E Jackson Allison

Acute myocardial infarction in chest pain patients with nondiagnostic ECGs: Serial CK-MB sampling in the emergency department

STUDY OBJECTIVES This study tested the hypothesis that serial creatine phosphokinase (CK)-MB sampling in the emergency department can identify acute myocardial infarction (AMI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. DESIGN Patients more than 30 years old who were evaluated initially in the ED and hospitalized for chest pain were studied. Serial CK-MB levels were analyzed prospectively using a rapid serum immunochemical assay for identification of AMI patients in the ED. Presenting ECGs showing new, greater than 1-mm ST elevation in two or more contiguous leads were considered diagnostic for AMI. All other ECGs were considered nondiagnostic ECGs. CK-MB levels were determined at ED presentation and hourly for three hours (total of four levels). Patients with at least one level of more than 7 ng/mL were considered to have a positive enzyme study. The in-hospital diagnosis of AMI was determined by the development of typical serial ECG changes or separate standard cardiac enzyme changes after admission. SETTING Eight tertiary-care medical center hospitals. METHODS AND MAIN RESULTS Of the 616 study patients, 108 (17.5%) were diagnosed in the hospital as AMI; 69 of these AMI patients (63.9%) had nondiagnostic ECGs in the ED. Of the patients with nondiagnostic ECGs, 55 (sensitivity, 79.7%) had a positive ED serial CK-MB enzyme study within three hours after presentation. Combining serial ED CK-MB assay results with diagnostic ECGs yielded an 88.4% sensitivity for AMI detection within three hours of ED presentation. The predictive value of a negative serial ED enzyme study for no AMI was 96.2% (specificity, 93.7%). CONCLUSION Serial CK-MB determination in the ED can help identify AMI patients with initial nondiagnostic ECGs. Use of serial CK-MB analysis may facilitate optimal in-hospital disposition and help guide therapeutic interventions in patients with suspected AMI despite a nondiagnostic ECG.

The psychological impact of disaster on rescue personnel

Seventy-nine rescue, fire, and medical personnel and police officers who treated victims of an apartment building explosion completed a questionnaire describing their emotional and coping responses to the disaster. Eighty percent had at least one symptom of posttraumatic stress disorder (PTSD). Eight of 21 PTSD symptoms were present in at least 10% of respondents. The most frequently reported symptom, intrusive thoughts about the disaster, occurred in 74% of those working with or searching for victims at the disaster site. On-the-scene rescue workers had significantly more (P less than .02) PTSD symptoms than did inhospital staff. Fifty-two percent of the respondents reported that family members and coworkers were supportive or very supportive in meeting their emotional needs following the disaster; 36% noted that support networks were not helpful. The coping behaviors most frequently used were to remind oneself that things could be worse (57%) and to try to keep a realistic perspective on the situation (53%). Eleven percent reported seeking emotional support from others or looking to others for direction. Emergency workers responding to a contained, small-scale disaster are likely to experience mild stress responses. Planning for the emotional aspects of these events is needed.

Factors associated with stress among emergency medicine residents.

A survey of members of the Emergency Medicine Residents Association was conducted to investigate the occupational stress and depression experienced by this group. The 488 respondents provided demographic information and completed measures of stress and depression. Multivariate analysis of variance revealed statistically significant differences in stress and depression by year of training (P less than .001), gender (P less than .01), and marital status (P less than .01). Univariate analyses of variance revealed overall differences in both stress and depression. Mean levels of stress and depression were higher for women residents, and unmarried residents reported more depressive symptomatology. The results indicate that women emergency medicine residents experience more stress and depression than men and that spouses can buffer some of the stress of residency training for men and women residents. No significant differences in stress or depression by year in training were revealed by univariate analysis of variance, which suggests that residents experience stress throughout the course of training. The similarities and differences in the occupational stress and depression experienced by emergency medicine residents in comparison with residents from other specialties suggest that additional study in emergency medicine is warranted.

Work-related stress and depression among practicing emergency physicians: An International study

STUDY OBJECTIVE To compare the levels of work-related stress and depression reported by practicing emergency physicians in three survey sites and to determine the effects of gender and marital status on the stress and depression experienced by these physicians. DESIGN Cross-sectional mail surveys. SETTING AND PARTICIPANTS Seven hundred sixty-four practicing emergency physicians from the United States, 91 fellows in full-time practice from Australasia, and 154 consultants and 47 senior registrars from the United Kingdom. INTERVENTION Administration of questionnaires requesting demographic information and including an inventory to assess work-related stress and a scale to measure depressive symptomatology. MEASUREMENTS AND MAIN RESULTS A 3 x 2 x 2 multivariate analysis of variance performed to compare scores on the stress inventory and depression scale simultaneously by survey site, gender, and marital status revealed significant differences in stress and depression by survey site and marital status. Univariate analyses of variance revealed significant differences in both stress and depression among the three survey sites and in depression by marital status. Adjusted means indicated that physicians from the United Kingdom reported higher levels of stress and depression than physicians from the United States and Australasia. Physicians from the United States and Australasia did not differ with respect to stress or depression. Physicians who were not married reported higher levels of depression than married physicians. No large mean differences, actual or adjusted, were found for any of the grouping factors. CONCLUSION Statistical differences among practicing emergency physicians from the United States, Australasia, and the United Kingdom were observed, but the actual levels of work-related stress and depression were similar and did not appear severe. Marriage was associated with lower levels of depressive symptomatology.

Work-related stress and depression among physicians pursuing postgraduate training in emergency medicine: An international study

STUDY OBJECTIVE To compare the levels of work-related stress and depression reported by physicians-in-training in emergency medicine in three survey sites and to determine the effects of gender and marital status on stress and depression among these physicians. DESIGN Cross-sectional mail surveys. SETTING AND TYPE OF PARTICIPANTS Physicians-in-training in the United States, United Kingdom, and Australasia. INTERVENTION Questionnaires requesting demographic information and including scales assessing work-related stress and depression were administered. MEASUREMENTS AND RESULTS A 3 x 2 x 2 multivariate analysis of variance in which survey site, gender, and marital status were independent variables and stress and depression scale scores were dependent variables revealed significant differences when stress and depression were analyzed simultaneously. Univariate analyses of variance revealed significant differences in stress by survey site and gender and in depression for all three independent variables. Comparison of adjusted means revealed that respondents from the United Kingdom reported significantly higher levels of stress than did respondents from the United States and that women reported significantly higher levels than men. Respondents from the United States reported significantly higher levels of depression than did respondents from the other countries, women reported higher levels than men, and unmarried respondents reported higher levels than married respondents. CONCLUSION Despite limitations resulting from self-report bias, cross-sectional survey methodology, sampling error, and differences in training among the three survey sites, the respondents experienced similar levels of stress and depression attributable to anticipated sources.

Thigh compartment syndrome without lower extremity trauma following application of pneumatic antishock trousers

Reported are two cases of thigh compartment syndrome following application of a pneumatic antishock trouser suit. Both patients developed compartment syndromes after prolonged antishock suit use in the absence of any apparent leg trauma. We recommend that suit compartment pressures be no more than required to restore adequate blood pressure. The duration of application should be no longer than is clinically necessary. Patients with prolonged application (greater than 120 minutes) should be closely monitored for the development of compartment syndromes.

Environmental temperature variations cause degradations in epinephrine concentration and biological activity

This study determined the biological consequence of temperature induced epinephrine degradation. Two different epinephrine preparations (1:1,000 and 1:10,000) were exposed to either cold (5 degrees C) or hot (70 degrees C) temperature. The exposure occurred for 8-hour periods each day in 4-, 8-, and 12-week intervals. Samples and identical controls were then chemically evaluated using high-pressure liquid chromatography (HPLC), and biological activity of samples showing chemical degradation was assessed in conscious rats. Epinephrine (1:10,000) underwent a significant degradation and a loss of concentration of the parent compound after 8 weeks of heat treatment. By 12 weeks, 64% of the epinephrine was degraded. A smaller (30%) but significant loss of cardiovascular potency was determined by blood pressure and heart rate responses in conscious rats. The degradation of epinephrine (1:1,000) was not statistically significant even after 12 weeks of heat exposure. No change was noted from control in either epinephrine concentration when exposed to cold temperatures. In conclusion, epinephrine (1:10,000) deteriorates in the presence of elevated temperature and should be protected from high temperatures when carried by EMS providers. The degradation products may possess biological activity.

The esophageal obturator airway: A reassessment of use by paramedics

A study was undertaken to determine the incidence of failures and complications of EGTA. The life history of 31 airways was followed. Ten failed prior to 5 usages. Paramedics successfully intubated 88% of the patients but experienced difficulties maintaining adequate airways in 15%. While the EGTA is a valuable tool in prehospital care, its utilization to the exclusion of endotracheal intubation should be carefully considered.

Suspected Brown Recluse Envenomation: A Case Report and Review of Different Treatment Modalities

BACKGROUND The Loxosceles reclusa, commonly known as the brown recluse spider, is responsible for virtually all cases of spider bites leading to a significant necrosis. CASE REPORT We report the case of a 72-year-old man who presented to the Emergency Department complaining of back pain, weakness, and diarrhea. The patient stated that he sustained a bug bite 1 week before presenting to the hospital. His wound was necrotizing in nature and after an exhaustive work-up, the most likely etiology was found to be envenomation by a brown recluse spider, Loxosceles reclusa. CONCLUSION This is an endemic cause of a necrotizing wound bite in areas of the Midwestern and Southern United States, but it is rarely reported in the Northeast.

American College of Emergency Physicians Ethics Manual

Ethical concerns are a major part of the clinical practice of emergency medicine. The emergency physician must make hard choices, not only with regard to the scientific/technical aspects but also with regard to the moral aspects of caring for emergency patients. By the nature of the specialty, emergency physicians face ethical dilemmas often requiring prompt decisions with limited information. This manual identifies important moral principles and values in emergency medicine. The underlying assumption is that a knowledge of moral principles and ethical values helps the emergency physician make responsible moral choices. Neither the scientific nor the moral aspects of clinical decision making can be reduced to simple formulas. Nevertheless, decisions must be made. Emergency physicians should, therefore, be cognizant of the ethical principles that are important for emergency medicine, understand the process of ethical reasoning, and be capable of making rational moral decisions based on a stable framework of values.