Counterpoint: contract management groups--a detriment to the specialty and practitioners of emergency medicine.
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Contract Services↗
Biomedical subjects
R M McNamara
Publications and source records attributed to R M McNamara.
Chemical dependency in emergency medicine residency programs: perspective of the program directors.
STUDY OBJECTIVE: To evaluate the educational background, knowledge, and experiences regarding chemical dependency among emergency medicine program directors. The program directors' awareness of substance use and alcohol abuse among emergency medicine residents was examined by comparing their estimates with the actual rates reported by the residents. DESIGN: An anonymous survey mailed in March 1992. TYPE OF PARTICIPANTS: The program directors of all 86 Accreditation Council for Graduate Medical Education-approved emergency medicine residencies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 67 responding program directors represented 1,637 (77%) of the 2,130 emergency medicine residents on duty at the time of the survey. Thirty-three (49%) had suspected chemical dependency in a resident at least once, 22 (33%) had identified a chemically dependent resident, and nine (13%) hired a resident known to be in recovery. Substantial percentages reported no or slight knowledge regarding physician impairment issues. Twenty program directors (30%) received no education or only informal education regarding physician impairment. Compared to a February 1992 survey of emergency medicine residents, the program directors' estimates of resident use rates in the past year for seven substances were fairly accurate. However, the program directors estimated that only 16 (1.0%) of their current residents were impaired by alcohol; the resident survey yielded CAGE scores consistent with presumed or suspected alcoholism in 12.5% of emergency medicine residents. CONCLUSION: Emergency medicine program directors must be more attentive to potential alcohol abuse among emergency medicine residents and should receive additional education regarding chemical dependency.
Data Collection↗
Doxapram reversal of respiratory failure in a patient refusing assisted ventilation.
A 75-year-old man with severe chronic obstructive pulmonary disease and epistaxis experienced progressive respiratory failure after receiving an injection of meperidine and hydroxyzine in preparation for nasal packing. The patient and his family refused endotracheal intubation; despite aggressive medical care, he continued to deteriorate toward an expected fatal outcome. An i.v. infusion of doxapram hydrochloride at 2 mg/min rapidly reversed his downhill course and hypercarbic coma. This case illustrates the potential usefulness of doxapram in the emergency setting. The mechanism of action, indications, dosing methods, and potential side effects of this agent are discussed.
Aged↗
Intramuscular methylprednisolone acetate for the prevention of relapse in acute asthma.
STUDY OBJECTIVE: To examine the hypothesis that an IM long-acting steroid injection will decrease the relapse rate of asthma patients. DESIGN: A randomized, single-blind, placebo-controlled trial. SETTING: The emergency department of an urban academic medical center. TYPE OF PARTICIPANTS: Acute asthma patients aged 18 to 45 years who were treated successfully in the ED. INTERVENTIONS: Participants received either IM saline placebo or 240 mg methylprednisolone acetate suspension at the time of discharge. MEASUREMENTS AND MAIN OUTCOME: Relapse, defined as the need to seek nonroutine medical care for asthma within seven days of discharge, was the main outcome measure. Of 70 patients entered, 56 (80%) completed follow-up, including 30 in the steroid group and 26 in the placebo group. The groups had similar characteristics and peak expiratory flow values on arrival and at discharge. Relapse occurred in two steroid patients (6.7%) and eight placebo recipients (30.8%) (P < .05). There was one death in the placebo group. Reported side effects were similar. CONCLUSION: IM long-acting steroids reduced the rate of relapse in patients with acute asthma.
Adolescent↗
Reduction of anterior shoulder dislocations by scapular manipulation.
STUDY OBJECTIVES: This study examined the success rate, time required, technical ease, and reported patient discomfort for the use of scapular manipulation in the reduction of anterior shoulder dislocation. This study included a new variation of this technique using the seated position. DESIGN: Prospective case series over a 19-month period. SETTING: The emergency departments of a university and a community hospital. TYPE OF PARTICIPANTS: Patients with anterior shoulder dislocations. INTERVENTIONS: Emergency medicine resident and attending physicians were instructed in the technique of scapular manipulation in a classroom setting and requested to use this method initially for the reduction of anterior shoulder dislocations. Premedication was at the physician's discretion. MEASUREMENTS AND MAIN RESULTS: There were 54 patients with 61 dislocations. Scapular manipulation was attempted by 19 residents and 12 attending physicians. The overall success rate of scapular manipulation was 79%, whereas that of physicians experienced with the technique was 86%. Of the successful reductions, 65% were performed in less than one minute, and physicians rated the technique as very easy or easy to perform in 74% of these cases. No premedication was used in 64% of the attempts at scapular manipulation, and these patients reported pain ratings similar to those of the premedicated groups. No complications were noted in this study. CONCLUSION: Scapular manipulation generally is a simple, rapid, and reliable technique for the reduction of anterior shoulder dislocation.
Adolescent↗
Intravenous magnesium for acute asthma.
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Asthma↗
Inefficacy of intraperitoneal fluid administration in a shock model.
Intraperitoneal (IP) fluid administration has been previously used to treat dehydrated children. The relative ease and reported safety of this route suggests its potential utility for volume resuscitation in the acutely ill child. Previous research regarding IP fluid infusion has not examined its use in shock states. This experiment sought to examine the efficacy of an IP fluid infusion in a shock model. Ten immature swine were randomized to receive either no treatment (n = 5) or 30 ml/kg of warmed lactated Ringer's solution (n = 5) IP 20 minutes after a graded 40% hemorrhage. Mean arterial pressure (MAP), heart rate (HR), hematocrit (Hct), pH, and PCO2 were determined serially, and the experiment concluded 60 minutes after intervention. A mean of 89.5% of the administered fluid load was recovered from the peritoneal cavity, and the IP infusion had no ameliorative effect on MAP or HR. The lack of clinically significant absorption of an administered isotonic intraperitoneal fluid infusion in this model suggests that this route should not be relied upon in the critically ill child presenting in shock.
Animals↗
Geriatric emergency medicine: a survey of practicing emergency physicians.
STUDY OBJECTIVES: To evaluate the current status of clinical, educational, social, ethical, and resource issues related to the care of the elderly among practitioners of emergency medicine. DESIGN: A mailed survey instrument. SETTING: None. TYPE OF PARTICIPANTS: Practicing emergency physicians randomly drawn from the membership list of the American College of Emergency Physicians. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 971 surveys were mailed, with 433 usable surveys among the 485 (50%) respondents. The surveyed emergency physicians anticipated a major impact on emergency department patient flow and bed availability in the hospital and ICU as the population ages. For each of seven clinical presentations (abdominal pain, altered mental status, chest pain, dizziness/vertigo, fever without a source, headache, multisystem trauma), 45% or more of the emergency physicians have more difficulty in the management of older compared with younger patients. Most respondents reported that each of these presentations required more time and resources for older patients. The majority believed research, the availability of continuing medical education, and time spent during residency training regarding geriatric emergency medicine was inadequate. CONCLUSION: Practicing emergency physicians are uncomfortable with elderly patients, and this may reflect the inadequacies of training, research, and continuing education in geriatric emergency medicine.
Aged↗
Geriatric patient emergency visits. Part I: Comparison of visits by geriatric and younger patients.
OBJECTIVES: To describe emergency department use by the elderly, to define problems associated with emergency care of the elderly, and to compare these results with those for younger adult patients. DESIGN: Retrospective, controlled chart review. SETTING: Six geographically distinct US hospital EDs. PARTICIPANTS: From each site, a stratified sample (approximately 7:3) of elderly (65 years or older) and nonelderly (21 to 64 years old) control patients treated during the same time period was used. METHODS: Standardized review of ED records and billing charges. Comparisons of elderly and control patient groups using chi 2 analysis and Mann-Whitney U test (alpha = 0.05). RESULTS: Four hundred eighteen elderly patients and 175 nonelderly controls were entered into the study. The elderly were more likely to arrive by ambulance (35% versus 11%; P less than .00001). More elderly than controls presented with conditions of either high or intermediate urgency (78% versus 61%; P less than .0003). The elderly more frequently presented with comorbid diseases (94% versus 63%; P less than .00001). Other findings for the elderly included a longer mean stay in the ED (185 versus 155 minutes; P less than .003), higher laboratory (78% versus 53%; P less than .00001) and radiology (77% versus 52%; P less than .00001) test rates, higher mean overall care charges ($471 versus $344; P less than .00001), and an admission rate (47% versus 19%; P less than .00001) twice that of younger adults. CONCLUSION: Resource use and charges associated with emergency care are higher for the elderly than for younger patients. Increases in emergency resources and personnel or improvement in efficiency will be needed to maintain emergency care at present levels as the US population continues to grow and age.
Adult↗
Geriatric patient emergency visits. Part II: Perceptions of visits by geriatric and younger patients.
OBJECTIVES: To compare group perceptions of reasons for emergency department care, ED use patterns, and the effect of illness on self-care ability for elderly and younger adult patients. DESIGN: Patient survey. SETTING: Six geographically distinct US hospital EDs. PARTICIPANTS: From each site, a stratified sample (approximately 7:3) of elderly (65 years and older) and nonelderly (21 to 64 years old) control ED patients treated during the same time period was contacted. METHODS: Three hundred ninety-nine elderly patients and 172 adult controls were interviewed using a structured survey instrument. Groups were compared using chi 2 analysis and the Mann-Whitney U test. RESULTS: Both the elderly and the control patients (49% versus 38%) commonly stated that the most important reason for coming to the ED was because they were "too sick to wait for an office visit." Of patients with a regular physician, both groups often were referred to the ED by their primary care provider (35% versus 26%). While the elderly had more visits to their primary care provider (3.3 versus 2.9 visits; P less than .00001), there was no difference in the number of ED visits (1.5 versus 1.6 visits) during the preceding six months. Of those released from the ED, more elderly noted deterioration in their ability to care for themselves as a result of their illness (21% versus 11%; P less than .03). CONCLUSION: The elderly use the ED for reasons similar to those for younger adults. Often they feel too ill to wait for an office visit or are referred in by their primary care provider. Elderly patients more commonly have difficulty with self care after release home, and emergency physicians must plan accordingly.
Adult↗
Impact of an emergency medicine residency program on the quality of care in an urban community hospital emergency department.
STUDY OBJECTIVES: To assess the impact of the introduction of an emergency medicine residency program on the quality of care in an urban community hospital emergency department. DESIGN: A retrospective chart review of all ED encounters for a three-month period beginning six months before and six months after the introduction of an emergency medicine residency. SETTING: A 27,000-visit-per-year urban community hospital ED. TYPE OF PARTICIPANTS: All patients who presented to the ED with one of five complaints and subsequently were discharged home. The five presenting categories examined were nontraumatic chest pain when age 30 years or more, lower abdominal pain in women aged 15 to 40 years, recent head trauma, headache of nontraumatic origin, and extremity laceration. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The frequency of physician documentation on the ED record of explicit criteria related to the five presenting complaints was used as a measure of the quality of care. Items sought for documentation included elements of the history and physical examination and diagnostic evaluations. The explicit criteria lists were drawn from the literature, including clinical policy guidelines. For each of the presenting complaints evaluated, documentation of the majority of items reflecting the quality of care was higher during the residency period. In no instance did the level of documentation decrease. CONCLUSION: As measured by a process evaluation, documentation of the medical record, the introduction of an emergency medicine residency significantly improved the quality of care in this urban community hospital ED.
Abdominal Pain↗
Cost of care in the emergency department: impact of an emergency medicine residency program.
STUDY OBJECTIVE: To evaluate the impact of an emergency medicine residency training program on the cost of care in the emergency department. DESIGN: A retrospective chart review was conducted of all ED encounters for a three-month period, six months before and six months after the introduction of an emergency medicine residency program into an urban community hospital. Physician staffing of this ED before the residency period was by nonemergency medicine residency-trained emergency physicians. SETTING: A 27,000-visit-per-year urban community hospital ED. TYPE OF PATIENTS: A consecutive sample of all patients discharged home from the emergency center with one of six diagnoses. The diagnoses studied were viral upper respiratory infection, pharyngitis, acute asthma, seizure, lumbosacral strain, and cervical strain. MAIN OUTCOME MEASURES: Frequency of laboratory test and radiograph ordering pertinent to the evaluation of each diagnostic category were used as a marker of cost of care. RESULTS: The presence of the residency training program did not increase the cost of care as measured by test use and, for three of the six diagnoses, actually lowered the cost of care. This effect was most prominent in the evaluation of lumbosacral and cervical strain when the residency physicians ordered radiographs at a rate five and 2.3 times lower, respectively, than the previous group and in the approach to pharyngitis when they ordered throat cultures 2.8 times less frequently. CONCLUSION: As measured by selected test use for six common discharge diagnoses, the introduction of an emergency medicine residency program did not increase the cost of care in this urban community hospital ED.
Adolescent↗
Utility of the peak expiratory flow rate in the differentiation of acute dyspnea. Cardiac vs pulmonary origin.
This study examined the utility of a peak expiratory flow rate (PEFR) measurement in the differentiation of acute moderate to severe dyspnea secondary to congestive heart failure or chronic lung disease. A PEFR was determined in 41 episodes of acute respiratory distress in 40 patients prior to emergency department therapy. The mean PEFR +/- SD for the congestive heart failure group (n = 18) was 224 +/- 82 L/min, which was significantly higher (p less than 0.001) than that of the chronic lung disease group (n = 23), which had a mean PEFR of 108 +/- 49 L/min. No single cutoff value allowed 100 percent accurate classification, but the results suggest that the PEFR may be a useful adjunctive tool in the differentiation of acute dyspnea of cardiac vs pulmonary origin.
Acute Disease↗
Serum glucose after intraperitoneal infusion of 5% dextrose solution.
STUDY OBJECTIVE: This study investigated the use of intraperitoneal (IP) glucose infusion as a therapy for hypoglycemia. DESIGN: Randomized, placebo-controlled, crossover design, with each animal serving as its own control. SETTING: Laboratory investigation. TYPE OF PARTICIPANTS: Seven female New Zealand White rabbits with a mean weight of 3.7 kg. INTERVENTIONS: Each animal was subjected to three experiments separated by a four-day period. After baseline measurements, the following interventions were undertaken: Control day, no treatment; placebo day, 10 mL/kg 0.9% normal saline solution IP; and treatment day, 10 mL/kg 5% dextrose solution IP. MEASUREMENTS AND MAIN RESULTS: Serial serum glucose levels were obtained. Compared with control and placebo, the mean absolute serum glucose value of the treatment group was significantly higher beginning at ten minutes after intervention and continuing until conclusion of the study at 30 minutes. For these time points, the mean increase in serum glucose levels (percent change) of the treatment group compared with the control group was as follows: ten minutes, 15.5 mg/dL (0.86 mmol/L) (11%), P less than .01; 15 minutes, 20.6 mg/dL (1.14 mmol/L) (14%), P less than .01; 20 minutes, 36.5 mg/dL (2.03 mmol/L) (26%), P less than .001; and 30 minutes, 34.7 mg/dL (1.93 mmol/L) (24%), P less than .001. CONCLUSION: Glucose instilled into the peritoneal cavity of rabbits is absorbed rapidly into the systemic circulation.
Absorption↗
Hypokalemia complicating emergency fluid resuscitation in children.
Our clinical observations suggested that vigorous fluid therapy in children often resulted in hypokalemia. A retrospective review was conducted of four years of admissions to a pediatric intensive care unit. A total of 29 patients were identified who received at least 20 ml/kg of intravenous fluid in their first hour of care and had a pretreatment and posthydration serum K obtained. The potassium levels dropped from a mean pretreatment value of 4.6 +/- 1.0 mEq/L to a mean of 3.3 +/- 0.8 mEq/L (P less than 0.005). Coincidental arterial pH measurements were available in 16 cases. A separate analysis of potassium change in this group revealed that pH change alone could not account for the drop in serum K. Significant hypokalemia may occur after aggressive rehydration of critically ill pediatric patients.
Adolescent↗
Intravenous magnesium sulfate for the treatment of acute asthma in the emergency department.
Conventional nebulized beta-agonist therapy has met with disappointing results in an increasing number of moderate to severe asthmatics who may be characterized as "poor responders." Thirty-eight patients suffering from acute exacerbations of moderate to severe asthma were treated in an emergency department with an intravenous infusion of saline placebo or 1.2 g of magnesium sulfate after conventional beta-agonist therapy failed to produce significant improvement in peak expiratory flow rate. Nineteen patients were randomized into each of two groups in a placebo-controlled, double-blind clinical trial. The treatment group demonstrated an increase in peak expiratory flow rate from 225 to 297 L/min as compared with 208 to 216 L/min seen in the placebo group. In addition, the number admitted vs discharged was significantly better for the treatment group (7 vs 12) than the placebo group (15 vs 4). Intravenous magnesium sulfate may represent a beneficial adjunct therapy in patients with moderate to severe asthma who show little improvement with beta-agonists.
Adolescent↗
More on ingestion of a toothpick.
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Digestive System↗