School of Medicine, Dayton, Ohio Development of the skills to establish and expand . the academic basis Ior emergency medicine .o",in*, ,o t a high prioritv torchalrs and program directors within this s p e c i a l t y .i " . t , o f t t ! m a i o r _r e p r e s e n t a t i v e s o c i e t i e s i n e m e r g e n c y m e d l i i n e hrrr. dil rected considerable attention to this tJpic.'Still, many faculty have not mastered or even be.r, ."posld-to th"r. skills. The clinical demand of emergency medicine pir"ti".-ott"r, pr""f"a., the opportunity for contempirtiu., -"rrir..a-gio*tt and devel_ opment of academic faculty. without an estabiished network oi mentors/ emergency medicine faculty must turn to textbooks rrom authors outside the fieid for a written source o{ infotmation These books ,r. of ""ryirrg quality and ::_{f{y.d*elopment. apprrcabllrty/and the time to evaluate them in tlre iontext of one's needs is limited. In an,effort to improvc access to quality texlbooks applicable to faculty seeking io lea.r, new academic skills, the author has developei a libraiy i; i;;ity a.u"top_..ri topics. Over sixty books were reviewed, i"r, *"r. selected to torm a useful core library that can serve as tL. str.tmjpoint for iearn_ ing or refreshing skills in management, terChing, research, grantsmanship, interpretation of the medical literaturi, statistics; applications, audiovisual aids, :ompule.r. _writing, ""a prfiirl_gl
To establishand maintain these skills it . "r,tf,oi ,.ti"o."t.ffi the.necessityof sufficient ume, a supporttve environment, and assignmcntthat reinforcestearningthrougir ap_ 1ll^,:f:1.T,91 I hrs lr,brarywas createdto support inrerest,,cc.ss, and lltj1,l3l, contrnuedgrowth tor those servingin academicemergency medicine.
!-O-1 . Diagn^osticErrors in Emergency Medicjne: A Gonsequence of Inadlquate Fautty bata Interfieiiri"" or Case Snoqte_dge, Type?
T Allen,G Bordage/ Sectionde medecined,urgence; pedagogiemedicate (Officeof Medicat Educa'iion), F^r].ir1 9" facuttede medecine,Universit6Laval,eu6bec, Canada Thr5c,sourccso[. diagnosticcrrors were investigated:lack ol , taulty data rnterpretation, and casc types. Forty_five Ll:*l:oC!, vrgnett..s.y",le preparedbasedon actual emergencycases :rt-lnr:al been initiatty_ or found to be partitularly :lll,i:1 -misdiagnosed cjr?ll,engrngSubtects(N:140) were asked to generatea differen_ rral olagnosrstor.each.vignette;they then completeda knowledge rnventory assessingthe essential factual knowledge required io co,lregtdiagnoses.This techniquc has previously fl:::t:,,: :h..to Deenshown distinguishdata interpretationirrorstrom knowi_ erlrors. groups of randomly selectedpracticing physi_ :l-qj trom lour clans the province of euebec participated: certifie*demer_ pengyRhfsicians,non-certifiedemergencyphysicians,certilied ramlry physrcrans,and non_certifiedfamily physicians. Three typg: 9f casepresentationwere used: 15 "ilti""l_",.." cases,15 misfitting-cue cases,and 15 atypical c^res. Ou.i"ll 44% oI the misdiagn,gs,e.d (averageof 20 errors pcr 45 cases, :T..r,,*..,.. s=r.ll, rne test rs reltablefor group comparisons ialpha coeffi_ c r e n r =0 . 6 9 ) - T h c .m a j o r c a u s c o f m i s d i a g n o s i si s n b t l a c k o f {notlld^g: lzl%1 bur a taulty interpretationof availableclinical d^ta l/9Yol. There is a significant intdraction between physician groupsand.casctypes(F= I0.5, p< .0001);nonetheless differences Detwee_n physrcian groups (F:5.2, p<.OOZland berween case P<-0001)are significant. Certified emergencyphy_ Itli 1t:9;t, betrer iScheffe,stesr, p<.05) than both groups :r,.ilT.p:tt?t-ed ot lamrly physicians,making an averageof 29.g{s:6.gJ c'orrecr oragnoses_as opposedrc 24.21s=5 2l and 23.51s:4.6).Each par_ ticipant obtained proiile of his performance,identifying each I error as a. knowledge or data inteipretation deficiency.The {requency of error types for each case was also co-puied fo, ih. grotlp.oi participants. These results have two rmportant :4/]]:le eo::1!tonal rmplications. First, training programs in emergency meolcrneshould tocus on interpretation of availableclinical data asknowledgealone doesnot guaranteediagnostic*""".., prrtr"_ ularly for certain types of cases.Second,ihe lndividuali;.jJ p;;_ Ille permtts a practicing emergencyphysician to identi{v ,p."ifi"
45
weaknessesin knowledge.and in data interpretation, and to plan hrs continu.ing medrcal education accordingly
7O2 Evaluation of a Hospitat.Based t{eticopter Emerg_encyMedical Servic6 CCe"yJtJierotson /
TiaumaServices,lvlemorial MedicalCenterlnc, Savannah, Georgia The HHEMS has becomea growing and important part of the pre-hospitalcare of the trauma patlent. As rn any aspeit oi medi_ Quality Assurance should be an integrai part of th. :3J__.-r19, HHEMS. Outcome review should be objective,bised tn , .."o!nized standard,and an ongoingpart of the HHEMS program.The TRISSMethod offers such a standardand is describid.the fiscal responsibiiityof the programmust be reviewedbasedon financial data collection and tracked to satisfy the sponsoringhospital,s financial position. A safety program to include nighi decis;s and weather considerationsihoutd be developedprior to imple_ menting service.Methods:.All trau_mapatients i.r.rrport.d by to th-e base_horpitrl *"r. prospectively :l:,HTE#S I.lyt3r:C studred. The initial Tiauma_Score,the Injury SeveritySiore, ani Patient age were used in the TRISS Meihodology of th" lt"|o, Tiauma Outcome Study to determine probabilitli'of survival. irinancial data to include all charges,.eu..ru., ".rd .o.t, were collected. A safety program _wasdesignedprioi to implementation and revrewedon a monthly basis.Results:Three groups were :o-^pglgg 4ll trauma patients in the hospital trauma regrsrry (n:259a1,HHEMS trauma patients(n: lsli and the Maior"frau_ ma Outcome Group (n:25322). Distribution and survival curves tor the groups reveal the HHEMS group to be more severelyin_ iured.but with improved survival. TRISSmethodologyresults are as follows: N,4ean TraumaScore I 1 . 8 Actual Mortality tg.2% MeanISS 2 8 2 PredictedMortality 26.5% A c t u a lN u m b e ro f D e a t h s 29 % Reductionin Predicted PredictedNumberof Deaths 40.7 N4ortality ZB.B% - 2.34 Z Statlstic 28% reductionin predictedmortalityis significantto the p< .025 level
Multispecialty panel review revealedno preventabledeathsat_ tributable to HHEMS or trauma center care. Financial data ret:*:9.r^.^"^,.1 program cost of g1,246,387including srart up costs or b.ll4luuu.New patrentrevenuewas $1,136,192. The net effect ot the program consideringonly the new patients was 27,500. Conclusions:The TRISS Method offers an objective national norm for comparisonof outcome data for trauma patients trans_ ported by HHEMS. This patient population revealeda statis_ tically significant reduction in morlality oI 2g.g%.2) processre_ y-r_._y 9! mortality is a necessarypart o{ outcome review. 3) A HHEMS can be financially feasibleif new patient revenueis considered-in_the, analysis.4) A safety program should be , p"r, of every HHEMS.
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Gontingency
planning
Durinq an
Emergency Medical Servicei striidri-*yan,
RD Stewart,R Kennedy,J Overton,A LaRosee/ Divrsronof EmergencyMedicine,University of pittsburgh;Centerfor EmergencyMedicineof Westernpennsylvaiia;City of pittsburgh EmergencyMedicalServicesBureau . Among the problems in disaster management faced by EMS physiciansin their practice of medicine thiorrgh phyrl"ian surro_ perhapsnone presents^ grr^tt challenge ffles.{laraledics), rnan rne malntenance of patient care during withdrawal of service by EMS personnelduring a labor/-manalgement dispute. On the morning of November 2g,19g6,lg0 {ield i-trls p.rso.rnet w.rrt the re-questof the Mayo4 a strike contingencyplan -::^.T11:lA, was developedtor the city that ensured continued provision o{ service without sacrifice of quality of care. The basrc tenets of the plan included: l. That requestsfor servicewould be answered