Joseph F. Waeckerle

Emergency Department Impact of the Oklahoma City Terrorist Bombing

STUDY OBJECTIVE To collect descriptive epidemiologic injury data on patients who suffered acute injuries after the April 19, 1995, Oklahoma City bombing and to describe the effect on metropolitan emergency departments. METHODS A retrospective review of the medical records of victims seen for injury or illness related to the bombing at 1 of the 13 study hospitals from 9:02 AM to midnight April 19, 1995. Rescue workers and nontransported fatalities were excluded. RESULTS Three hundred eighty-eight patients met inclusion criteria; 72 (18.6%) were admitted, 312 (80.4%) were treated and released, 3 (.7%) were dead on arrival, and 1 had undocumented disposition. Patients requiring admission took longer to arrive to EDs than patients treated and released (P =.0065). The EDs geographically closest to the blast site (1.5 radial miles) received significantly more victims than more distant EDs (P <.0001). Among the 90 patients with documented prehospital care, the most common interventions were spinal immobilization (964/90, 71.1%), field dressings (40/90, 44.4%), and intravenous fluids (32/90, 35.5%). No patients requiring prehospital CPR survived. Patients transported by EMS had higher admission rates than those arriving by any other mode (P <.0001). The most common procedures performed were wound care and intravenous infusion lines. The most common diagnoses were lacerations/contusion, fractures, strains, head injury, abrasions, and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and analgesics were the most common pharmaceutical agents used. Plain radiology, computed tomographic radiology, and the hospital laboratory were the most significantly utilized ancillary services. CONCLUSION EMS providers tended to transport the more seriously injured patients, who tended to arrive in a second wave at EDs. The closest hospitals received the greatest number of victims by all transport methods. The effects on pharmaceutical use and ancillary service were consistent with the care of penetrating and blunt trauma. The diagnoses in the ED support previous reports of the complex but often nonlethal nature of bombing injuries.

Chemical Warfare Agents: Emergency Medical and Emergency Public Health Issues

The threat of exposure to chemical warfare agents has traditionally been considered a military issue. Several recent events have demonstrated that civilians may also be exposed to these agents. The intentional or unintentional release of a chemical warfare agent in a civilian community has the potential to create thousands of casualties, thereby overwhelming local health and medical resources. The resources of US communities to respond to chemical incidents have been designed primarily for industrial agents, but must be expanded and developed regarding incident management, agent detection, protection of emergency personnel, and clinical care. We present an overview of the risk that chemical warfare agents presently pose to civilian populations and a discussion of the emergency medical and emergency public health issues related to preparedness and response.

Who reviews the reviewers? Feasibility of using a fictitious manuscript to evaluate peer reviewer performance.

STUDY OBJECTIVE To determine whether a fictitious manuscript into which purposeful errors were placed could be used as an instrument to evaluate peer reviewer performance. METHODS An instrument for reviewer evaluation was created in the form of a fictitious manuscript into which deliberate errors were placed in order to develop an approach for the analysis of peer reviewer performance. The manuscript described a double-blind, placebo control study purportedly demonstrating that intravenous propranolol reduced the pain of acute migraine headache. There were 10 major and 13 minor errors placed in the manuscript. The work was distributed to all reviewers of Annals of Emergency Medicine for review. RESULTS The manuscript was sent to 262 reviewers; 203 (78%) reviews were returned. One-hundred ninety-nine reviewers recommended a disposition for the manuscript: 15 recommended acceptance, 117 rejection, and 67 revision. The 15 who recommended acceptance identified 17.3% (95% confidence interval [CI] 11.3% to 23.4%) of the major and 11.8% (CI 7.3% to 16.3%) of the minor errors. The 117 who recommended rejection identified 39.1 % (CI 36.3% to 41.9%) of the major and 25.2% (CI 23.0% to 27.4%) of the minor errors. The 67 who recommended revision identified 29.6% (CI 26.1% to 33.1%) of the major and 22.0% (CI 19.3% to 24.8%) of the minor errors. The number of errors identified differed significantly across recommended disposition. Sixty-eight percent of the reviewers did not realize that the conclusions of the work were not supported by the results. CONCLUSION These data suggest that the use of a preconceived manuscript into which purposeful errors are placed may be a viable approach to evaluate reviewer performance. Peer reviewers in this study failed to identify two thirds of the major errors in such a manuscript.

TAC use and absorption of cocaine in a pediatric emergency department.

The topical anesthetic TAC (tetracaine 0.5%, adrenaline 0.05%, cocaine 11.8%) has been reported to be effective in pain control for local procedures. However, it has the potential for cocaine toxicity by absorption through an open wound. A study was undertaken to assess the systemic absorption of cocaine and its metabolites when TAC is used as a local anesthetic. Fifty-one children, 1 to 14 years of age, were enrolled in the study. Plasma for cocaine and/or its metabolite levels was available from 46 children and obtained 20 to 40 minutes after the topical anesthetic was applied. No plasma sample had detectable parent cocaine levels; however, 26 (56.5%) had cocaine metabolite levels. Ecgonine methylester levels were detected in plasma from six children and ranged from 59 to 985 ng/mL. Benzoylecgonine levels were detected in none of 19 specimens not preserved with sodium fluoride, and in 23 of 27 specimens to which sodium fluoride had been added. Benzoylecgonine levels ranged from 40 to more than 600 ng/mL. No clinical sign of cocaine toxicity was observed in any child.

Strategies for Improving Information Management in Emergency Medicine to Meet Clinical, Research, and Administrative Needs☆☆☆★

The emergency department of the future will require the effective integration of information technologies into clinical care. This article proposes strategies for improving information management in emergency medicine to facilitate patient care, public health surveillance, clinical research, medical education, and health care management. [Cordell WH, Overhage JM, Waeckerle JF, for the Information Management Work Group: Strategies for improving information management in emergency medicine to meet clinical, research, and administrative needs. Ann Emerg Med February 1998;31:172-178.].

A prospective study identifying the sensitivity of radiographic findings and the efficacy of clinical findings in carpal navicular fractures

Carpal navicular fracture is the most common wrist bone fracture. Improper diagnosis and inadequate treatment result in potentially serious complications, including delayed fracture union, pseudoarthrosis, avascular necrosis, and wrist instability ultimately leading to deformity and osteoarthritis. Initial radiographs do not always demonstrate a discernible fracture line. To better define the frequency of initially negative radiographs of the navicular associated with true navicular fractures, and to test the efficacy of the three clinical signs (snuffbox tenderness, pain with supination against resistance, and pain with longitudinal compression of the thumb toward the navicular), a prospective study of 85 patients who presented to the emergency department during a four-year period with a mechanism of injury suggesting possible navicular injury was conducted. Forty-five patients had no demonstrable fracture or instability on initial examination or during the follow-up period. Forty patients ultimately were shown to have navicular fractures. Patients with negative radiographs and positive clinical findings were reevaluated after ten to 14 days of immobilization. Thirty-two patients had fracture lines visible on initial radiographic examination, and eight had lucent fracture lines demonstrated after ten to 14 days of immobilization. Snuffbox tenderness had a sensitivity of 100% and a specificity of 98% for fracture; supination against resistance had a sensitivity of 100% and a specificity of 98%; and longitudinal compression of the thumb had a sensitivity of 98% and a specificity of 98%. Chi-square analysis revealed a P value less than .001 for each of the three clinical maneuvers. This study reports a 20% occurrence of initially false-negative radiographs, which is higher than previously reported.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiometabolic Abnormalities in Current National Football League Players

Media reports suggested an increased prevalence of cardiovascular disease and premature death in former National Football League (NFL) players. The prevalence of cardiometabolic syndrome was determined in current active NFL players. The presence of cardiometabolic syndrome was defined as > or =3 of (1) blood pressure > or =130/85 mm Hg, (2) fasting glucose > or =100 mg/dl, (3) triglycerides > or =150 mg/dl, (4) waist circumference > or =100 cm, and (5) high-density lipoprotein cholesterol < or =40 mg/dl. Sixty-nine of 91 players (76%) from 1 NFL team were studied before the 2008 preseason training camp. Cardiometabolic syndrome markers, body mass index (BMI), waist-height ratio, and triglycerides/high-density lipoprotein cholesterol ratio were compared between 69 players and an age- and gender-matched reference population from NHANES (1999 to 2002) and by player position of linemen versus nonlinemen. Blood pressure > or =130/85 mm Hg, glucose > or =100 mg/dl, and BMI > or =30 kg/m(2) were significantly more prevalent in the 69 players than the NHANES cohort (28% vs 17%, p = 0.032; 19% vs 7%, p = 0.002; and 51% vs 21%, p <0.001, respectively), although cardiometabolic syndrome prevalence was similar in both groups. However, cardiometabolic syndrome prevalence, BMI > or =30 kg/m(2), and waist-height ratio >0.5 were significantly more common in the linemen versus the nonlinemen subgroup (22% vs 0%, p = 0.004; 100% vs 32%, p <0.001, and 95% vs 36%, p <0.001 respectively). In conclusion, cardiometabolic syndrome and its individual components were noted in current NFL players, particularly linemen.

Evidence-based emergency medicine : Integrating research into practice

Abstract [Waeckerle JF, Cordell WH, Wyer P, Osborn HH: Evidence-based emergency medicine: Integrating research into practice. Ann Emerg Med November 1997;30:626-628.]

Emergency treatment of burn injury

Emergency physicians often encounter patients who have suffered burn injuries. Most are minor in nature but approximately 100,000 a year are true emergencies. Regardless of severity, the emergency physician and staff must possess the evaluative skills and knowledge of current treatment regimens to appropriately treat these patients. Burn injuries are classified according to extent of body surface involved and depth of skin injury. This classification, together with an understanding of the pathophysiology based on the source of injury, will allow categorization and thereby determine initial therapy and definitive management. The treatment of minor burns focuses on three primary objectives: relief of pain, prevention of infection and additional trauma, and minimizing of scarring and contracture. With major burns the first hours after injury are characterized by life-threatening problems. Airway injuries, trauma other than the burn injury, treatment of shock, and pain relief are of the highest priority, overriding the management of the burn wound itself. The care that the minor burn victim receives is critical to ultimate outcome; the care that the major burn victim receives is critical to both immediate survival and ultimate outcome. The emergency physician must provide optimal care to ensure optimal results.

Observation ward utilization

The observation ward in the Department of Emergency Health Services at Kansas City General Hospital and Medical Center is described as to policies, procedures and staffing. One thousand patients were studied retro-spectively for identification, patient utilization, abuse, and pitfalls. It should be stressed that the observation ward must be closely monitored to assure that it is fulfilling intended roles. Based on this study it was concluded that the observation ward has an important role in the operation of this emergency department.