SAEM (UAEMS)1977 Annual Meeting Program

UA 4.p

EMS

University Association for Emergency Medical Services

Annual Meeting 'New Frontiers of Academic Emergency Medicine'

PROGRAM CROWN CENTER HOTEL KANSAS CITY, MISSOURI

New frontiers in academic emergency medicine. . . . . . a r e being opened almost daily a s t h e challenges of providing quality emergency care a r e being m e t by a whole new breed of physicians. I n every p a r t of t h e country, d e m a n d s a r e being made for better, more relevant educational programs t o m e e t t h e n e e d s of t h i s r a p- i d l y- d e v e l o p i n g p r a c t i c e specialty. Medical school curricula, ;esidency programs and continuing education programs a r e being re-examined in t h e light of increased demand for training t h a t is oriented. to t h e specific needs of t h e emergency physician.

This meeting provides a broad spectrum of scientific papers, lectures a n d panel discussions t h a t deal w i t h t h e latest developments in emergency medicine. It will be t h e meeting place where practitioners and educators c a n mutually seek the best possible s o l u t i o n s to p r o b l e m s t h a t a r e f a c i n g everyone connected with t h e exploding universe of emergency medical services.

You should join us in K a n s a s City if you have a n interest - a s practitioner o r educator - in emergency medical services. J o i n your colleagues for t h e Seventh Annual Meeting of the University Association for E m e r g e n c y Medical Services, May 15-18 a t t h e Crown Center Hotel.

Kenneth L. Mattox, M D Program Chairman

Table of Contents Welcome . . . . . . . . . . . . . . . . . . . . . .Inside front cover General Information . . . . . . . . . . . . . . . . . . . . . . . . . .1 Executive Council a n d Committee Meetings Schedule . . . . . . . . . . . . . . . 4 General Session Agenda . . . . . . . . . . . . . . . . . . . . . . . 4 STEMWorkshop . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 VadeMecum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 0 Robert H. Kennedy Lecturer . . . . . . . . . . . . . . . . . 1 2 Scientific Paper Abstracts . . . . . . . . . . . . . . . . . . . . 1 3

General lnformation Registration The UAiEMS Registration Desk will be located in the Roanoke Foyer of the Crown Center Hotel beginning Monday, May 16 a t 2:00 p.m. The Registration Desk will be moved to the Century Lounge on Tuesday and will be open from 7:30 a.m. until 5:00 p.m. On Wednesday t h e Registration Desk will be open from 7:30 a.m. until 9:00 a.m. only. Everyone attending the Annual Meeting is required to regist6E. The registration fee includes all planned act i v i t i e s d u r i n g t h e A n n u a l M e e t i n g including lunches, with the exception of the Tiffany Attic dinner and play and certain other functions a s indicated in the program.

lnformation Desk The Information Desk will be located in the Registration area.

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.

Placement lnformation A bulletin board to list positions and physicians available will be located near the Registration Desk.

Message Center Phone messages will be posted on a bulletin board near the Registration Desk. Registrants may also post messages on this board.

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

Annual Business Meeting Wednesday, May 18, immediately following the luncheon, t h e Annual Business Meeting will be conducted. Agenda items will include: reports from the committees, election of officers, Constitution

and Bylaws amendments, and other items of business presented by t h e membership.

Kansas City

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has something for everyone.

For those who love a r t , t h e Nelson Gallery of A r t offers many different styles from Flemish Masters to stainless steel and light sculpture. The gallery also features one of t h e finest Oriental a r t collections in t h e country.

Close by t h e Nelson Galleries i s C o u n t r y C l u b Plaza, t h e nation's first, a n d one of its finest, shopping c e n t e r s . S h o p p e r s m a y p u r c h a s e a n y t h i n g from Baccarat crystal to a candy apple to a Givenchy original.

A n o t h e r o r i y i n a l w a s t h e m a n from M i s s o u r i , Harry S T r u m a n . The T r u m a n Library is just a s h o r t d r i v e from d o w n t o w n K a n s a s C i t y . T h e d r a m a of his tempestuous career c a n be found here along w i t h Thomas H a r t Benton's m u r a l , "Independence and t h e Opening of the West."

For those who believe t h e good-old-days were t h e best, K a n s a s City offers t h e River Quay, a n a u thentic recreation of t h e 1820's riverfront. At the Quay, visitors may t a k e a boat trip down t h e river, explore shops, antique stores and more.

And pervading everything is t h e friendliness a n d vitality for which the mid-West is justly famous.

You'll like K a n s a s City.

San Francisco in 1 9 7 8 . .

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. . . will be t h e site of t h e UAIEMS Annual Meeting.

A unique city of myriad cultural influences, S a n Francisco is easy to visit and hard to leave. The meeting will be held in t h e H y a t t on Union Square, in t h e h e a r t of downtown S a n Francisco. The Hyatt h a s excellent facilities for t h e presentation of scientific materials. D a t e s for t h e m e e t i n g a r e May 15-18, 1978.

Program Chairman, Kenneth L. Mattox, MD h a s announced t h a t he will accept abstracts for scientific papers to be presented a t t h e 1978 A n n u a l Meeting. Members a n d others in t h e field a r e urged to submit original scientific contributions relating -, to t h e field of emergency medicine.

Abstracts should be limited to 250 words a n d typed double-spaced on BY2 x 11 p a p e r . T h r e e copies

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should be submitted for consideration. Abstracts must be authored, co-authored or sponsored by a UAiEMS member with t h e name, title a n d address of each a u t h o r appearing on t h e abstract title sheet.

Deadline for submission i s December 15, 1977.

Copies of t h e abstract should be s e n t to: Kenneth L. Mattox, MD, UAIEMS, 3900 Capital City Boulevard, Lansing, Michigan 48906.

Executive Council and Committee Meetings Sunday, May 15,1977 8:30 a.m.3:00 p.m.

Liaison Residency Westport Rm. Endorsement Committee (LREC)

Monday, May 16,1977 8:30 a.m.- Executive Council Meeting 12:OO noon 1:00 p.m.4:00 p.m.

1:00 p.m.5:00 p.m.

Westport Rm.

UAiEMS Committee Meetings Medical Education Senators' Rm. Resources & Public Information Congressional Rm. Research Mayors Rm. Constitution & BylawsAmbassadors Rm. UAiEMS Office Opens Convention Office

2:00 p.m.5:00 p.m.

Registration Desk Opens

4:00 p.m.5:30 p.m.

Executive Council Reconvenes

7:00 p.m.9:00 p.m.

Reception Cash Bar

Roanoke Foyer

Westport Rm.

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Shawnee-Mission Rm.

General Sessions Tuesday, May 17,1977 7:30 a.m.5:00 p.m.

Registration Desk Opens

8:00 a.m.8:15 a.m.

Welcoming Remarks David K. Wagner, MD

8:15 a.m.8:45 a.m.

Robert H. Kennedy Lectureship Peter Safar, MD

8:45 a.m.10:OO a.m.

SCIENTIFIC PAPER Centennial A SESSION I David K. Wagner, MD, Moderator

Century Lounge Centennial A

Centennial A

1. Pre-Hospital Coronary Care: The IIlusion of Consensus J e a n n e Sims, MA

2. A Study of Cognitive a n d Technical Skill Deterioration Among Trained Paramedics Mary Beth Skelton, RN 3. A Nationwide Paramedic Clearinghouse Teresa Romano, BSN 4. T a p p i n g F e d e r a l EMS Information Sources for Use by UAiEMS Physicians Lary C. Rampp

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5. Priorities in EMS Research Lawrence R. Rose, MD 10:W a.m.- Coffee Break 19:15 a.m.

10:15 a.m.- SCIENTIFIC PAPER Centennial A 12:W noon SESSION I1 Leslie E. Rudolf, MI), Moderator 6. The Foreign Medical Graduate i n t h e Emergency Department Cyril T. M. Cameron, MD 7. The Patient is (Almost) Always Right J o s e p h B. Vander Veer, Jr., MD 8. P a t t e r n s in the Number of Patients Seen Hourly in a Community Hospital Emergency Department Stephen Karas, J r . , MD 9. Assessing t h e Validity of EMS Data C. Gene Cayten, MD

10. Basic Decisions in E m e r g e n c y Department Care: A Logical Approach Barry W. Wolcott, MD 11. Variables Influencing t h e Development of Emergency Medicine Residency P r o g r a m s Rebecca A. H. Anwar, P h D

12:OO noon- Luncheon Liberty Rm. Carl Jelenko, 111, MD, presiding 1:45 p.m.

Presidential Address David K. Wagner, MD 1:45 p.m.3:30 p.m.

SCIENTIFIC PAPER Centennial A SESSION 111 George Johnson, Jr., MD, Moderator 12. VIPs: An EMS Challenge Chester L. Ward, MD 13. The Integrated Trauma Service Concept: Out of Many - One Kimball I. Maull, MD 14. Evaluation of t h e Patient Advocacy P r o g r a m of t h e J o h n s H o p k i n s Emergency Department Marla Salmon White, BSN, RN 15. Strategies of C a r e for Patients Not Returning for S u t u r e Removal Nancy Fink, BA 16. Respiratory Function Following Application of MAST Trousers Norman E. McSwain, Jr., MD 17. Value of G-Suit i n Traumatic Shock Daniel Lowe, MD 18. The IV i n Readiness: A Mixed Blessing?

J o h n R. Saucier, MD

3:30 p.m.3:45 p.m.

Coffee Break

3:45 p.m.5:00 p.m.

SCIENTIFIC PAPERS Centennial A SESSION IV Cleve Trimble, MD, Moderator 19. P a r a s y m p a t h e t i c a n d S y m p a t h e t i c Mechanisms i n S u d d e n Death a n d Immediate Response t o Trauma a n d Injury George R. Schwartz, MD 20. Percutaneous Transtracheal Ventilation D u r i n g C a r d i o p u l m o n a r y Resuscitation Laurence B. Dunlap, MD 21. T r a u m a Centers: A P r a g m a t i c Approach t o Need, Cost, a n d Staffing Patterns William Teufel, MD 22. Malignant Lactic Acidemia d u e t o Phenformin Randall G. Cook, MD 23. Walk-Out P a t i e n t s i n t h e Hospital Emergency Department Geoffrey Gibson, P h D

6:00 p.m.

Buses leave for Tiffany's Dinner and Play

Hotel Lobby

Wednesday, May 18,1977 7:30 a.m.9:00 a.m.

Registration Desk Opens

8:00 a.m.9:15 a.m.

SCIENTIFIC PAPER Centennial A SESSION V. Ronald L. Krome, MD, Moderator 24. Zygomatic F r a c t u r e s i n t h e E m e r gency Department: Evaluation a n d a n d Approach t o Treatment A. Neal Wilson, MD

Century Lounge

25. Airless P a i n t Gun Injuries: A Progress Report J o h n M. Hiebert, MD 26. Survey of Abdominal T r a u m a 1972 Through 1975 Christine E. Haycock, MD 27. Survival Rates of Major Abdominal Vascular Injury in a Seven Year Period P e t e r B. Yaw, MD

9:15 a.m.10:15 a.m.

28. Suspecting Thoracic Aortic Transection Kenneth L. Mattox, MD Panel: Centennial A Development of Emergency Medicine Programs in the Medical School David K. Wagner, MD, Moderator

David R. Challoner, MD, Dean St. Louis University School of Medicine M. Kenton King, MD, Dean Washington University School of Medicine Lee L. Langley, PhD, Associate Dean University of Missouri-Kansas City Charles C. Lobeck, MD, Dean University of Missouri Columbia School of Medicine Perry G . Rigby, MD, Dean University of Nebraska College of Medicine David Waxman, MD, Vice Chancellor for Academic Affairs University of Kansas School of Medicine Coffee Break SCIENTIFIC PAPER SESSION VI Erwin Thal, MD, Moderator

Centennial A

29. A M o r e R e l i a b l e G r a m S t a i n i n g

Technic for the Emergency Medical Physician Michael D. Spengler, BS

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30. Digoxin Lithium Drug Interaction David Ralph, MD 31. Quality Control of Radiological Interpretation in t h e Emergency Department George Podgorny, MD 32. Emergency Department Observation Unit: Utilization in a University Hospital a n d Role in Physician Training William F. Bobzien, 111, MD UAIEMS Luncheon and Annual Business Meeting

Centennial B

EMRA Luncheon and Annual Business Meeting

Mission Rm.

Centennial A SCIENTIFIC PAPER SESSION VII Richard Edlich, MD, Moderator

33. R a p i d S e r i a l a n d Low E n e r g y DC Shock for Transthoracic Ventricular Defibrillation of Man J o s e p h A. Gascho, MD 34. Autotransfusion of Contaminated In-

t r a ~ e r i t o n e a lBlood: An Experimental S t u d y J o h n L. Glover, MD

35. Rhabdomyolysis a n d Acute Renal Failure David Ralph, MD

36. Xiphisternal Costochondritis: The

Imitator of Severe Disease Carl Jelenko, 111, MD 37. Emergency Service Treatment of Pa-

tients with Chest Pain - A Comparative Analysis Bernard Slosberg, MD 38. Clinically Validated Algorithm for Management of Extremity Trauma Archie M. Brugger, MD 39. Hypertension: An Audit of Emer-

gency Department Detection a n d Management Anne L. Kaszuba, BA Coffee Break SCIENTIFIC PAPER Centennial A SESSION VIII Carl Jelenko, 111, MD, Moderator 40. Major Motor Seizures: Some Patho-

physiologic Considerations Lawrence B. Bookman, DO 41. The Weak and Dizzy Patient

J o h n Skiendzielewski, MD 42. Emergency Management of Cervical

Spine Injuries Norman E. McSwain, Jr., MD 43. Role of the Clinical Pharmacist in

Emergency Medicine: Description and Evaluation Joseph F. Waeckerle, MD 44. Daily Chart Audit in an Emergency Department As a Quality Control Device Linda A. Ornelas, MD Residents' Reception

Roanoke Rm.

American Board of Senators' Board Rm. Emergency Medicine (ABEM)

Workshop on Evaluating Clinical Competence Sponsored by

Society of Teachers of Emergency Medicine and American College of Emergency Physicians Thursday, May 19,1977 8fl0 a.m.

Registration

Roanoke Foyer

8:30 a.m. Performance Rating Multimedia Forum & 1:30 p.m. Workshop Seminar Room C Session Goal: To demonstrate through participatory experiences and discussion:

1. Issues and problems in assessment of clinical competence.

2. Methods of assessment to be used in the certification examination.

3. Criteria that can be utilized in the assessment of diagnostic and management skills.

Participants will review and discuss empirical data on the rating of candidate performance under controlled conditions during a certification exam, observe and r a t e two physicians' performance on a simulated patient encounter, and discuss the advantages and disadvantages of specific criteria t h a t can be employed to rate clinical performance.

A tentative list of criteria will be derived for use in a field test of the certification examination.

12:30 p.m. STEM luncheon and business meeting

Liberty Rm.

8:30 a.m. Problems and Liberty Rm. & 1:30 p.m. Procedures of Objective Examinations Session Goal: To familiarize participants with the use of objective testing in the assessment of clinical knowledge. Participants will practice the principles of objective-test writing, item reviewing and rewriting techniques, and will receive training methods to avoid common item writing errors.

4:30 p.m.

Forum on Emergency Liberty Rm. Medicine Residency Establishment Session Goal: To assist physicians in initiating and improving residency training programs. A panel of residency directors and residents will help participants solve problems encountered in new or existing programs.

5:00 p.m.

Adjournment

Faculty Rebecca Anwar, PhD Philadelphia, Pennsylvania G. Richard Braen, MD Lexington, Kentucky Desmond P. Colohan, MD East Lansing, Michigan Steven M. Downing, P h D (Cand.)

East Lansing, Michigan Jack L. Maatsch, P h D East Lansing, Michigan Peter Rosen, MD Chicago, Illinois C. C. Roussi, MD Akron, Ohio

Vade Mecum UAlEMS Annual Awards Mackenzie Award 1976 - J a m e s Mackenzie, MD Imago Obscura Award 1976 - Norman E. McSwain, J r . , MD Best Paper 1976 - W. Wilson DeFore, MD

Kennedy Lecturers 1973 - Fraser N. Gurd, MD 1974 - Oscar P. Hampton, J r . , MD 1975 - Curtis Artz, MD 1976 - J o h n H. Wiegenstein, MD 1977 - Peter Safar, MD

UAiEMS Future Meeting Sites 1978 - S a n Francisco, California 1979 - Montreal, Quebec, C a n a d a 1980 - St. Louis, Missouri

Past Annual Meetings 1st Annual Meeting May 14-15, 1971 Ann Arbor, Michigan Charles Frey, MD, President 2nd Annual Meeting May 12-13, 1972 Washington, DC Alan R. Dimick, MD, President

3rd Annual Meeting May 23-25, 1973 Hamilton, Ontario Robert B. Rutherford, MD, President 4th Annual Meeting May 28-June 1, 1974 Dallas, Texas J a m e s R. Mackenzie, MD, President 5th Annual Meeting May 20-24, 1975 Vancouver, British Columbia George Johnson, J r . , MD, President 6th Annual Meeting May 11-15, 1976 Philadelphia, Pennsylvania Leslie E . Rudolf, MD, President 7th Annual Meeting May 15-18, 1977 Kansas City, Missouri David K. Wagner, MD, President

UAIEMS Past Presidents 1970-1971 - Charles Frey, MD 1971-1972 - Alan R. Dimick, MD 1972-1973 - Robert B. Rutherford, MD 1973-1974 - J a m e s R. Mackenzie, MD 1974-1975 - George Johnson, J r . , MD 1975-1976 - Leslie E. Rudolf, MD 1976-1977 - David K . Wagner, MD

Honorary UAIEMS Members 1973 - Robert H. Kennedy, MD Fraser N. Gurd, MD C. Barber Mueller, MD 1974 - J o h n G. Wiegenstein, MD Alexander Walt, MD 1975 - Oscar P. Hampton, MD N. H. McNally, MD Curtis P. Artz, M D 1976 - Anita M. Dorr, RN Eugene L. Nagel, MD

KENNEDY LECTURER Peter Safar, MD, of Pittsburgh, will deliver t h e Robert H. Kennedy Lecture d u r i n g t h e seventh ann u a l meeting of t h e University Association for Emergency Medical Services. T h e subject of Dr. Safar's lecture is "The Continuum of Care: Partnership of Emergency and Critical C a r e Medicine."

The Kennedy lecture is named in honor of Robert H. Kennedy, MD, FACS, a pioneer in t h e development of quality emergency c a r e nationwide. Dr. Kennedy served a s chairman of t h e American College of Surgeons' C o m m i t t e e o n T r a u m a for 1 3 years and a s director of its field program for nine years.

Dr. Safar is professor and c h a i r m a n of t h e Department of Anesthesiology, which he founded in 1961, a t t h e University of P i t t s b u r g h School of Medicine. The department is t h e largest in the United States employing 100 full-time physicians and some 200 allied health care personnel.

A founding member of t h e Society of Critical C a r e Medicine, D r . S a f a r i s a m e m b e r of t h e American Medical Association's Commission on Emergency Medical Services a n d t h e American H e a r t Association's Committee on Cardiopulmonary Resuscitation and Emergency Cardiac Care.

A native of Vienna, Austria, Dr. Safar earned his MD degree a t the University of Vienna in 1938. H e completed a residency in anesthesiology a t t h e University of Pennsylvania in 1950.

Dr. Safar has served a s a n advisor to t h e Dep a r t m e n t of H e a l t h , E d u c a t i o n a n d W e l f a r e ' s Emergency Medical Services Division a n d w a s appointed to the Interagency White House Committee o n E m e r g e n c y M e d i c a l S e r v i c e s by Presi.dent Gerald R. Ford in 1974.

University Association for Emergency Medical Services Annual Meeting Scientific Paper Abstracts May 16-18,1977

1',%following abstracts appear

i n the same order as presented during the program.

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Pre-Hospital Coronary Care: The Illusion of Consensus Jeanne Sims, MA Linda Cole, MA Rudolf Staroscik, MD Joel Morganroth, MD C. Gene Cayten, MD Center for the Study of Emergency Health Services, University of Pennsylvania, Philadelphia, Pennsylvania.

Although there is a lack of consensus on the role of the EMT-Paramedics, in terms of length and content of training and prescribed tasks, i t has been assumed t h a t the medical staff directing activities of EMT-Paramedics concur on what constitutes appropriate pre-hospital coronary care. Results fkom a study currently underway a t the C e n t e r for t h e S t u d y of Emergency H e a l t h Services (CSEHS) reveal a lack of consensus regarding not only the role of the EMT-Paramedic but the appropriate procedures for pre-hospital coronary care.

The survey emerged from a grant to develop a series of clinical algorithms for assessing EMT performance. The first algorithm, dealing with cardiac care, was sent to a national panel of experts for review and comment. The panel, composed of physicians, nurses, administrators and EMTs all working in the area of emergency medicine, was asked to assess the cardiac algorithm in terms of general format, logic, ease in use and medical accuracy. Results reveal a lack of consensus on: a ) drug administration and dosage; b) appropriate treatment steps for a r rhythmias; and c) appropriate EMT-Paramedic role.

The results of the survey not only produced a cardiac algorithm reflecting local consensus, but also indicated the reactions of the national panel to the local cardiac protocol. This project has implications for future national standardization of pre-hospital coronary care a s well a s for EMT training programs and refresher courses.

A Study of Cognitive and Technical Skill Deterioration Among Trained Paramedics Mary Beth Skelton, RN Associate Director, Emergency Mobile Intensive Care

Norman E. McSwain, J r . , MD Assistant Professor of Surgery, Director of Emergency Medical Training, University of Kansas Medical Center, Kansas City, Kansas A study was completed with 30 trained paramedics to measure cognitive and technical skill deterioration six months to one year after completion of their individual training. Included in the group were paramedics with six months and one year of training. The purpose of the study was to identify needed areas of continuing education and to determine the correlation in the rate of skill deteriora-

tlon with the amount of training received.

During this study the individuals were given the same final written and technical skill examinations a s were required at the end of their training. The individuals' two sets of scores were then compared. The skill deterioration identified by the scores of those with six months of training was then compared to those with one year of training.

Review of the material to be tested was not allowed.

The study indicates t h a t the skills requiring the most technical knowledge deteriorate the fastest. The paper discusses the individual areas of skill deterioration and recommends specific needs of continuing education in individual areas to prevent deterioration of the skills. The study also indicates a correlation between the length of training and the rate of skill deterioration.

A Nationwide Paramedic Clearinghouse Teresa Romano, BSN Associate Director

C. Gene Cayten, MD, MPH Steven Eisenberg, BA Richard Lepper, MPA Carlos Fernandez Caballero, MSLS University of Pennsylvania. Department of Community Medicine, Philadelphia, Pennsylvania The rapid proliferation of paramedic (Advanced EMT) programs over the past five years has resulted in a state of confusion in the field of pre-hospital advanced life support. Besides the still unanswered question of how much and what kind of training to provide paramedics, little evidence exists a s to the most cost-effective, clinically efficient method of developing a n advanced life support system. The more t h a n 200 known paramedic programs across the country all employ different styles of education, modes of operation and methods of evaluation.

To date, there has heen no comprehensive data as to the actual numher of paramedic programs in the country and the primary features of each. The growing interest in advanced life support promises to magnify rather than diminish this diversity.

A nationwide survey is now being conducted to provide the first comprehensive status report of paramedic programs in the country. Paramedic programs have been identified through a state-by-state search and a questionnaire distributed through t h e National Emergency Medical Technician Newsletter. The survey instrument includes information on education, type of service, communication use and personnel reciprocity.

Preliminary information will be presented on the current number and distribution of paramedic programs and their existing management structure. Future data will provide baseline information on numerous educational and operational issues which will provide a clear picture of existing advanced life support in the country.

Tapping Federal EMS Information Sources For Use by UAIEMS Physicians Lary C. Rampp Hyattsville, Maryland The recent availability of federal support dollars for EMS systems development has been a boon to hospitals and communities across the country. EMS systems and the EMS support elements in hospitals (emergency department) now exist where, up to a few years ago, the knowledge level alone would have made it impossible to support an effective EMS. Concurrent w ~ t hthe proliferation of operational EMS systems has been the increased pressure placed on the academic side of EMS, ergo, the increased need for the universitv based medical schools or medical centers t o develop better methods of EMS delivery and emerging treatment techniques through academic based research. Activities of hospitals and the great efforts of doctors are attempts to prevent a medical gap from developing between the EMS delivery and the EMS research efforts carried on in hospitals and medical centers, large and small. So, it is important t h a t the EMS doctor perfbrming timely emergency medical research in EMS be aware of the most current literature dealing with emergency medical services and his research interest.

Therefore, the purpose of this paper is to explore the accessibility of the latest information sources sponsored bv the federal government. A doctor doing research in EMS, as with a researcher working on a non-medical subject, must have easy access to the most current tind~ngsin his field of interest.

The federal government, working with private groups and public agencies, has the most comprehensive research effbrt in all areas of computer-based literature retrieval related to emergency medlcine in the world. The MEDLARS system is the most familiar example of such computerbased systems.

Tapping the results of the latest research efforts can prove to be a frustrating experience, tbr although many different government agencies have developed vely extensive and comprehensive computer d a t a bases t h a t getting the literature citations for research would be no problem, the bureaucracy t h a t surrounds them, and the fact t h a t some of these useful systems a r e virtually unknown to the medical researcher make this task difficult.

The anticipated result of this paper will be the assur: ance that the reader will possess enough knowledge about these varied systems to effectively access the precise source needed to better assist him with his own research.

(Fact sheets on each system will be distributed to delegates and guests for their retention and use.)

Priorities in EMS Research Lawrence R. Rose, MD Acting Director, Division of Health Systems Design and Development Department of Health, Education and Welfare, Rockville, Maryland The federal program to improve emergency services provides only "seed money." Local communities and regional organizations a r e responsible for completing and maintaining their own EMS systems after earmarked federal funds have been exhausted. Communities are becoming increasingly a w a r e of problems in allocating resources, and recognizing the economic pitfalls accompanying federally-funded health service programs, particularly those which deal with issues a s visible to the public a s emergency medical care. Local officials need to be able to document both the effectiveness and the efficiency of proposed EMS systems, and this need requires a selective and intensive research effort to improve our capabilities to evaluate system performance.

The primary focus of the EMS research program a t present is the development and testing of measures of system effectiveness, which must include dimensions of the quality of care provided. For example, we are trying to develop indices of severity to compare EMS workloads in various settings. We a r e also attempting to define "appropriate" emergency care procedures, from dispatch protocols to medical review criteria, and to judge the results of emergency care, since it seems certain t h a t mortality rates, health status indices, and similar outcome measures are probably not sufficiently sensitive to changes in EMS systems.

Operations research methods, economic models, patient utilization surveys, a n d similar approaches represent another research focus, designed to assist regions in using existing health resources in efficient a n d imaginative ways.

Research is also directed toward major policy issues which are likely to have significant effects on the financing, management, and continued operation of emergency care systems. The most significant of these issues is, of course, the effects of the proposed National Health Insurance programs on the organization and delivery of emergency care.

It is also important to develop methods to estimate the role of proposed new devices and techniques in improving emergency medical care. Innovation is important in EMS systems, but new methods often produce enormous costs in technology and in personnel. It is not enough to be able to show that a new approach is feasible; it must also be shown to be a n effective and efficient solution to a significant EMS problem.

The choice of problems selected for emphasis in EMS research is limited by the availability for appropriate research methods, competent investigators, and adequate study sites. The list of research priorities is open to revi-

sion based on the reasoned opinions and careful judgments of thoughtful and experienced persons working in EMS settings.

The Foreign Medical Graduate in the Emergency Department Cyril T. M. Cameron, MD, FRCS, FACS Director, Emergency Department Samaritan Hospital, Troy, New York When speaking before civic and service organizations, the writer - who is a foreign graduate - has often been asked why there are so many foreign doctors (FMGs) in emergency departments. O t h e r observations have included unfavorable comments on certain aspects of treatment by FMGs. Between one-fifth and one-sixth of all physicians in the US a r e FMGs. Because i t is e a s i e r for US medical graduates (USMGs) to enter what are a t present considered more desirable specialties, there is a higher proportion of FMGs practicing emergency medicine. An unpublished personal study of 100 applicants for two salaried emergency department positions showed t h a t 90 were FMGs, whose average was 23 years younger than that of the 10 USMGs applying. Two-thirds of the FMG applicants were surgeons, either board eligible or certified or with a higher degree in surgery such a s FRCS. The greatest single barrier to good public relations by FMGs may be failure to understand and to speak American English. With few exceptions, FMGs do not become easier to understand with continued stay in the US, even though they may understand the language better with time. One reason is t h a t FMGs often sett,le where there are many of their countrymen and do not speak English solely. Another is t h a t there 1s not much s o c ~ a lintercourse between natives and foreigners.

Apart from language, there are also other significant cultural differences, even between Americans and such s ~ m l l a rpeoples a s Canadians and Australians. !3iff'erences between A m e r ~ c a n ss n d non-English-speaking peoples are even greater. .In attitude of apparent unconcern on the part ot't,he FMGs :s one which zreatly distresser 1IS patients. Nut gnly do US patlents complaln about FMGs, nut the reverse also a p p i ~ e s To date. the problems cre:ate.d by FMGs ;n tsrnrryencv fiepartments have not been riicetl and no slgnlfieant dttempts have been made to correct them. Sol~ltl<)ns ~nt-lude ~:onipulsorpstudies tbr E'M(;.= !n E:nylisti, i ' S cuiture, and dcr~ng public reiations, to be urovrded !'rev by no.~p!t;~lr .vorkini hriurs. rtrgcthe:. :vith <.r,ni!~itstew ~ i l ~ n g n r shy s FMGs to uruct;ct3 .n the .-imrr~c.:tr; niannr?

The Patient is (Almost) Always Right: Aphorisms from Patient Complaints Joseph B. Vander Veer, Jr., MD Director of Emergency Services

Gregory B. Lorts, MD Emergency Medicine Resident Providence Medical Center, Portland, Oregon The major airlines have found t h a t a smoothly running service generates about four times a s many complaints a s compliments. When the ratio is three to one, they are ecstatic; when it grows to five to one, they look for remedial causes of dissatisfaction.

Although there were many pleasant responses to a standard questionnaire given to all emergency patients, a total of 100 complaints from a large metropolitan community department were received over a periodof 24 months. These were analyzed and divided into several major complaint categories, and specific "operational aphorisms" were formulated in an attempt to improve services and provide a preventive approach to the dissatisfied patient.

The categories receiving the most numerous complaints were those relating to fees charged for services, and misunderstood communications. Other specific areas were long waits, adverse results, patients "loaded for bear," mistaken diagnoses, appearance or attitudes of the emergency department staff, and discrepancies between the expectations of the patient and of the physician. Representative examples are cited with their resultant aphorisms.

Patterns in the Number of Patients Seen Hourly in a Community Hospital Emergency Department Stephen Karas, J r . , MD Tri-City Hospital Emergency Department, San Diego, California The increasing burden upon emergency departments across the country has stimulated interest in improving department efficiency to meet this growing load. Without careful analysis and appreciation of accurate load statistics, erroneous conclusions can often be reached. It is the purpose of this study to apply numerical analysis to the number of patients seen hourly in a community hospital emergency d e p a r t m e n t t o d e l i n e a t e p a t t e r n s i n t h e number of patients seen.

The patient population studied were patients seen hourly a t the Tri-City Hospital Emergency Department, a community hospital in Northern San Diego County. The hospital saw approximately 2,700 patientslmonth between April a n d J u n e , 1976. T h e hourly p a t i e n t d a t a w a s analyzed on a Tektronix 4051 microcompuler, a device with the capability to program mathematical analysis in Extended BASIC and display the results In graphic form.

On the 4051. programs were written in Extended BASIC to analyze the patient load data as follows: 1 1 signal detection, 2 ) systematic period reconnaissance, 3 , Bartel's Test of Significance, and 4 ) graphic analysis.

The preliminary results of this analysis reveal the following daily pattern: 1 ) a nighttime quiet period from midnight to 6:OO-7:00 a.m., 21 morning peak between 8:00 and 10:OO a.m., 3 , a relatively quieter period between 10:OO a.m. to 1:00 or 2:00 p.m., 4 ) multiple large peaks from 1:00 p.m. until 9:00 p.m., 5 ) minor peaks from 9:00 p.m. until midnight. In addition, there appears to be a cycle slightly larger than 23 hours in t h e data which is being analyzed further.

The results of this analysis are being utilized for physician and nursing staffing to meet these patterns.

Assessing the Validity of EMS Data C. Gene Cayten, MD, MPH Susan Walsh, RN Nira Herrmann, PhD Linda Cole, MA Center for the Study of Emergency Health Services, University of Pennsylvan~a,Ph~ladelphia,Pennsylvania Although there appears to be great interest in the development of uniform d a t a collection mechanisms, the internal validity of clinical data elements is rarely addressed.

In the process of developing a data collection instrum e n t , questions arose concerning the accuracy o f t h e clinical data supplied by emergency department nurses and EMTs. The validity testing methodology devised involved the selection of a small number of clinical data elements which could be objectively measured and the establishment of tolerance ranges within which measurements would be considered accurate. The data elements selected were respiration r a t e , pulse r a t e a n d blood pressure.

Twenty emergency department nurses a n d thirty-five EMTs were tested for their proficiency In taking these vital signs.

The overall results indicate that the nurses' readings deviated from the defined tolerance ranges 20% of the time and those of the EMTs deviated 273 of the time.

Comparisons of the nurses' results with those of the EMTs for each data element show the nurses to be the consistently more accurate group.

The ramification of these findings fbr EMS research and evaluation are considerable. If t h e validity of a small number of clearly defined and routinely collected data elements cannot be established, how accurately recorded are other, less easily quantifiable data elements? This study highlights a problem area that, although neglected, is common to all EMS research and evaluation and may force a re-evaluation of traditional methods of data collection and utilization.

Basic Decisions in Emergency Care: A Logical Approach Barry W. Wolcott, MD Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas Physician education in patient evaluation traditionally occurs in predominantly in-patient settings, and emphasizes estahlishing a precise pathophysiolog~c diagnosis. Such emphasis is generally appropriate in the hospitalized patient. Emergency department medical evalurrtions cannot have this same emphasis since the limited contact period frequently precludes definitive diagnosis.

Many patients evaluated in emergency departments have limited complaints and exact pathophys~ologicdiagnosis cannot he reached. Education techniques in emergency medicine must acknowledge these diff'erences and stress the unique aspects of emergency medical evaluation. To facilitate this education, we have developed a n algorithm which stresses the following major goals of patient evaluation in the emergency department: a. Rapid identification of the patient requiring significant resuscitative efforts.

h. Rapid admission to the hosp~ta!of patients for whom further emergency department evaluation will not alter disposition. c. Diagnostic evaluation of remaining patients to tletermine if they: t l i Require a d m i s s ~ o nfor f u r t h e r evaluation or

therapy.

( 2 ) Can be given definitive care in the emergency department without neecl for referral.

131 Require entry into a system of continuing care for diagnostic e v a l u a t i o n a n d / o r prolonged therapy.

This algorithm has fhcilitated house of'ficer training in emergency medicine a n d improved t h e practice technlques of the full-time emergency department stafr a s measured by ongoing chrirt audit.

Variables Influencing the Development of Emergency Medicine Residency Programs: An Evaluation Process for Graduate Medical Education Rebecca A. H. Anwar, PhD Assistant Professor

Dorothy E. Kurz, P h D Adrienne Gioe, MEd David K. Wagner, MD Emergency Medical Services, The Medical College of Pennsylvania, Philadelphia, Pennsylvania

The number of emergency physicians working in community hospitals in t h e United States is estimated a t over 15,000. Most of these physicians come from other areas of medical specialization. The development of educational programs in emergency medicine for medical students and graduates are needed to meet present and future demands in emergency care. Yet, even with these needs and demands, the definition of emergency medicine a s a specialty has not been formally accepted within the framework of t h e American Medical Association.

The purpose of this paper is to explicate a small part of a larger study on t h e development of emergency medicine a s a specialty. The intent is to examine residency programs in this area and compare them to programs in the more traditional specialties of i n t e r n a l medicine a n d surgery. The focus is toward presenting some of the structural variables underlying the development of emergency medicine a s a specialty, and the development of residency programs in this area.

Data for this paper consists of interviews with directors of emergency medicine residency programs t h a t a r e approved or eligible for approval by the Liaison Residency Endorsement Committee of the University Association for Emergency Medical Services. American College of Emergency Physicians and American Board of Emergency Medicine. In addition, comparative data a r e presented from emergency medicine residency programs t h a t have been discontinued.

Analysis includes information about (1) the development of residencies; (2) problems in maintaining residencies; ( 3 ) t h e selection of residents; ( 4 ) t h e content of training; and (5) the resident-product. Knowledge of t h e structural settings of residencies is necessary for understanding the underlying c o n s t r a i n t ~of operating a new area in graduate training. However, while t h e fate of emergency medicine depends i n part on what happens within national associations such a s t h e AMA, ACEP, and UAIEMS, it also depends on what emergency physicians a r e able to achieve i n hospitals a n d medical schools around the country.

At t h e h o s p i t a l a n d medical school level, i t i s hypothesized t h a t directors of emergency medicine residencies a r e attempting to: 1. develop a distinct identity for emergency medicine;

2. document the need for trained physicians in emergency medicine through graduate programs; 3. develop enough prestige i n their own institutions to acquire sufficient resources to maintain and expand their programs.

Therefore, if emergency physicians, through their residencies in particular, demonstrate successes and gain recognition a t the local level, it is further hypothesized t h a t the field will be more likely to gain formal recognition a t the national level.

The conceptual framework used for analyzing the data is one in which emergency medicine is viewed a s a "seg-

ment" of the medical profession. Within this frame of ref-erence, major questions to be addressed are: "How do emergency physicians forge new roles within traditional institutional settings where other segments control more resources and have more status?"What unique services a r e claimed by the emergency physician?" and "What specialized areas of research are held a s unique to emergency medicine?"

Within the sampling scope of this phase of the study. hypotheses will be tested and generalizations will be made about emergency medicine graduate education development. The results should have significance in the context of future emergency residency program planning, research, and evaluation.

VIPs - An EMS Challenge Chester L. Ward, MD Former Assistant White House Physician, Washington, DC The components and inner workings of an Emergency Medical Services System (EMSS) a r e known and understood by most of the professional personnel working in t h e acute, critical medical care field. The presence of VIPs in a n area and the possibility t h a t one o r more may require emergency medical treatment offers some very interesting challenges to the community and its Emergency Medical Services System.

Some of the challenging areas and topics discussed in this presentation a r e the definition of a VIP; schedule factors; information concerning capabilities and entry into the local medical community; the determination of the specific responsibilities among the medical components, security forces and other support activities: multiple jurisdictions and overlapping "interface" situations; resources (manpower and budget); hospitalization of a VIP; the news media, and a n adverse outcome o r result of the EMSS's efforts.

The Integrated Trauma Service Concept: Out of Many - One Kimball I. Maull, MD B. W. I-Iaynes, Jr., MD, FACS Department of Surgery, Trauma Division, Medical College of Virginia, Richmond, Virginia Trauma seldom respects lines of traditional specialty domain. The determination of who should assume primary care responsibility of the acutely injured is often made in the heat of battle a t the junior resident level.

When early care is assumed by a specialty service, injuries to other systems are often neglected, care is fragmented, and morbidity increases.

An integrated trauma service, through coordination of preexisting hospital manpower a n d resources, ensures the availability of care to patients suffering unforeseen or critical physical injuries and their sequelae. Provided a n examination of t h e overall Emergency Medical Service capabilities of t h e community dictates t h e need for a trauma service, the first step is to secure a surgeon interested in the care of the t r a u m a patient. Cooperation of physician colleagues is gained either by inclusion of the specialty resident staff on the Trauma Service or by a policy of mandatory consultations whenever injuries involve specialty areas.

Trauma Service involvement begins with initial assessment, resuscitation, and prioritization of the patient in the emergency area a n d extends through definitive care, management of injury sequelae, and rehabilitation.

The "isolated injury" is defined by the T r a u m a Service and the appropriate specialty service notified. Injuries involving two or more body systems dictate admission to the Trauma Service except for the patient with a n unstable cervical spine injury or deteriorating neurologic status.

Under such circumstances, a neurosurgical admission is instituted and the Trauma Service consults.

When operational, the Trauma Service contributes to educational programs a t all levels. Compilation of clinical data a t discharge for later computer analysis bypasses the i n a d e q u a t e I n t e r n a t i o n a l Classification of Diseases, Adapted system used by most medical records departments and provides easy retrieval of meaningful data for future research. The problem of t r a u m a care follow-up is approached through a multi-disciplinaly clinic.

Implementation of such a broad-based program is not problem-free. Recent experience a t the Medical College of Virginla is cited.

Evaluation of the Patient Advocacy Program of the Johns Hopkins Emergency Department

Marla Salmon White, BSN, RN Director of Nursing

Geoffrey Gibson, PhD Associate Director Emergency Department, J o h n s Hopkins Hospital, Baltimore, Maryland In recent years, hospitals and other health services institutions have experienced increased public awareness of problems related to the delivery of health care. Demands for increased community participation in the provision of such services h a s resulted in the institutional realization that more responsive and accountable modes of care must be explored and that the needs of the individual patient must be addressed. Emergency departments in particular have experienced the squeeze between public demand for such care and institutional ability to provide it. In 1974,

the Johns Hopkins emergency department established a program of patient advocacy to address problems relating to patient satisfaction, knowledge and therapy-related behavior. While t h e program was concerned with t h c issue of patients' rights, the role of t h e advocates was defined primarily in terms of patient teaching, provision of emotional support, social service referral, providing communication between staff, patient and family, and crisis intervention. The program was also set u p to acquaint first-year medical and health associate students of the Johns Hopkins University with the skills of interaction necessary to thc role described above. These students were trained and served under supervision a s the advocates for the emergency department.

This paper describes a n evaluation of the Johns Hopkins emergency department program in patient advocacy.

The purpose of the study was to evaluate the impact of patient advocacy on patient satisfaction, knowledge and behavior. Through a controlled trial carried out in surnrner of 1974, 412 patients presenting with any of five of the fifteen most common complaints were assigned to one of the four study groups: patient advocacy, halo, placebo and control groups. These patients were then interviewed to determine levels of knowledge and satisfaction. Patient behavior was measured in terms of appointment keeping behavior and other behaviors related to the process of care in the emergency department. The study findings are discussed in this paper, both in terms of programmatic and organizational implications. Emphasis has been placed on the issue of source of support for programs in patient advocacy and its possible impact of the efficacy of t h a t role.

Strategies of Care for Patients not Returning for Suture Removal Nancy Fink, BA William B. Greenough, 111, MD Geoffrey Gibson, PhD Health Services Research and Development Center, Division of Emergency Medicine, The Johns Hopkins Medical Institutions, Baltimore, Maryland Patients utilizing emergency departments are noted for their high rate of noncompliance with follow-up care. This lack of compliance contributes to t h e problems of unknown outcomes and continuity of care for providers of emergency medicine. This study is concerned specifically with patients presenting in the Johns Hopkins Hospital emergency department with lacerations t h a t require follow-up for suture removal.

A retrospective audit of 100 patients treated in the emergency department for minor wounds revealed t h a t 51 percent did not return for their Surgical Dressing Clinic tSDC) appointment. A prospective study of 200 patients was undertaken to confirm these findings and to describe the outcomes of patients not returning for follow-up care.

All patients selected in t h e prospective study were interviewed three to five days after their scheduled SDC ap-

pointment by telephone or in person. The findings of this study indicated t h a t 4546 of the patients did not return to the SDC for suture removal but t h a t 74% of the patients did have their sutures removed a t the time of the interview. The two most frequently stated reasons for not returning for SDC follow-up were inconvenient clinic hours and high clinic costs. The interviews revealed t h a t 25% of the patients were removing their sutures a t home. These findings indicated a need to evolve methods whereby patients choosing not to return for follow-up care could remove their own sutures a t home with instructions provided by the emergency department.

An intervention study was designed to assess the impact of patient self-care. Patients were randomly assigned to the experimental group in which they were given the choice of receiving a suture removal kit with instructions or a scheduled follow-up appointment for suture removal in the emergency department or to the control group in which they were given a scheduled follow-up appointment for suture removal in the SDC. Patterns of patient compliance a n d outcomes a r e documented by a follow-up household interview and photograph of the wound three to five days after scheduled suture removal. Assessment and comparisons are made of the two methods of wound management with regard to patient outcomes and costeffectiveness.

Respiratory Function Following Application of MAST Trousers Norman E. McSwain, Jr., MD, FACS Department of Surgery, The University of Kansas Medical Center College of Health Sciences and Hospital, Kansas City, Kansas The effectiveness of MAS?' Trousers in combating hypotension from a variety of causes has been well den]onstrated. There has been some question a s to compromise of respiratory function because of ahdomirial compression, and therefore, drtcreased excursion of t h e diaphragm and incorriplete lung expansion. 61 patients w i t h a p p l i c a t i o n of p n e u m a t i c t r o u s e r s h a v e been evaluated. Presentation on the effectiveness of MAS?' Trousers was presented a t t h e 1976 Meeting of t h e American Association for the Surgery of Traurna.

In order to evaluate the possibility t h a t pulmonary function is compromised, arterial blood gasses and mixed venous blood gasses were evaluated on these patients. Patients with thoracic in:uries and patients ti-om whom no initial blood gasses were obtained until institution or high flow oxygen or endotracheal intubation was begun were eliminated. The average pH was 7.42, PO2 was 46. The initial conclusion is t h a t there is no s i p i f i c a n t adverse effect i n p a t i e n t s whose hlood loss hypotension w a s treated with MAST Trousers.

As more patients a r e treated with pneumatic trousers, they will be added to the study so t h a t a t time of presentation, the study will be a s up-to-date a s ~wssible.

Value of G-Suit in Traumatic Shock Daniel Lowe, MD Leo R. Radigan, MD J o h n L. Glover, MO Department of Surgery, Indiana University Medical Center. Wishard Memorial Hospital, Indianapolis, Indiana The value of t.ht? G-suits in emergency management of hypovolemic shock patients has been attributed to its autotransfusion effect. Our studies indicate other sound physiological benetits t,c its use when properly applied.

Experimental shock studies, analyzirig venous blood from all major organs, revealed t h a t prcjgressive acidemia is primarily a result ot' hyppi-rfused skeletal nluscle. Little acid n~etaboliteis produced from vit;~lorgans.

Other studies in patients and animals, utilizing tourniquets, show: ai little acidosis during the recovery phase as measured hy muscle pl3 prohe$ and venous sampling, s seen with and b) none of the cellular c h a ~ ~ g eusually shock. Therefore, total ischen~iiiof'skelrtal niuscle is better tolerated and less deterir~lentalt h a n low flow states.

Our paramedic prolocol fbr use of the "shock pants" will be outlined, emphas~zingthe irnpi)rt.anre of monitoring and maintaining compression pre.ssure above systolic pressure. The plan for release of pressure must be carefully followed also.

The IV in Readiness: A Mixed Blessing?

J o h n R. Saucier, MI) Allen P. Klippel, MI) Department of C o m ~ n u l ~ i tHealth y and Med~caiCare, St. I ~ u i County. s Missouri

A bacteriologic stud; was undertukeri to det,ernline the level of contarninat~ullof' TV solutions and tubing left hanging in readiness in !he enicrgcucv department. Samples of the ccimn~onlyused solutions, as well as IV tubing, were cultured after the 1V set-ups had heen left opened for various time periods f'ronl 21 hours to one a r e k . fldsed on concerr~inghaving IV sothe results, recorr~rnendut.io~ls lutions in re:idiness are o f i r e d .

Parasympathetic arid Sympathetic Mechanisms in Sudden Death and Immediate Responses to Trauma and Injury George K. Scliwant,~,MD Director, Emergency Metlicints. Wehi .lerst+y Jiospittrl, Carnden, N e w ,ler.it,v While parasyrrlpcrt.het~~ rchponses tend to he mediated through neural ~.outcsand are rnaniSested withill a second or two, ryrnpattietic reslxlnsez, tiept>ridbngon suh3tance re-

lease and blood-borne hormones, tend to he more delayed.

Analys~sof 100 cases of sudden death demonstrates the likelihood of a n initial response with disastrous results.

The sympathetic system, which serves a s the protector, requires more time for functioning and sudden death occurs prior to this response. The use of sympathetic blocking. such as those for hypertension, may result in a tendency towards sudden death in some individuals.

Discussion of this potentially fatal predisposition resulting from use of sympathetic blocking agents raises serious questions as to need tbr more judicious use of such agents.

Implications for prevention of sudden death are discussed.

Percutaneous Transtracheal Ventilation During Cardiopulmonary Resuscitation Laurence B. Dunlap, M D Josephine General Hospital, Grants Pass, Oregon Pulmonary venl~lationuslng intermittent jets of 100% oxygen is currently practiced during microsurgery of the larynx and with ventilating bronchoscopes. The introduction of a 14 gauge "intravenous" Teflon catheter through the cricothyroid membrane for jet ventilation of nonbreathing patients has been proposed by Smith and others as a n emergency resuscitative measure in situations where endotracheal intubation cannot be rapldly performed. Experimental studies have indicated t h a t blood PO2 can be maintained, b u t t h a t COz washout is not adequate to reliably prevent a gradual increase in blood PC02.

This study attempts to demonstrate t h a t C02 washout will occur when jet ventilation of the trachea is augmented by manual compressions of t h e chest such a s riccur during closed cardiac massage. Studies of blood gas changes d u r ~ n gthe transtracheal jet ventilation of apneic , ~ n dapneic fibril1;tting dogs undergoing closed chest cardiac massage will be presented. Results f'rc~mt h e irnmedi:ite post mortem ventilation of' human subjects will also be presented. The a u t h o r concludes t h a t m a n u a l chest comprt7ssion improves pulmonaly transtracheal jet \.entilation sufficiently to warrant the re-evrrluation of this technique in selected emergency situiitions.

Trauma Centers: A Pragmatic Approach to Need, Cost and Staffing Patterns William Teuf'el, MD Assistant Professor of Surgery

Donald D. Trunkey, MD Associate Professor of Surgery Trauma Center, Sarl Francisco General Hospital, S a n Francisco, C:riiSorni;i In recent years. both government and organized medicine have attempted to define and characterize optimal trauma

centers. While some guidelines have evolved. costs have not been discussed and guidelines may penalize the nonteaching hospital in respect to manpower.

Using criteria developed by the American College of Surgeons iACSi and Health Services Administration (HSAI, we have computed the annual cost for manpower in an "optimal" trauma center. Assuming 24-hour coverage, it will cost 3.5 million dollars under ACS guidelines and 2.6 million dollars under HSA guidelines. This does not include back-up teams once a single patient has entered the system.

Since residents may serve a s surrogates for 24-hour coverage, the teaching hospital has a n advantage over the "community hospital" in reducing manpower costs. On call specialists within 30 minutes is a more viable alternative to the community hospital, and should not connote a "suboptimal" traunia center. On the other hand, not every community hospital should be a t r a u m a center. This should be based on area needs and a large enough patient load to insure utilization of a costly service, and to maintain physicians and paraprofessional skills. An adequate patient load is difficult to define, but should be a t least three cases per day. Alternative solutions such a s improved transport systems will require development when the area needs do not justify a trauma center.

Finally, the t r a u m a center must demonstrate that costs, staffing patterns and satisfaction of need have improved quality ofcare. Suggestions for measurement of this will be presented.

Malignant Lactic Acidemia Due to Phenformin Randall G. Cook, MD Carl Jelenko, 111, MD Burn Serv~cesand Laboratories, Med~calCollegts of Georgia, Augusta, Georgia Phenformln hydrochloride tI>BI, DRI-TD, Meltroli, is a n oral agent sometimes used i n the management of adultonset, non-ketotic diabetes mellitis. The drug has several actions which include an ahility to block conversion of lact ~ ac c ~ dto pyruvic acid and reduction of the kidney's ahility to excrete an acid load. Several reports have implicated Phenf'orniin tPf) a s the -tiologic agent in lactic acidosis observed in diabetics who present with a severely depressed pH and only a mild elevation in glucose ooncentration w ~ t h o u tketoacidosis. Mortality from Pf-related lactic acidemia is reported to be as high a s 80'1.

Seven patients with this lesion have been observed in our institution. All have died - all with associated renal failure and cardiovascular collapse. A recent patient was a 65-year-old, obese woman who s u s t a ~ n e dsuperficial burns to 30'; of her body surfaces. S h e was managed with modest fluid restriction and continuation of her diabetic regi~new h ~ c hincluded 200 mg Pf daily. On her eighth postburn day she hecanle oliguric, confused and somolent.

S h e then developed respiratory distress a n d a n u r i a .

Serum pH was 6.63 with a bicarbonate of 6 m*. She died on her tenth postburn day of a massive myocardial infarction having required more t h a n 3,000 mEq (60 ampules) sodium bicarbonate over 26 hours to sustain her pH a t 7.20-7.35, Hypernatremia developed pre-terminally and was earlier controlled by peritoneal dialysis.

Pf-related lactic acidemia must be suspected by the emergency physician when there is unexplained acidosis in a diabetic patient taking the drug. This is especially true if there is no ketonemia and only a modest elevation in serum glucose. In addition to our own cases, a summary of t h e cases in prior reports suggests t h a t the pathophysiology of the lesion is such t h a t i t may affect a different type of diabetic patient than does ketoacidosis.

Walk-Out Patients in the Hospital Emergency Department Geoffrey Gibson, PhD Lois A. Maiman, MA Health Services Research and Development Center, The J o h n s Hopkins Medical Institution, Baltimore, Maryland Patients who leave the emergency department before treatment place hospitals in potential clinical a n d legal jeopardy a n d constitute a phenomenon of s u b s t a n t i a l interest to the emergency department in assessing its effectiveness a n d m a n a g e m e n t process. T h e r a t e a n d characteristics of walk-out patients may serve a s a n important monitoring mechanism for patient satisfaction and emergency department effectiveness. Despite this, only one study exists of walk-out patients and it did not involve systematic follow-up of patients, nor matched pair comparisons between walk-out and non-walk-out patients.

The patient series being reported a r e all patients leaving The Johns Hopkins Hospital emergency department before treatment over a 12-month period ( n = 200). The walk-out patients were matched with a n eligible nonwalk-out patient with regard to shiR, age group, and presenting complaint. Both walk-out patients and t h e i r matches were interviewed within two weeks aRer their emergency department encounter by telephone or in person. The study was aimed a t explaining the motivation of patients leaving before treatment and a n assessment of the decision to walk-out on the patient's health status.

Walk-out patients are compared with their matched controls in terms of delay in seeking care; mode of arrival; payment status; care seeking behavior; dissatisfaction with emergency department waiting time, staff and procedure; subsequent health care and utilization behavior; a n d reduction (pre- a n d post-emergency d e p a r t m e n t visits) of discomfortipain, anxiety, and symptom levels, and willingness to be treated by non-physician provider.

Zygomatic Fractures in the Emergency Department: Evaluation and an Approach to Treatment A. Neal Wilson, MD J . Howard Binns, MD Department of Plastic Surgery, Wayne State University Medical School, Detroit, Michigan Diagnosis of facial fractures in the emergency department usually relies on three main features: 1 ) a history of facial trauma; 2) clinical signs of facial trauma; 3) routine facial bone x-rays. Zygomatic fractures may be usually diagnosed on clinical symptoms and signs, but most reliance tends to be placed on the routine x-rays a s specialized x-ray procedures are often unavailable to the emergency physician.

The importance of zygomatic fractures rests on three main features: 1 ) the degree of disruption of the orbital floor; 2 ) permanent difficulties with mastication, a n d 3 ) the aesthetic deformity of the "slipped" cheek bone.

Difficulties arise for the emergency physician when the clinical signs a r e inconclusive and the available x-rays a r e unclear. Under these circumstances, a specialist's opinion should be sought.

Our approach to evaluation and treatment is to reduce the fractures under direct vision via incisions over the orbital margin fracture sites; accurate reduction results in correct spatial re-alignment of t h e body of the zygoma which is then transfixed with a Kirschner wire.

In 11 cases so treated, the results have been good with minimal complications. Three cases will be described: 1 ) good clinical signs, "positive" x-rays, fracture a t exploration; 2) inconclusive signs, "positive" x-ray report and no fractures a t exploration; 3 ) inconclusive signs, negative x-ray report and fractures a t exploration.

Airless Paint Gun Injuries: A Progress Report

John M. Heibert, MD George T. Rodeheaver, PhD Cameron A. Gillespie, MD Richard F. Edlich, MD, PhD Emergency Medical Services, University of Virginia Medical Center, Charlottesville, Virginia The new airless paint gun has been designed to increase the rate of paint application by the painter. If this high pressure jet of paint strikes a n extremity, the paint will be blasted through the skin The end result of a majority of these accidental injuries 1s amputation despite immediate treatment.

A standardized experimental model has been developed to provide insight into the definition and management of this injury. Utilizing this model, the structure of paint

materials could be correlated with their toxicity. Once a component of paint was injected into tissues, it was extremely dificult to remove by either incision a n d drainage and/or irrigation. Antibiotics appear to have a n important place in the care of a paint injury. They markedly reduced the number of bacteria in contaminated paint injuries and minimized t h e deleterious effects of infection.

The difficulties encountered in treating paint injuries confirm the necessity for safety regulati'on and standards for all high pressure injection devices. On the basis of these studies, the Consumer Product Safety Commission (CPSC) issued a press release to alert and inform exposed population groups of the demonstrated hazards. Corrective, active plans were then developed by the CPSC to remedy the demonstrated hazards of airless paint gun injuries.

Survey of Abdominal Trauma 1972 Through 1975 Christine E. Haycock, MD Menvan Mistry, MD Kenneth Swan, MD Department of Surgery, College of Medicine and Dentistry of New Jersey, New Jersey Medical School, Martland Hospital. Newark, New Jersey Martland Medical Center is the main teaching hospital of New Jersey Medical School, NJCMD, Newark, New Jersey. Better than 65% of the cases seen in the cases are gunshot wounds or stab wounds, with a lesser number of automobile accident cases a n d o t h e r t y p e s of b l u n t trauma. In order to evaluate t h e type of treatment and the ultimate outcome of all of our abdominal injury cases from 1972 through 1975, a n extensive search of the medical records was carried out and 565 cases were identified.

296 of these were stab wounds, 142 were gunshot wounds, and the remaining cases were blunt trauma.

Among the factors documented were the location of t h e injury, the extent of the injury, t h e organs involved, the number of pints of blood necessary during treatment a n d surgical intervention, the approximate amount of electrolyte solution administered, the type of treatment received, the complications, and the ultimate results. Additional factors included were the problems encountered by the fact t h a t many of these injuries occurred to patients who are alcoholics, drug addicts or psychotic, thus adding to the severity of t h e case. The immediate care rendered in the emergency department is discussed in relation to the type of definitive surgical procedure ultimately carried out.

Of the 565 cases seen, 29 were mortalities, with a 10% complication rate post-operatively. Considering the severity of the cases, we feel t h a t the overall statistics represent the efforts of a well-trained resident team accustomed to trauma, and acting rapidly to insure a successful outcome in the majority of cases. We feel t h a t the statistics of

this 540 bed state hospital compare favorably with those of the larger medical centers in the country.

Survival Rates of Major Abdominal Vascular Injury in a Seven Year Period

Peter B. Yaw, MD Michal Zahm, MD John L. Glover, MD Department of Surgery, Wishard Memorial Hospital, Indiana University Medical Center, Indianapolis, Indiana Nationwide, millions of dollars a r e being spent annually to improve emergency medical services, but proof t h a t t h i s e x p e n d i t u r e a c t u a l l y improves s u r v i v a l of traumatized patients is lacking. We have reviewed our experience with penetrating injuries of the inferior vena cava and abdominal aorta from 1968 to 1975, a time when emergency medical capabilities in o u r community progressively improved. Our results show no improvement in patient survival during this time period when dealing with this devastating injury. We conclude t h a t t h e proof of benefits from investment in emergency medical services for t h e traumatized patient must be obtained by review of survival rates of patients with less severe injuries than penetration or disruption of t h e abdominal aorta and inferior vena cava.

Suspecting Thoracic Aortic Transection

Kenneth L. Mattox, MD Laurens Pickard, MD Raul Garcia-Rinaldi, MD Cora and Webb Mading Department of Surgery, Baylor College of Medicine, and the Ben Taub General Hospital, Houston, Texas Deceleration thoracic accidents produce a complex of potentially fatal injuries. With improvement i n community emergency medical services communication a n d transportation, the initial evaluating physician must be acutely aware of clues suggestive of reversible potential lethal injuries.

Of the more t h a n 10,000 patients with thoracic injuries presenting to t h e emergency c e n t e r over a n 11-year period, 100 had clinical or radiographic clues suggestive of blunt t r a u m a decelerative injury to the great vessels.

Among these 100 patients. 23 had transection of the descending thoracic aorta and five had avulsion of the innominate artery. One patient had a double transection.

Six patients expired in the emergency center before proximal control could be achieved.

As the rate of injury h a s increased from one aortic transection per four years in 1966 to four per year in 1976, emergency physicians should be a w a r e of signs suggestive of this complex vascular injury.

A More Reliable Gram Staining Technic for the Emergency Medical Physician Michael D. Spengler, BS George T. Rodeheaver, PhD Christopher Magee, BA Milton T. Edgerton, MD Richard F. Edlich, MD, PhD Emergency Medical Services, University of Virginia Medical Center, Charlottesville, Virginia When presented with a n infection, the emergency physician must select a n antibiotic t h a t will limit the growth of the pathogen or kill it. The decision must be made immediately to limit the spread of the pathogen. The information derived from the microscope examination of a Gramstained specimen helps considerably in selecting a n antimicrobial agent.

The purpose of this study was to identify pitfalls in the Gram-staining technic t h a t limit its diagnostic value. In our clinical experience in the emergency department, gram-positive organisms were often decolorized too easily.

Factors have been identified that alter the susceptibility of gram-positive o r g a n i s m s to decolorization i n t h e Gram-staining technic. The age of the bacterial culture, the preparation of the smear, the fixation technic, and the mordant have a n important influence on the ease with which gram-positive organisms are decolorized. On the basis of these studies, a more reliable and reproducible Gram-staining technic has been developed for the diapnosis of infections. The reagents employed in this technic have been assembled and are commercially available in a kit for use in the emergency department.

Digoxin-Lithium Drug Interaction David Ralph, MD Assistant Professor, Section of' Emergency Medicine, D e p a r t m e n t of I n t e r n a l Medicine, University of California, Davis, Sacramento Medical Center, Sacramento, California Lithium salts and digitalis glycosides are classes of drugs t h a t share a s common properties a narrow toxic1 therapeutic ratio and a propensity to induce cardiac arrhythmias, even a t "therapeutic" blood levels. We describe a patient taking commonly-used dosages of lithium carbonate and digoxin who presented with increasing tremulousness, marked confusion, and a severe nodal bradycardia alternating with slow atrial fibrillation. The lithium blood level was in the toxic range a t 2.0 mEqiliter and the digoxin level was in the lower therapeutic range a t 0.7 ngtml a t the time of admission when the patient had a junctional bradycardia at a rate of 52 beatslminute. However, despite discontinuation of both medicines, the rate fell to 30 the following day, requiring activation of a temporary pacemaker which had to be kept in place for six days before the patient reverted to normal sinus rhythm. Although the serum

potassium level was always normal, we postulate t h a t t h e intercellular potassium depletion known to be caused by lithium increased the effect of t h e digoxin and t h u s led to a synergistic toxic effect resulting in t h e prolonged arrhythmia. This is the first report describing such a clinical presentation. As lithium salts become more commonly used in the elderly population, which also has fiequent use of digoxin, increasing numbers of patients will risk similar arrhythmias.

A drug-induced etiology must be considered by t h e emergency physician treating a patient with a bradyarrhythmia. Such arrhythmias can be quite prolonged.

Quality Control of Radiological Interpretation in the Emergency Department George Podgorny, MD Gary Quick, MD Department of Emergency Medicine, Forsyth Memorial Hospital a n d F o r s y t h E m e r g e n c y S e r v i c e s , P . A . , Winston-Salem, North Carolina Of the traditional specialty areas, radiology is of utmost importance in the practice of emergency medicine, for the emergency physician is required to make many therapeutic decisions based upon findings and interpretations.

There are essentially two ways of integrating the interpretation of t h e radiographs into the emergency care of a patient and the subsequent record: 1) All the radiographs, upon completion, are examined and interpreted by the radiologist. The subsequent report is communicated to the emergency physician either orally or in writing.

2 ) Radiographs, upon completion, are brought to the emergency physician's attention, who examines and interprets them. Clinical decisions a r e made based on such interpretation. Within t h e next twenty-four hours, t h e radiographs are also seen and interpreted by a radiologist, a s is required by the Joint Commission on Accreditation of Hospitals.

At Forsyth Memorial Hospital in Winston-Salem, North Carolina, a 750-bed facility, with approximately 75,000 visits occurring annually to t h e Department of Emergency Medicine, radiographs a r e completed a s described in Number Two above.

In order t o ascertain t h e q u a l i t y of t h e system of radiological interpretation in the Department of Emergency Medicine, a s well a s the quality of the interpretation itself, which bears directly on t h e quality of t h e emergency care rendered, a retrospective study was performed.

Basic DurDoses were (1) to determine accuracy of interpretation of radiographs by emergency physicians, (2) to develop a n educational tool for t h e emergency physician and residents in training for emergency medicine, ( 3 ) &

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56

to establish a n acceptable and duplicable standard for radiographic interpretation by the emergency physician, and (4) to provide a meaningful and acceptable audit.

Two separate studies were carried out, one covering a period of two months, and t h e other a separate period of five months. During the seven months, the emergency physicians ordered 32,226 radiographic procedures. Total number of nonconcordant interpretations was 369. A nonconcordant interpretation was any difference between the interpretation made by the emergency physician and the subsequent interpretation by the radiologist. After a review of the entire group, 59 of the 369 were thought to be "significant" nonconcordant interpretations.

The 59 nonconcordant procedures were reviewed in great detail in a meeting o f t h e Department of Emergency Medicine and Radiology. The majority of these represented chest radiographs a n d t h e nonconcordance involved differences of opinions in interpreting chronic and occasionally acute changes in the thoracic structures. The remaining 13 were found to be significantly nonconcordant structures and represented a definite radiological pathology t h a t was not appreciated a t the time by the emergency physician.

In the first study, the nonconcordant radiographic interpretat~onswere 2.49 percent. In the second study, this percentage dropped to 0.71c2. This significant reduction was the result of extensive conferences between emergency physicians a n d radiologists and t h e emergency physicians among themselves.

Emergency Department Observation Unit: Utilization in a University Hospital and Role in Physician Training

W.F. Bobzien, 111. MD Department of Medicine, University of North Carolina.

Chapel Hill, North Carolina Emergency department ( E D ]observation unlts are used ro define diagnosis, treat acute illnesses in whict; rapid ,mprovement can be expected, or limlt inpatient hos~italizationin exacerbation of chronic illnesses. In a hospital engaged in physician training, the prrjv~slonut'a saie .liternative to r ~ t h e ra d n ~ ~ s s i oto n the h o s p ~ t a i.)r dis:harge fiom the E l l may be a n aaditional benefit. .\ iour-bed o b s e r v a t ~ o nu n i t was est;ihlished a t the '.Torth (I:rrolina .Memonai Hospital in 1973. Admiss~on1s !imlted to '11 hours, and patients requiring specialized (:;Ire or :non~toringI r e excluded. 'To drtermlne eff'ectiveness of utilization rind the apgrupriatenezs of clinical deci.;on making, a detailed retrospect~vr. ~ n u l y s ~wits s made .)iail admissions d u n n ~ :r rive-month period.

There were 4-15 admi:is~ons.The .mean duration of ad71:s~ionwas !;).? iiuurs. Ninety-eight patients were sub5equentlv :~dmlttedt o the n n s u ~ t a l*?"'? '. No deaths oc:~urrecl.and no excesp mort~lditycould br r~t.trihutedto the . : ~ c or'obierv;~rion. t Six prrcnit of :iurri:ss~onsto the unit

were judged to have been inappropriate in t h a t adequate definition of diagnosis or significant improvement could not be anticipated.

The ED observation unit appears to offer a safe, costeffective alternative to regular hospitalization for appropriately selected patients. In a training institution it can also provide clues to the determinants of clinical decision making and identify problems of faulty decision making on the part of house officers.

Rapid Serial and Low Energy DC Shocks for Transthoracic Ventricular Defibrillation of Man Joseph A. Gascho, MD Frank P. Hunter, BEE Michael L. Chenvek, MD Richard S. Crampton, MD University of Virginia Medical Center, Charlottesville, Virginia Since the energy dose to defibrillation is disputed (retrospectively derived a t 6.6 jouleslkg or more above 46 kg body weight versus prospectively successful 1-3 jlkg u p to 145 kg), we prospectively assessed 149 shocks in 111 episodes of ventricular fibrillation (VF). In 32 patients, 25 male, mean (range) age was 63 (13-86) yrs, weight 75 (48-101) kg, stored energy 219 (50-400) j, and delivered energy 189 (45-349) j or 2.6 (0.9-6.6) jlkg. Tested via 50 ohm load, 14 devices provided 5 msec shocks for 106 (71%) and 12 msec for 43 (2%). The first shock ended VF in ~ W Cthe , second and third in 4% for 9 5 4 cumulative success. Twelve patients with 46 secondary VF in acute myocardial infarction (AMI) weighed less a t 74 (48-101) k g and received more energy (2.7 j/kg) than 6 with 26 primary VF in AM1 who weighed more a t 81 (68-91) k g and received less energy (1.9 jlkg). The first shock (1.8 jlkg) defibrillated 23 of 26 (88.5410) primary VF in 6 AMI. The first shock (2.5 jlkg) defibrillated 12 of 12 (100%) primary V F in three coronary patients without AMI. T h u s 35 of 38 (9%) primary VF received 2.1 jlkg. Ten with other diagnoses weighed 71 (54-101) k g and received 2.9 (1.9-4.3)jlkg like secondary VF. The fourth shock ended all VF except !3% secondary VF. The first shock ended 31 of 46 (69%,)secondary V F with 1 3 of 19 (68%) 5 msec and 1 8 of 26 (6% 12 msec pulses. Eight patients had 14 double and 15 triple rapid serial shocks 1.8-30 sec apart with 63% double success (total dose 4.9 jlkg) and 80% triple success (total dose 8.0 jlkg). Four patients survived short and four long term.

In summary, single and rapid serial low energy shocks ended VF a t 40% of recommended high energy. It reduced counterproductive electrical heart burn. Since low energy a n d rapid serial shocks ended secondary V F in 91% and primary VF in l o w , they deserve wider use because of efficacy and safety.

Autotransfusion of Contaminated Intraperitoneal Blood: An Experimental Study John L. Glover, MD Richard N. Smith, MD Peter B. Yaw, MD Department of Surgery, Indiana University Medical Center, Wishard Memorial Hospital, Indianapolis, Indiana Contamination of blood by bowel contents h a s been generally acknowledged a s a n absolute contraindication to autotransfusion. Since abdominal t r a u m a is frequently accompanied by bowel injury and massive blood loss, a potential major use for autotransfusion has been precluded.

To test this presumption, autologous blood grossly contaminated with feces was incubated in the peritoneal cavity and then autotransfused to dogs. The animals were hemorrhaged 20, 30, or 40% of their estimated blood volume producing mild t o severe hypovolemic shock. Reinfusion of contaminated blood produced little effect on survival with 20% or Y W o hemorrhage but contamination markedly decreased survival with 40% hemorrhage. 90% survived without contamination while only 30% survived with contamination. The use of antibiotics, in a similar group of dogs subjected to 40% hemorrhage, essentially eliminated the risk of autotransfusion. With antibiotics, 90% survived autotransfusion of contaminated blood.

Rhabdomyolysis and Acute Renal Failure David Ralph, MD Assistant Professor, Section of Emergency Medicine, University of California, Davis, Sacramento Medical Center, Sacramento, California Rhabdomyolysis seems to be a more commonly recognized event than h a s been reported in the past. The presentations and clinical courses describe three patients with acute rhabdomyolysis who entered our emergency department within a four-month period. One patient, n 29-year-old sporadic heroin user, fell asleep for fitteen hours with his iegs dangling over the edge of' a pool table and presented to the emergency department with sensor?; complaints in his lower extremities. Originai at,tention tocused on ?is neurological problen~. and nor until the ,lrinalysis showed orthotolidin-positive urine w ~ t h o u tred cells was the diagnosis of rhabtlomyolysis considered. The patient subsequently had a prolonged hospital course requiring seven aays ot' diaiys~sbt?tbre :~dequaterenal Func::on returned. Another patient, an wlcc~holicwho denied yecent trauma. presented with hllateral c;i~!'con~u:irrmc~i~t syndromes. cute renal failure requiring di:llysi? t'rom rnahdomyolys~s .ultli symptomatic hvpoc.alcemra, :ind :I (YPK of over :5,5.tiO(i. \ third pat?r.nt who il.zq btviaten and :av :ncapacitatcfl on his .rp;tl.tn~entiloor. !i)r t;vo d a y s preienceri wlrh a C-PK ~t over ;O.OU(j hut 'lad o n i v pr.t,-renal a?.ottm~a.

Rhabdomyolysis may occur in a variety of situations from non-traumatic a s well as traumatic causes. The clinical course often involves hyperkalemia, hypocalcemia, and acute renal failure with a rapidly rising creatinine.

Proper attention to early volume replacement a n d a t tempts a t inducing urine flow with mannitol and diuretics is important. The acute emergency department diagnosis and management of rhabdomyolysis will be described.

Xiphisternal Costochondritis: The Imitator of Severe Disease Carl Jelenko, 111, MD Professor of Surgery, Department of Surgery, Medical College of Georgia, Augusta, Georgia In 1921 Tietze described a syndrome of tender nonsupprative swelling of one o r more costal cartilage. In 1974, the first cases were reported in which the xiphisternal joint was involved.

In the past 24 months we have observed eleven patients with a documented history of prior gastrointestinal, biliary tract, pancreatic or cardiac disease whose current symptoms a n d signs strongly suggested recurrence of their previous problem. Since our routine examination includes pressure over the xiphistemal joint, we produced a duplication of each patient's signs and symptoms by this maneuver. Infiltration of the joint with Lidocaine, containing hydrocortisone, relieved all patients immediately.

Among the more interesting presentations was a patient with a documented history of cardiovascular disease who was admitted with epigastric and substernal pain with radiation into the left shoulder and medial upper a r m . T h e r e were no electrocardiographic or enzyme changes, and the problem was resolved with the intraarticular infiltration described. A 54-year-old man with a documented previous peptic ulcer disease, pancreatitis and cholecystitis presented with bloating, vomiting, and epigastric pain radiating to t h e back. There was tenderness in t h e upper abdomen and duplication of the symptoms on xiphisternal pressure. All signs and symptoms were relieved immediatelv intraarticular iniection. " bv " Three patients presented w i t h a p p a r e n t incarcerated properitoneal hernias; four with a presumptive diagnosis of peptic ulcer disease; three with presumptive diagnoses of pancreatitis or biliary tract disease; and one with a presumptive diagnosis of myocardial infarction.

Because of the probable relative frequency of the entity and the need to differentiate it from more severe disease, we believe t h a t it is wise for t h e emergency physician to consider the entity and to include the maneuver of pressure over the xiphisternal joint - and perhaps intraarticular Lidocaine infiltration -- when dealing with midepigastric andior low retrosternal pain.

Emergency Service Treatment of Patients with Chest Pain: A Comparative Analysis Bernard Slosberg, MD, M P H Division of Emergency Medicine, Baltimore City Hospital

Nancy Fink, BA Geoffrey Gibson, P h D Health Services Research and Development Center Division of Emergency Medicine, The J o h n s Hopkins Medical Institutions, Baltimore, Maryland Since cardiovascular accident represents the number one cause of death and significant morbidity for the population, a great deal of emergency service effort is legitimately directed toward the care and evaluation of such problems.

A key element of this care is distinguishing patients with chest pain who require intensive immediate treatment, from those who require minimal care. This study is a comparative analysis between two major metropolitan hospital emergency departments' treatment of patients presenting with the complaint of chest pain.

Six hundred and forty patients presenting to the Baltimore City Hospitals a n d Johns Hopkins Hospital emergency departments for a n initial evaluation with chest pain were evaluated with regard to the process of medical care and outcome of care two weeks following the visit.

Twenty-two percent (140) required immediate hospitalization. D a t a on t h a t process of care was collected from emergency department records and subsequent inpatient records. A telephone questionnaire was administered two weeks following the visit, including d a t a on the need for additional unscheduled care (both hospitalization a n d additional visits), symptom status and disability.

The analysis of this d a t a will allow a description of the age, sex, race a n d geographic distribution of patients using two urban emergency departments for a given problem. Furthermore, differences in the process of medical care such a s t h e use of laboratory tests and relative threshold for admitting chest pain patients will be determined. The outcome of medical care i n terms of symptoms, death, and delayed hospitalization will also be determined between these two institutions.

Clinically Validated Algorithm for Management of Extremity Trauma Archie M. Brugger, MD Barry W. Wolcott, MD Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas Extremity trauma is a frequent presenti~lgcomplaint of patients in all emergency departments. The evaluation of patients with these complaints utilizes physician a n d 1

radiologic resources. We conducted a n experiment designed to develop a n algorithm for the evaluation of extremity t r a u m a t h a t would more appropriately utilize these scarce resources.

Using a standardized d a t a collection s h e e t (DCS), emergency department physicians evaluated 500 patients with extremity trauma. The DCS was also used to record diagnostic tests ordered, initial impression, and prescribed therapy. Subsequent chart review and telephone follow-up determined the outcome of care. Based on computer analysis of these data, a new algorithm was designed to provide appropriate patient care with reduced utilization of resources. Since this algorithm logic is based on prospectively collected data, it has medical and legal validity superior to algorithm based on non-standardized opinions of physicians or committees.

Hypertension: An Audit o f Emergency Department Detection and Management Anne L. Kaszuba, BA Genevieve Matanoski, MD, DPH Geoffrey Gibson, PhD Health Services Research and Development Center, Division of Emergency Medicine, The J o h n s Hopkins Medical Institutions, Baltimore, Maryland Because of its prevalence, asymptomatic nature a n d significant related morbidity and mortality, hypertension has been t h e subject of extensive study aimed a t improving t h e detection and management of this health problem.

Numerous studies have found t h e prevalence of hypertension to be especially high i n certain sub-groups of the population, notably among blacks a n d t h e poor. These same groups have been found to utilize the urban emergency department a s their primary, and often only, regular source of care. Viewed i n this context, the emergency department may be considered a logical site for hypertension screening a n d referral.

The study reported here is a retrospective audit aimed a t describing t h e prevalence of hypertension among emergency department patients and the system response to it. The study population consists of a random sample of patients presenting a t t h e Johns Hopkins Hospital emergency department during a ten month period (N = 1500), of whom approximately 25% were found to have elevated blood pressure readings. Data are presented on the demographic characteristics, complaint, diagnosis and disposition of all sample subjects. In addition, emergency department response to hypertension, as indicated by documented patient history, physical exam findings, laboratory tests and results, a n d disposition (referral, medication) is described. Finally, the emergency department provider's decision to recognize or ignore a n elevated blood pressure reading a s a n indicator of hypertension is evaluated by patient outcome a t three weeks, a s measured by continued elevation of blood pressure. The data

are used to evaluate current system performance with regard to emergency department detection a n d management of hypertension, and to describe the advantages and limitations of the use of this site a s a center for hypertension screening.

Major Motor Seizures: Some Pathophysiologic Considerations Lawrence B. Bookman, DO Emergency Medicine Resident

Kevin M. O'Keeffe, MD Staff Physician Emergency Services Division, Denver General Hospital, Denver, Colorado The interrelationships between major motor seizures, hypoxia and acidosis have been subjected to varied interpretations in medical literature. I t has been recently shown that during induced seizures in animals, the lactate and cerebral venous 02 tension was higher than in control animals. This implied a "non-hypoxic" cerebral lactic acidosis.

The current study was done in 14* patients with spontaneously occurring seizures while in the emergency department of Denver General Hospital. Arterial blood gas determinations were made serially, starting no more t h a n three minutes after cessation of the supplemental (h. All 14 patients were acidotic initially (7.33to 7.08)and none were hypoxic. Furthermore, after 30 minutes, only one patient was still acidotic, indicating rapid resolution of altered physiology. In all but one patient, hyperventilation was a part of the compensatory mechanism, but unexpectedly, 7 of 11 patients who had pH determinations made less than 30 minutes post seizure were alkalotic. The clinical relevance of these findings to emergency management is discussed, along with a review of the pertinent literature. *Additional patients will be collected until the time of presentation.

The Weak and Dizzy Patient John Skiendzielewski, MD Thomas C. Royer, MD Geisinger Medical Center, Danville, Pennsylvania The patient with the nonspecific complaints of weakness and dizziness often presents a challenging a n d frustrating diagnostic dilemma for the emergency physician.

The Geisinger Medical Center Emergency Department, partly because of the relative paucity of primary care physicians in the area, and partly because of the role of the Medical Center a s the major referral center in northcentral Pennsylvania is confronted with a relatively large volume of such symptomatology.

This paper will first attempt to categorize such patients, identifying those whose history should raise a greater suspicion of organic disease. I t will t h e n attempt to formulate a reasonable system of attaining a differential diagnosis, and suggest additional diagnostic measures to be performed either i n the emergency department or on a n outpatient basis.

Emergency Management of Cervical Spine Injuries Norman E. McSwain. J r . , MD Department of Surgery, The University of Kansas Medical Center College of Health Sciences and Hospital, Kansas City, Kansas Detection of cervical spine injuries requires a high degree of suspicion. Patients in the following categories are assumed to have a significant cervical spine injury until proven otherwise: (1) neck pain or tenderness; (2) decreased level of consciousness; (3) soft tissue injury involving the head or neck; and ( 4 ) any unusual position of the neck, particularly rotation. Immobilization should be maintained until adequate cervical spine films a r e obtained, particularly a lateral including t h e C7-TI articulation.

WITHOUT NEUROLOGIC DEFICIT: In the conscious patient, diagnosis is usually not difficult. If the A P lateral and oblique spine films a r e completely normal, then flexion-extension films must be obtained to rule out a more subtle injury such a s a partial posterior ligamentous disruption. The straightening of the normal cervical lordosis without dislocation or fracture indicates a ligamentous injury. Outpatient treatment with orthotic support followed by isometric exercises is sufficient. Dislocations require prompt reduction with skull traction followed by a cervical orthosis, a halo-case, or internal stabilization depending on the degree of instability and reliability of the patient. Irreducible dislocations require open reduction and internal stabilization by posterior interspinous wiring.

WITH NEUROLOGIC DEFICIT: Progressive neurologic deficit requires prompt decompression by reduction of the dislocation with skull traction or removal of anterior intraspinal bone or disc fragments. Posterior laminectomy alone has questionable value.

Total immediate paraplegia and tetraplegia a r e not indications for laminectomy.

Neurologic deficit adds to the mechanical instability and indicates a more aggressive approach to internal stabilization. Patients may t h e n be rapidly mobilized without external support to prevent multiple complications.

Role of the Clinical Pharmacist in Emergency Medicine: Description and Evaluation Joseph F. Waeckerle, MD Assistant Professor, School of Medicine, Vice Chairman, Department of Emergency Health Services

W. Kendall McNabney, MD Associate Professor, School of Medicine, Chairman, Department of Emergency Health Services

Robert M. Elenbaas, P h D Assistant Professor, Schools of Medicine and Pharmacy University of Missouri-Kansas City, Department of Emergency Health Services, Kansas City, Missouri The physician who practices in emergency medicine provides not only general, non-urgent care but also definitive care in life-threatening and urgent situations. The emergency physician encounters problems t h a t run the gamut from colds to cardiogenic shock with each episode requiring specific knowledge of both the pathophysiology and pharmacology of treatment. Moreover, i t is estimated that every year approximately 1.5 million hospital admissions and a n unknown, but significant number of deaths are from drug-related causes.

Because of this, the Department of Emergency Health Services, T r u m a n Medical Center, University of Missouri-Kansas City School of Medicine h a s employed a full-time clinical pharmacist. He is a doctoral-level pharmacist (Pharm.D.) who h a s completed a professional academic program a n d two years of postgraduate residency specializing in clinical pharmacology and therapeutics. The clinical pharmacist promotes rational therapeutics in all aspects of care offered by the Department of Emergency Health Services through a variety of formal and informal educational programs, consultations, patient care, patient education and research.

To assess physician a n d nurse acceptance of the role of the clinical pharmacist in emergency medicine, a 14-item, independently reviewed questionnaire was administered to the emergency department attending and resident physicians a n d nursing staff. Fifty-four questionnaires were distributed, 39 were completed. Twenty-six physicians and 13 nurses responded to the survey. Results indicate that the clinical pharmacist is considered a n important member of the Department of Emergency Health Services staff and that his activities are felt to have benefited the patient care, education and research programs of the department. Importantly, 95% of the physicians responding felt that the role may be transferred to other emergency departments.

The present study did not attempt to prove that the clinical pharmacist has improved patient care within the department; however, i t indicates a high level of acceptance by health professionals of the role of the clinical pharmacist in emergency medicine.

Daily Chart Audit in an Emergency Department as a Quality Control Device Linda A. Ornelas, MD Barry W. Wolcott, MD Ambulatory Care Research Unit, Department of Medicine, Brooke Army Medical Center, Fort Sam Houston, 1 Texas The quality of the emergency department outpatient record assumes paramount importance a s patients' use of the emergency department a s "their physician" and a s litigation related to emergency visits increases. Numerous studies have attempted to document improvement in physician adherence to format criteria for chart entries following audit of t h e medical record. If any improvement at all was noted it was minimal.

In the emergency department of Brooke Army Medical Center, 50-708 of all charts are audited daily by t h e staff faculty using rigid format criteria and flexible content criteria. The audit is done in the presence of the primary physician (intern or resident) who corrects errors as they are detected. The audit takes place a t 0700 hours and 1700 hours each day and is a formal part of the teaching program in t h e emergency department.

To assess t h e impact of this audit format, emergency department charts from a pre-audit and post-audit period were selected for review. Using predefined criteria, these records were reviewed for format and content. A statistically significant improvement i n adherence t o a u d i t criteria was documented. Such audit techniques a r e useful in improving the quality of the medical record.

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