r i n g t h e period of ear1.v fhllow-up for tracheoesophageal fistula.

Of prime importance in successful m a n a g e m e n t of upper airway trauma is prompt recognition of injury by careful a t t e n t i o n t o physical f i n d i n g s , a p p r o p r i a t e roentgenologic examination, and endoscopic evaluation.

In addition, adequate resuscitation and immediate control of the airway are mandatory.

Rape Evidence Kit: Simplified Procedures For the Emergency Department Linda Cryer Kenneth L. Mattox, MD The City Health Department and the Ben Taub General Hospital, Houston, Texas The crime of rape requires medical evaluation and therapy concomitant with the collection of legal evidenct for future potential prosecution. Emergency department personnel are intimately associated with both actions and occasionally wish to avoid legal involvement. A practical inexpensive evidence kit has been designed which satisfactorily meets the needs of the local health department. police department, hospital emergency centers and district attorney personnel.

Costs of' assembly and specimen analysis are assumed hy the police department. Chain of' custody is assured through tamper-proof bags, appropriate reporting forms and police involvement in specimen pick-up. Victims participate in chain of custody by sharing in collection and authorization. The requirement for physician appearance in court is thus lessened. Standardization of examination and reporting prompts all community hospitals to share in examinations, preventing overloading of a single, busy facility. Six months' experience has born out the anticipated siniplification of collection, standardization of reporting, and reducing physician involvement in legal procedures.

Necrotizing Fasciitis: A Persistent Surgical Problem

W. W. Defore, MD Michael Dang, MD Kenneth L. Mattox, MD George L. Jordan, J r . , MD Cora and Webb Mnding Department of' S ~ ~ r g e r yBay. lor College of Medicine and the Ben 'rauh General 130spital. Houston, Texas Necrotizing fasciitis is a rare but specific clinical entity whlch, IT not diagnosed and treated early, rnp~dlyleads to the demise of the patient. The disease was firqt descrihetl

by Meleney in 1920 and is manifested by a severe infectious process, the sine q u a nor1 of which is widespread fascia1 necrosis and extensive undermining of adjacent tissue. The initial mechanism of Injury may vary as well as location. The predominant organism is beta hemolytic Streptococcus in most cases, but any form of virulent bacteria may cause the superactive fasciitis.

Over the past ten years, from 1965-1975, we have r r viewed 19 cases of necrotizing fasciitis. We have ilttempted to correlate mechanisms of injury, etiologic organism. clinical manifestations, and treatment of these cases to observed mortality. Most often, mortality was related to associated diwase and failure to promptly recognize the disease process. We conclude t h a t mortality in this group of acutely ill patients may he lo~veredby early recognition and prompt surgical intervention coupled with intensive therapy.

Abscess Formation as a Complication of Parenteral Methylphenidate Abuse Robert M. Elenbaas, Pharm. D. Clinical Pharmacist, Dept. of Emergency Health Services, Kansas City General Hospital & Medical Center: Assistant Professor of Clinical Pharmacv. Schools of Medicine & Pharmacy, University of Missouri-Kansas City

Joseph F. Waeckerle, MD Dept, of Emergency Health Services, Kansas City General Hospital & Medical Center: Assistant Professor, School of Medicine, University of Missouri-Kansas City

W. Kendall McNabney, MD Chairman, Dept, of Emergency Health Services, Kansas City General Hospital & Medical Center; Associate Professor of Surgery, School of Medicine, University of Missouri-Kansas City Methylphenidate (Ritalin" is a central nervous system stimulant very similar in pharmacologic;al effect to thc amphetamines. It is a common drug of ahuse ;and when

injected intravenously subjects the user to a wide variety of' medical and surgical complications. These may include: a variety of infectious processes (endocarditis, cystic pulmonary emboli, tetanus, pneumonia, septic arthritis and myositis, etc.): hepatitis, peripheral arteritis; mycotic a n e u r y s m ; necrotizing fasciitis o r a n g i t i s ; t a l c a n d cornstarch emboli; cerebro-vascular hemorrhage and vasospasm with subsequent gangrene of hands or feet following inadvertent intra-arterial injection.

We recently observed four patients within a one-month period suffering from either skin abscesses or cellulitis following parenteral methylphenidate abuse. All four had prepared their solution for injection by dissolving oral tablets in tap water. Three patients had similar lesions consisting of abscesses or cellulitis which demonstrated typical signs and symptoms of an infective process. These patients were treated with local symptomatic therapy, incision and drainage if' indicated, and systemic antibiotics.

However, the fourth patient suffered from a circular necrotic, nonpurulent ulcer on the dorsum of the right foot which produced no local or systemic toxic efl'ects. Attempts to culture a responsible organism yielded Streptococcus uirlciius, a n organism which is normal flora of the skin and although opportunistic, is generally considered nonpathogenic. The purpose of reporting these cases is to further substantiate the belief t h a t local vasospasm or chemical irritation or both produced by the ~nethylphenidate solution may primarily cause a necrotic ulcer which is susceptible to secondary bacterial inkction. Tbis concept is in contrast to the idea t h a t drug abusers initially inoculate themselves with pathogenic organisms due to injection technique and/or contaminated paraphernalia.

The Crush Injury: A High Risk Wound Charles Cardany, MD John Thacker, PhD George T. Rodeheaver, PhD Milton T. Edgerton, MD Richard F. Edlich, MD The Department of Plastic Surgery, [Jnivers~tyof' Virginia School of Medicine, Charlottexv~lle.Virginia Clinical experience has demonstrated t h a t wounds in patients resulting from high velocity collision or crush injury display a high incidence of infection. The wounds are frequently characterized by multiple stellate lacerations a t the site of impact. Despite antimicrobial prophylaxis and meticulous wound care, healing is often delayed due to the development of infection.

The damaging effects of' irnpact injury have been quantitated using a standardized experimental model. A drop weight impact instrument has been constructed so a s to deliver a measurable amount of fbrce over a finite area. A 339 g m drop weight with a 1 cm diameter surfjce impact area was allowed to fall by gravity from various meas'ured heights onto the surgically prepared dorsal skin of anes-

thet~zed gulnea p ~ g s The Impact was expressed a s thc energy absorbed per unit area Stellate lacerations were encountered only in wounds receiving 2.54 joules/cm2. T h i s w a s associated with marked vascular ischemia a t the site of ~ m p a c tinjury, a s measured by the distribution of intra\~enouslyadministered fluorescein dye. The magnitude of tissue ischemia was proportional to the energy ahsorbed per unit area.

This vascular compromise was associated w ~ t h~ m p a i r ment in the tissue's ability to resist infection. The growth of bacteria was considerably greater in wounds subjected to impact than in the cor~trolwounds without ~rnpact.This damaging effect of impact of tissue defenses is similar to t h e effect of' local injections of v:rsoconstrictors like epinephrine. Once \:osoconstriction is i n ~ t i a t e d ,the inflammatory cells cannot gain access to the tissue and defend against infection. As a result, t h e crush wound must be considered a s a high risk wound t h a t is very susceptible to infection.

Self-Instructional Emergency Medicine Course For Medical Students F r a n k Block, BA William Watson, BA, MEd Frederick Berry, MD Richard F. Edlich, MD, P h D Emergency Medical Services, Charlottesville, Virginia A self-instructional course in emergency medicine has been integrated into t h e academic curriculum of all freshman medical students in our school. The structure of t h e course follows t h e textbook "Emergency Care o n d Transportation of'the Sick a n d Injure&' published by the American Academy of Orthopedic Surgeons. The text 1s supplemented b y specifically-developed video-tapes which facilitate t h e student's learning of t h e practical training techniques. While viewing these audiovisual aids. the student performs the outlined techniques on manikins using the appropriate equipment. During the tralning exercise, the student can interrupt the playing of the tape a t any point, allowing him to learn a t his own pace. Once the student feels t h a t he has mastered these skills, faculty a r e available to critique his performance. These audiovisual aids have enhanced student learning while saving a considerable amount of faculty time. The course also includes seven didactic lectures which focus on highlights of the curriculum. Successful completion of the course is judged by their passing the State Emergency Medical Technician written and practical examination. All graduates of the program are certified emergency medical technicians and are eligible to become members of a rescue squad. This additional manpower is particularly important in rural communities in which there is already considerable shortage of trained emergency medical technicians.

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Practical Applications of a Portable Doppler in EMS Care Kevin M. O'Keeffe, MD Staff Physician

Lawrence Bookman, MD Emergency Medicine Resident Emergency Medical Services Denver General Hospital Denver, Colorado O u r clty-county hospital emergency depnrtlnent a n d ambulance service has been able to investigate t h e practical application of a new i n s t r u m e n t to t h e care of t h e emergency patient. This new tool is a stethoscope-sl~ed portable Doppler ultrasound device soon to be commercially available.

Initially a study was performed on healthy volunteers and random patients to familiarize t h e authors with use of t h e instrument and to ascertain t h e accuracy and reproducibility of Doppler blood pressures versus routine auscultatory a n d palpatory readings. As a further corrclation, a n u m b e r of patients who h a d intraarterial lines were examined to check t h e Doppler readings agalnsl l r u e arterial pressure. It was Ibund t h a t this device was sufliciently accurate to aid in clinical e v a l u a t ~ o na n d was of higher accuracy t h a n traditional measures In low flow states.

We t h e n applied the use of t h e Doppler to a variety of' clinical s i t u a t i o n s c o m m o n l y e n c o u n t e r e d i n a busy emergency department. Most dramatically this included t h e assessment of adequacy of CPR a n d verification of electro-mechanical dissociation. However, other systemic low flow states were assisted in approach by t h e Doppler such a s supraventricular t a c h y c a r d ~ a s with hypotension and multiple t r a u m a .

We were also able to contirm def'inite value to t h e Doppler in t h e assessment of local arterial injury. However. we mere not able to establish a n y value to this particular instrument a s being sensitive enough fbr t h e evaluation of venous disease unlike w h a t has been reported for more sophisticated Doppler a p p n r a t i . Finally, we found t h e Doppler to be of g r e a t use in obtaining vital signs in all patients in the high noise environment of o u r ambulances when compared to normal auscultation.

We have concluded t h a t t h i s device w ~ l lprove to he a worthwhile a n d cost-effective tool as a n adjunct to t h c emergency system evaluation a n d disposition of' a significant proportion of' patients encountereti.

Complications of Calcium Infusion: Clinical Experience and Animal Studies James R. Roberts, MD, C h ~ e fRe51dent

Rebecca Anwar, PhD Section of Emergency Med~clne The Medical College of P e n n s y l v a n ~ , ~ Philadelphia, Pennr\ I \ anla Four cases of infants treated with calcium gluconate infusion for hypocalcemin, resulting in various complications, a r e presented. The gross and histologic appearance. and the natural course of t h e soft tissue lesions in an rxperimental dog are also discussed. Complication.; of' inadvertant soft tissue are extravasation of'calc~umgluconate and calcium chloride are erythema, subcutaneous calcification, tissue necrosis, and skin slough. A heretothre unreported transient radial nclrve damage with wrist drop is also presented. The soft tissue lesions may be mistaken for celiulitis, abscess, calcified hematoma, or osteomyelitis resulting in unnecessary antibiotic therapy or surgical intervention. Local skin necrosis can occur with a s little a s one half cc of 10f/i calcium chloride. Larger amounts of c a l c i u n ~g l u c o n a t e a r e r e q u i r e d to produce s i m i l a r changes. The l e s ~ o n sappear in two to three days in the case of calcium chloride and in sixteen to twenty days with calcium gluconnte. Radiographs are initially negative but soft tissue calcification appears in one to three weeks. Skin sloughs heal in four to six weeks without skin graftiilg and follow-up x-rays show complete resorption of' the calciun~over several months. Extreme care in the parenteral use of calcium gluconate, the strict avoidance of calcium chloride, and conservative treatment of' the complications a r e advocated.

Diagnosis and Treatment of Pelvic Inflammatory Disease and Gonorrhea in the Emergency Department Allan J. Sault, MD George Podgorny, MD Dept. of Emergency Medicine Forsvth Memorial Hospital \Vinaton-Salem, North Carolina Pelvic inflammatory disease in women is too often labeled gonorrhea and treated a s such. A study of 100 womeri diagnosed a s having pelvic inflammatory disease revealed se\.eral interesting findings and conclusions.

The study did not support the rived fhr procuring VDRL tests on patients suspected of having gonorrhea. Likewise the practice of doing cervical cultures in the emergency department on all patients h a \ . ~ n gsigns and symptoms of' peivic inflammatory disease was not sustained.

While one cannot deny t h e usefulness of procalne peiiicillin in the treatment of proven goilorrhrn. the hor-

derline cases of sexual contact disease.; and nonspecific pelvic inflammatory disease m a y be better treated with a n antibiotic of wider scope. Tetracvcline a n d a m p i c ~ l l i n a r e t h e antibiotics rcscornmended.

Teaching Initial Management of Shock in Children Thomas S. Morse, MD Division of P e d i a t r i c S u r g e r y , D e p a r t m e n t o f Surgery, Ohio S t a t e Ur~iversity College 01' Medicine a n d Children's Hospital. Columbus. Ohio

A simple plan fbr teachlng initial managenlent of shock in children h a s been developed in a n emergency department which annually handles 50,000 pediatric patients.

Common errors a r e failure to recognize shock. failure to recognize continuing blood loss, a n d inadequate replacem e n t due to lack of familiarity with t h e normal blood volu m e of children.

For practical purposes t h e normal blood volume of every child is 40 cc per pound. The blvod volume of children in hypovolemic shock is reduced by a t least one-thurth. An intravenous line is established, blood 1s drawn for cross matching. anti 10 cc of Ringer's lactate per pound is administered a s rapidly a s possihle. If t h i s bolus, which represents one-fourth of'the normal blood volume, brings t h e blood pressure to normal, only rualntenance fluid is then administered. If t h e child remains hypotensive, a second bolus of 1 0 cc per pound is e d m i n ~ s t e r e drapidly. Attempting to establish a central venous pressure line before half of the blood volume has been replaced is a waste of valuable tirue.

Children who require a second bolus of Klnger's lactate nearly always need blood transfusion also. Many of t h e m a r e still bleeding. Occult bleeding is usually in t h e ahdomen. If' a b d o m i n a l i n j u r y is ohvious, t h e a b d o m e n is explored. If intra-abdominal hlettding is possible but not definite, paracentesis using a n intracath is performed. If no blood returns, 10 cc of saline per pound is instilled a n d t h e return considered significant if more t h a n slightly pink.

This simple plan allows relatively inexperienced physicians to initiate t h e care of children i n hypovolemic shock confidently a n d expeditiously.

A Unique Academic Approach To Critical Care-Emergency Medical Training Charles J . Fisher, J r . , MD Section of Emergency Medicine University of California, Davis Sacramento Medical Center Sacramento, California Critical care medicine has been defined a s t h e "trii~dof 1) resuscitation, 21 emergency c a r e t'or life-threatening

cond~tions,a n d 31 intensive care: incIudir~ga11 components of t h e emergency and critical care medicine delivery system, prehospital a n d hospital."

Excellent t r a ~ n i n gprograms i n emergency medicine e x ~ s which t answer t h e needs of 1 a n d 2. These programs produce approximately 100 graduate emergency n~edicine physlcinns per year. With improved r ~ s u s c l t a t ~ oand n Increasing numbers of' emergency departments lnorcx critlcally ill patients a r e e n t e r ~ n gt h e health care system. Few physicians a r c trained. motivatetl or competent to t a k e c a r e of' t h e m . T h e emergency physiciarl 15 frequently se fhr called upon to manage t h e acutelv i l l i n - h o ~ ~ patient lack of a 24-hour d v "intcnsivist" or critical care m e d l c ~ n ephysician.

We propose a n i n t ~ , g r a t e d4 y e a r progr;im c o n ~ h ~ n ~ n g e m e r g e n c y m r d i c i n e a n d c r ~ t i c a lc a r e niedlclne. T h e graduate wouId be both s p e c ~ a l i s tand generalist and a n innovative leader i n a11 aspects of acute care. FIe woulti he a specialist in his in-depth knowledge of'the most current emergencylICU management philosophlcs a n d techniques common to a variety of' multi-system diseases. He uould be a generalist in his multidisciplinary approach having been trained by internists, surgeons, emergency medicine a n d intensive care physicians committed to critical care emergency medicine.

A physician so t r a ~ n e dwould be ideally sulted to group p r a c t i c e i n c o m m u n i t y h o s p i t a l s . s t a f f i n g t)otli t h e emergcncy department a n d t h e intensive care unlt. He would he equally qii,il~f'iedto pursue a n a c a d e n ~ i ccareer in elnergency-critical care m e d ~ c ~ naen d most certainly \\-r-ould be a leader: particularly in working w ~ t htraditiuntrl speclalists and npprlslng t h e m of our growlng a n d dynamic field.

Disaster Preparedness: A Combined Community-University Triage Approach Charles J . Fisher. J r . , MD Section of Emergency M e d i c ~ n e Lrniversity of C a l i f o r n ~ a D , av~s Sacramento Medical Center Sacramento. Califbrnia Experience h a s shown t h a t m a s s casualty accidc.nts a r e no longer a fear of t h e future b u t a r e happening with Increased frequency. Mass t r a n s i t accounts Lbr most mass accidents although n a t u r a l disaster a n d sabotage a r e sign ~ f ~ c a ncontributors. t Frequently t h e rescue eff'orts have been suboptimal in large p a r t d u e to inadcqiiate communlcatlon, lack of a n on-scene cornmandc~.o r poor predisaster planning.

We present a mobile triage team model operating rn o u r community. The goal 1s coord~natctlexpedient disposition of casualties to appropriate fhc~litieswithout overlo:iding a n y one facility.

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A.tnru! u!t?$.la.)lr?qq pau!ru.~alapa.rtls! 71 .uo!qr?ls ~ s w qaBt?!.~q at[? alcpdn 01 uaycl s! Ll!nnruwo~ at{? u! poolci a[qe[!t?A -I? pue ( u . I I ~ put? ( [ n!.lqt?!pad 'l137 '2-1ns/paruI spaq [vl!dsoq ~ ( q ~ l ~ r 11"! ~ .lo t ! snsu,wA'l!r?a .uo!lr?1s aseq a2y.11 ailq st: ~v$!dsc~q .C$!s.ra,\!un p u suo!lt?J!unwwos ~ hlunoo Aq Lllu!or paq~?u!p.~oos ruaqsAs o1pu.r 8 ~ ,3g$3s! u ~~a l s L suo!qr?J!unLu -ulo> a q 'uo~quo!j!)ou ~ jo salnu!Lu z u ! q l ! ~Su!puodsa.~ 1'1 a1qutlr?n wnaq aBr:!.rq a[!qoru ssaJsw alc!paurru! -1noy-pg L! su!elu!t?ru a.l?l.l.taq) puu a2n.r;l.hon ue!~!sLqd , l ) ~ ? ~ s - a s n o q pur? j,jqs/dllnntg .tnotl-pz swq lel!dsoq n'l!s.ra.\!un .In0

effort. T h e i m p a c t of stahili7ation t i m e , recognition of h y p o v o l e n i ~ a stscondayv t o t r a u m a o r h e n ~ o r t . h a g va s a cause of' cardiac a r r e s t . ;lnd use clf' ctrugs wil i bt, discllssed In t h e paper.

Parameters of the Emergency Department Population: Those Who Leave Prematurely Frederick J. I-Iirsch, MD (?hlef, Emergency Mcdic;ll S e r v i c c . ~Scxction Department 01'F;tmily a n d Conin~urlityhledicinv

Douglas Lindsey, MD T r a u m a Sectton. 1)epartrncnt ol' S u r g e r y Emergency Medical S e r v i r e . S(31.tion Departmerrt of' Farnily a n d Csommunit> M ( x c l ~ c t ~ ~ r

Peter W. Vann Senior hIedicul S t ~ u d e n t L:niversity of' Arizona College 01' Medicine Tucson. Arizona 85724 In t h e emergency service o f ' t l ~ cAr~c.on:lhfedtcal Cknter. t h c nurnher oS monthly patient visits a v e r a x e s 1900: of' thc,sr. 1.1''; le:ive hefore heing a d e c l ~ ~ n t e tl rye ; ~ t c d ,most 01' t h ~ n 1)ef'ore i heing seen by t h e e m e r g e n c y physician 0 1I1ou.w gfficer. In t h e mediccil p a ~ ~ l a n cteh.e y Icb~tvc":~g:linstrnedic;ll atlvlce." T h e acronym AMA will hc, i ~ s e t iin t h i s pwpt,r to describe t h i s population. It is not used 111 ;I discriminatory o r e v e n strictly correct sense, sinco n n ~ s of t these patients lrlt without even seeing a doctor 01. obtaining medic:tI :idvice. ?'he p u l p w e of t h i s five-month retrospective study was to ini.cstigate t h e p a r a m e t e r s of'th~::population o f p a t i c n t s to see if d e t e r m ~ n i n gfactors could 11e isolated. Previous work i n t h i s a r e a is scarce to nonexistent inaslhr a s ol),jective appraisal o l ' t h i s population is concc~.ncd T h e a r e n a o f s t u d y is t h e e m e r g e n c y serv1ct~ot'the300-hed Arizona h1edic:il C e n t e r , associated w i t h t h e U n i v e r s i t j ol' Arizona College of Metlicine. Tucson, Arizona. T h r study c:ncompassrs figures for patient visits from Septcmhcr 1974 to J a n u a r y 1975 via emergency d e p a r t m e n t ~,ecordSorms fi)r c,ac!~patient p l u telephone calls to select p ; ~ t i c n t swhc-~.t~ their records were Judgod i n a d e q u a t e .

'Yhe study inclutletl t i m e s p e n t i n t h e emergency (unit. t h e agv ol'the patients. t h e sex o f t h e patittnts, tlle t i m e of'd~iyot'

t h e i r emergency d e p a r t n i r n t visit. t h e tluration of thoir prg~blem,t h e type uf'prohlcm, a n d t h e i r reasons tor Ic,aving hefirre t r e a t m e n t .

T h e study pc~pulationspent less t i m e in tlic IJlliergency department t h a n t h e total emergency d e p a r t m e n t population, wc,re generally under 30 y e a r s of age, appeared a t t h e emergency d r p n r t ~ n e n tin e a r l y afternoon o r evening, had an acute probleln. a n d left p r i ~ n ; ~ r i hi ye c a u s e o l ' u ; ~ i t i n gtilnc, o r cost.

Recomrnrndations a r e presented to adclrrss thcb conciusions reached

52

University Emergency Service Reorganization to Improve Patient Care and Teaching Barry W. Wolcott, MD Leslie M. Burger, MD Larry E. Slay, MD Wayne G. Riskin, MD Alnhulatory C':~rts Kesc~al~chI ' i i ~ v e r s ~ t yDepnrttrlr,nt . of' Lledicine, Hrooke A r n ~ yMedicill ('c:ntrr, Siln Antonio. 'L'exas

Richard K. Tompkins, MD Robert Wood, MI) I7.S. Public tle;+lth Srrvice tIospital. Sc.at.tlr,. \V;rstiinglon The Emergency Clinic, sustaining 85.000 yearly visits in a teaching hospital, was reorganized in 1974. A triage section staffed by aides trained three weeks in the use of physician-written algorithms operates 24 hours a day.

Based on this encounter, 19':; of the patients are directed to an emergency trauma section; l l ' i to the r~iedicul emergency section; 60% to the Acute Minor Illness Clinic IAhIIC); and lor; to other hospital clinics.

Most patients referred to the AMIC (66'4 are managed by physician extenders who have received 12 wecks of training In data hase acquisition and algorithm use. One intern supervises these extenders: another sees those AMIC: patients too medically complex for extender rnirnagement. The trauma and medical emergency sections are also staffed hy house officers. Three full-time faculty rnernbers supervise and audit the performance of all staffmembers ;111d collduct filrmnl training in emergency medicine techniques.

Prior to reorganization ot'the clinic, waiting times ol'fbur to six hours prior to eva1u;rtton were common. Currently 80'4 of all patients referred to the AMIC are treated within 60 minutes ofarrival anci patients referred to the trauma or medical emergency sections hegin physician evaluation within Live minutes.

Quality of care is assessed hy routine audit of physiciancompleted ch;lrts based on predefined explicit critt,ria for chart fbrmat and implicit criteria for medical process, computerized audit of AMIC physician extenders compliance with algorithm logic, random telephone followup of AMIC treated patients, and reexamination by a hoard certified internist of randomly c l ~ c t e dAMIC physician-extender treated patients.

These techniques reveal phys~ciandelivered care to be acceptable and pl1ysici;rn extender care to equal t h a t of board certified internists. Patient acceptance is high a s measured by telephone survey and a decrease in formal complaints. High housestaff acceptance is indicated by increasing requests for emergency medicine electives and exit interview responses.

CONSTITUTION OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICAL SERVICES Amended, M a y 2 3 , 1975 ARTICLE I - NAME The n a m e of this organization slrall 1)c. "The LJniversity Association for En1c:rgency Mt:dic:al Services," lrereiri after rc:fcrred to as, "Tlre Association."

ARTICLE I1 - OBJECTIVES Scc:tiurr 1: The prirnary objective of this Assoc:i,rtion shall be irnprovernent in the quality of car(: of the acutely i l l and injured.

Section 2: The Associatiorr shall pursue this objective by (a) collecting a n d disseminating i l l f o r m a t i o n c o n c e r n i n g t h e o p e r a t i o n of e m e r g e n w rrledic:al servic:es. ( b ) p r o v i d i n g a forurri f o r t h e d i s c u s s i o n of p r o b l c r n s i r ~ emergency rnr:rlic;al care a n d their proposcd solutions, (cl aiding the u~liversitvphysician in the p l a n n i n g , adlrrirlistratiorr a n d p r o v i s i o n of emergelicy medical services, ( d ) fostering cducat i o n arid research i n t h e field of ernergellc:v medicine, ( e ) encouraging the university physician to take an active role, at the lo(:al. state, ant1 [rational l e v e l s , i n region;il p l a n ~ r i n g of emergency rnctlical services, ( f j rec;omn~c:rlding guidelines for: location, size ant1 f~lnctionaltiesign. intra-hospital relatior~ships,staffing, educational programs, a n d pcrformanc:e of hospital emergency st:rvices, ( g ] provitling, o ~ request, i ass i s t a n c e in t h e e v a l u a t i o n a n d p l a n n i n g of emergency medical services, (11) recornrnending appropriate changes in ilational, region;rl, state a n d local policies i n f l u e n c i n g or regulatirrg emergency medic;il scrvic:es, a n d ( i ) encouraging recognition of the ncatiemic value of service in this field.

Section 3: No part of the assets of the Association nor any incolnc or gains ttierefrorlr shall inure to the I~enefitof its members. In tlre c!vt:nt of dissolution of this Association, or i f for any reason the objectives of this Associdtion sholllcl becor~leirnpossible of performance, all assets remaining after all liabilities ant1 obligations of the Association have been paid, satisfied a n d dischargetl, or adequate provisiorl made therefore, sllall be dis-

tributed to one or more organizations, designated by t h e Executive Council of this Association, which is or are organized and operated for purIwses similar to the aims of this organization.

ARTICLE I11 - MEMBERSHIP Section 1: Clussificcltion There shall be three classes of ~ n e m b e r s h i p :active, associate a n d honorary.

Se(:tioli 2: Qucllifications (1) Candidates for active membership i n this Association shall be physicians of university or university-affiliated hospitals who hold rnedical school faculty appointments and w h o are continuing to participate actively in the field of emergency ~neclical care and services. whether i n a n administrative, teaching, o r clinical capacity. ( 2 ) Associate hlembership - Kesidents-ill-training. ant1 senior or inactive members by their own request, may be elected to associate membership. 111 addition. any official, representative or leading member of government agencies, lay or civic groups or other m e d i c a l c a r e a n d s e r v i c e s , w h o w o u l d not otherwise qualify tor active membership. may be elected to associate ~nernbership.(31 IIonorary Membership - outstanding medical or lay contrihutors in the field of emergency medical services.

ARTICLE IV - OFFICERS T h e officrrs of this organization shall be the President, Vice President. Secretary-Treasurer, and a n F:xer.utive Council consisting of the above officers, t h e last t h r e e p r e s i d e n t s a n d three Counc:il men-at-Large.

ARTICLE V

- COMMITTEES

'The standing comlnittees of the Association shall be: hle~nbership Co~nlnittee,Noniinating Committee, Program Co~nniittee,(:ornmittee o n Local Arrangements. (:onstitution a n d Bylaws Committee. Education Conirnittee, and Auditing Committee. Additional committees may be created by the Executive Council a n d ad hoc committees mag be created by the President to aid in the Associatinn efforts to achieve and further its goals.

ARTICLE VI - ANNUAL MEETING There shall be a n annual meaii~lgof this Associa-

57

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tive vote of two-thirtis of the rnernbers present a ~ v~o tdi ~ ~atg that meeting shall be necessary for tho a d o p t i o ~of~ such a n arnrntlment.

BYLAWS OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICAL SERVICES ARTICLE I

- MEMBERSHIP

Sf!c:fion 1: Appficrllion clr~tiElectioi~to Mernbr:rship Application forms may be obtained from the Scc:retary-Treasurer of the Assot:iation. The applicant must return the cornpleted application forms to the Secretary-Treasurer of the Association at least one month prior to the annual rneeting in order to be considered for membership at that t i ~ n e .Any letter supporting the application must also be fileti with the Secretary-Treasurer of the Association at least one month prior to meetings of the Executive <:ouncil to be considered with the application. The qualifications and recornmendations of candidates for active or associate m e m b e r s h i p will be reviewed by the bIembership Comnlittee at each meeting of the Kxecutive Council a n d their approval shall constitute election to m e ~ n b e r s h i p ,which will becorno effective i~nmediately.No lirnits will be set to restrict the size of the active membership.

Nomination for honorary membership may be s ~ ~ t ~ r n i t by t e dany active member of the Assoc:iation i n a letter to the Secretary-Treasurer which must be received at least one month before the mid-year m e e t i n g of t h e E x e c u t i v e C:ouncil.

Nominations mav also be personally presented to the Executive Council at that meeting. The Executive Council may choose a maxirnurn of t\vo honorary members annually \vho shall b e recognized at the subsequent annual meeting.

Sr:ctio~i2: Rights, Privileges, und Obligatio~isof Membership Active members may vote and hold office a n d shall pay clues. Failure to pay dues for t w o consecutive years \will result in automatic loss of m e m b e r s h i p . Associate a n d honorary nlembers may neither vote nor hold office. Associate members shall pay annual dues.

ARTICLE I1 - OFFICERS Section 1: Election of Officers The President and Vice l'resident shall each be elected for one year. with automatic succession from Vice President to President. T h e Secretary-Treasurer, a n d

Councilmen-at-Large shall each be elected to three year terms, the terms being staggered for the latter. Nominees for the above offices shall be selected by the Nominating Committee and must have agreed to stand for election prior to their formal nomination for election at the business session of the annual meeting. Alternative nominations from the floor shall be solicited. Such nominees must also agree to stand for election.

Election shall be by majority vote of the active members present and voting at the business session of the annual meeting.

Section 2: Duties of the President T h e President shall preside over both the educational program and business session of the annual meeting of the Association, and the meetings of the Executive Council. It shall be the duty of the President to see that the rules of order a n d decorum are properly enforced in all deliberations of the Association, and to sign the approved proceedings of each meeting. T h e President shall appoint active members to fill vacancies a n d unexpired terms on t h e Executive Council a n d Standing and A d Iloc Committees and the positions of regional chairmen. The President shall serve as exofficio member of all standing cornmittees.

Section 3: Duties of the Vice Presiderit In the absence or illness of the President, the Vice President shall preside. The Vice President shall serve a s Chairman of t h e N o m i n a t i n g C o m m i t t e e , Coordinator of Regional Chairmen a n d ex-officio member of all standing cornmittees.

Section 4: Duties of the Secrctarp-Treasurer It shall be the duty of the Secretarv-Treasurer to preside in the absence of both the President and Vice President, to kerp a true and correct record of the proceedings of the meeting, to preserve all books, papers, and articles belonging to the Association, to keep a n account of the Association with its members. to keep a register of the members with the dates of their admission, aiid current professional addresses. the latter to be circulated a n n u a l l y to t h e m e m b e r s h i p w i t h i n a month prior to the annual meeting. He shall report unfinished business from previous meetings requiring action, and attend to such other business as the Association niay direct. He shall also supervise and conduct all the correspondence of t h Association. ~ He shall collect the dues of the

Association, make disbursements of expenses, maintain the financial accounts a n d records of t h e Association a n d present t h e financial acc o l ~ n t sand records of the Association for review by the Auditing Committee within 24 hours prior to the business session of each annual meetinz. at which time h e shall present a n annual report of the financial condition of t h e Association to the membership. He shall be reimbursed for such cxpelises as he may incur in the proper execution of his duties. He shall serve as ex-officio ~nr:~nber of all standing colnlnittees.

Section 5 : Regional Directors T h e Directors for each of 20 designatcd regions within the llnited States a n d Canada shall be a p p o i n t e d by the I'resident to a term of three years. These regions c o ~ ~ s i of s t the iliree regions in Canada bountied by t l ~ c ! east and wcst borders of Ontario and 17 regions in tlin United Statc:s conforming to existing [ I . S. l'ublic Health Service Ilistricts or their subdivisions. The Regional Director shall (a) actively solicit representative membership and encourage acti1.e participation by all qualified faculty members of the medical schools within his region. (b] represent a n d prc~motethe interests and wishes of the rncrr~bersof his region to the b:xet:utive C o u ~ ~ cthrough il the coordinator of regional tlircc.tors. ((:) solic:it program suggestions a n d participants From the mernbersliip of his reg ~ o ntor r ~ c o m m e n t i , i t ~ o nto s the Program (:oml n ~ t t e ednd ( d ) orgar1lr.r and preside over regional workshop niuetings. These regional activities will be c o o r d i ~ ~ a t eby d the Vice President who will preside at a meeting of the Regional Direc~al tors at the time of he a n ~ i ~meeting

ARTICLE 111 - MEETING S ( v . f i o ~I ~: The Assoc:iation shall he governed by the: ac:iior~staken by a majority votc of t h e active rncrnbors prt?sc:rit and voting at thc business SASsion of its annual meetings. T h e presence of 15% of thc activt: members shall constitute a quorum at allv n~c?etingof this Association. In t h e int e r i ~ r . ,within t h e policies established by its m e n ~ t ~ e r s h i pthe , /\ssclciation shall be governed by the Executive C o u n ~ i l .Actions of the Executive Council shall bct (letermined by a majority \wit! of those of its mem1)ers present at its meeting, five members constituting a quorum.

Scc.tion 2: T h e annual mceting and any addi-

tional meetings of the Association shall be held at times and places fixed by the Association, or in the absence of action by the Association, by its Executive Council. Programs for t h e a n n u a l meetings shall be arranged by t h e Program Committee and approved by the President. A final notice of the time, place and program of each meeting shall be sent to all members of the Association by the Secretary-Treasurer at least 60 days before the meeting, but the tentative time and place for the next two annual meetings shall ordinarily be announced during the business session of each annual meeting. The site of the annual meetings shall be chosen by the Executive Council at its annual session immediately prior to the second previous annual meeting.

The education program of the annual meeting shall be opened to all Association members, to invited guests in the company of, or upon presenting a written invitation by, a n Association member and to any visiting physician upon approval of the Secretary-Treasurer or an Association member on the Committee on Local Arrangements, upon payment of the registration fee. The latter requirement may be waived by the Secretary-Treasurer or his designate for students, housestaff, postgraduate fellows and other such worthy exceptions.

ARTICLE IV - FINANCES Section 1: The annual mennbership dues for all members shall be determined by the Executive Council subject to approval by a majority of the active members present and voting at the business session of the next annual meeting. In the event of no action by the Executive Council or failure of a recommended change to gain approval by the membership, these dues will continue to be levied at the previous established level. The annual membership dues will be payable within 30 days of request by the SecretaryTreasurer.

ARTICLE V - PARLIAMENTARY AUTHORITY Section 1: Rule of Order Any question of order or procedure not specifically delineated or provided for by these bylaws a n d s u b s e q u e n t amendments shall be determined by parliamentary usage as contained in Roberts Rules of Order [Kevised].

ARTICLE VI

- STANDING COMMITTEES

Section 1 : The Nominating Committee shall consist of the Vice President, as Chairman, the two most recent past presidents a n d two elected m e m b e r s , w h o may not be m e m b e r s of t h e Executive C o u n c i l . T h e latter s h a l l s e r v e staggered two year terms. It shall be the task of this committee to select a slate of officers to fill the naturally occurring vacancies on the Executive Council and the standing committees not otherwise designated and provided for by these bylaws, and having obtained each candidate's permission to do so, place their names in nomination before the membership for election at the business session of the annual meeting Section 2: The Executive Council shall constitute t h e M e m b e r s h i p Committee. It s h a l l be t h e Secretary-Treasurer's duty to review the qualifications and recommendations of each applicant, for presentation and approval by the majority of the Membership Committee.

Section 3: The Program Committee shall be composed of a Chairman, elected for three years, and the two Councilmen-at-Large with the greatest remaining tenure. The Chairman of the Committee o n Local Arrangements shall be an ex-officio member of this committee. Its duties shall be to arrange, in conformity with instructions from the Executive Council, the program for the annual meeting and select its formal participants.

Section 4: T h e Committee o n Local Arrangements shall ordinarily consist of all active Association members who live in or near the city in which the meeting is held, its chairman shall be appointed by the President. The committee shall be expected to make all necessary local provisions to assure the success of the annual meeting, coordinating their efforts with the Program Committee a n d i n f o r m i n g t h e SecretaryTreasurer of such details of their arrangements as may be required for information of the Executive Council and membership.

Section 5: The Constitution and Bylaws Committee shall consist of a Chairman and two other members. elected for staggered three year terms so that the member with the least remaining tenu r e shall serve as Chairman during his final year on the Committee. This Committee shall

study the potential merits, adverse consequences and legal implications of all proposed constitutional amendments or changes in the bylaws a n d report their findings and recommendations to the President a n d Executive Council prior to t h e time of formal consideration of t h e proposed changes by t h e membership. In addition, they rrlay themselves suggest appropriate constitutional amendments a n d bylaws changes to the President and Executive Council u p o n study of problems arising out of the existing constitution and bylaws.

Section 6 : The Auditing Committee shall consist of two members appointed by the President to audit the financial accounts a n d records of the Association at the time of the annual meeting.

ARTICLE VII - DISSOLUTION OF THE ASSOCIATION Section 1: Dissolution of this Association can only be initiated by a two-thirds vote of all m e n bers of the Executive Council and must be approved by two-thirds of the active nlernbership responding within one month to a rrlail ballot.

Upon dissolution the remainder of the Association's funds shall be distributed to charity, as stipulated by the constitution, such distribution to be determined by a majority vote of the Executive Council.

UAIEMS LEADERSHIP Executive Council President Vice.President

L e s l ~ eRudolf. MD

Charlottesv~lle.V ~ r g ~ n ~ a

D a v d K. Wagner. MD

Immediate Past-President

Phladelphla. Pennsylvan~a

George Johnson Jr. MD

Secretary-Treasurer

Ronald L Krorne MD

Chapel HIII. North Carollna D e t r o ~ tM . chgan

Allen P Klppel. MD St LOUISMlssourl

James R. Mackenzie. MD Dundas. Ontarlo Canada

H. Arnold Muller. MD Hershey Pennsylvan~a

Robert 0 . Rutherford. MD Denver. Colorado

J Trevor Sandy. MD Vancouver. B r ~ t s hColumbia. Canada

COMMITTEES Constitution and Bylaws E r w ~ nR Thal. MD Dallas Texas

Local Arrangements C W Hanson M D Phladelphla P~nnsylvdnla

Icdr

Economics of Emergency M e d ~ c ~ n e G U,I.II~O IMD '5'1--ea.12,0 C,I 1o.n ,I

Medlcal E d u c a t ~ o n E:.llonl Mol,iqia,i MU Monlrea .I .POP' C,?rl,12,1

George Schwar!~ MD Carnden. New Jersey

Davld K Wagner MD Ph~ladeiphla Pennsylvan~a

ED O r g a n ~ z a t ~ o&n Planning H Thomas Blum MD C ~ n c ~ n n aOhlo t~

Nominating Committee D a v d K Wagner. MD Philadelphla Pennsylvan~a

Paramedical Education W ~ l l a mJ Carey MD Lexngton Kentucky

Public Information i n Canada James R Mackenz~e.MD Dundas. Ontarlo. Canada

Program Kenneth L Mattox, MD Houston Texas

Publicity C h r ~ s t ~ nHaycock. e MD Newark. New Jersey

Publicallons Carl Jelenko. Ill. MD Augusla. Georgla

Resources & Public Information k.

Alan R D ~ r n ~ cMD B ~ r m ~ n g h a rAlabama n

Cleve Tr~mhle MD Denver Colorado

Allen P K l ~ p p e lMD st LOUIS M~ssourl

UAIEMS Headquarters 3900 Capital City Boulevard Lansing, Michigan 48906

Executive Secretary

Fred

6 .Towns

UA' H

EMS

3900 Capital City Boulevard Lansing, Michigan 48906 (517) 374-7401