Michael Heller

A T WO - HOUR I NTERVENTION U SING START I MPROVES P REHOSPITAL T RIAGE OF M ASS C ASUALTY I NCIDENTS

Objective. There are few data concerning the ability of prehospital providers to triage patients in a mass casualty incident (MCI). The authors evaluated the effectiveness of a brief educational intervention on MCI triage with a written scenario and test. The START method (simple triage and rapid treatment) was used. Methods. The authors enrolled and tested 109 prehospital providers consisting of 31 paramedics and prehospital registered nurses (PHRNs) and 78 emergency medical technicians (EMTs) and first responders. A written scenario of an MCI was used to test participants before, immediately after, and again at one month after a two-hour educational intervention consisting of a slide and video presentation utilizing START. Results. The 109 participants completed the pre-intervention and post-intervention test; 72 (66%) completed the one-month post-intervention as well. Mean work experience was 9 years (ranging from 1 to 27 years). The mean immediate post-test score (75% correct) was significantly improved compared with the mean pre-test score (55% correct) for the 109 providers completing both tests (p < 0.001). Among advanced life support providers (EMT-Ps and PHRNs) completing all three surveys, the mean immediate post-test score (76% correct) and mean one-month post-test score (75% correct) were not significantly different. Among the basic life support providers completing all three surveys, a modest but statistically significant decay in mean scores from immediate post-test (74% correct) to one-month post-test (68% correct) was observed (p < 0.01). Prior training in MCI had no statistically significant effect on changes in mean test scores. Conclusion. The ability of prehospital providers of all levels of training and experience to triage patients in an MCI is less than optimal. However, this ability improved dramatically after a single didactic session, and improvement persisted one month later.

Are racial disparities in ED analgesia improving? Evidence from a national database.

OBJECTIVEnEthnic disparities in emergency department (ED) analgesic use have been noted previously; the purpose of this study was to determine if current ED practice has been altered subsequent to the widespread recognition of these inequalities.nnnMETHODSnUsing data from the National Hospital Ambulatory Care Survey, we analyzed ED analgesic treatment with respect to race for the complaints of headache (HA) and long bone fractures (LBF) for 1995 to 1999 (period A) and compared that with data for 2000 to 2003 (period B). We compared the use of any analgesics and opioids among blacks, whites, and Hispanics.nnnRESULTSnFor both HA and LBF, improvements over time were noted in all 3 ethnic subgroups. A statistically significant increase was documented in the treatment of HA among Hispanics using any analgesia (71.3% vs 80.8%, P = .011). Although individual differences between the 2 periods in the LBF cohort were not statistically significant for any of the 3 ethnic groups, there was an overall improvement noted when combining all ethnicities: among all patients treated for LBF, 66% received some analgesic and 42.8% received opioid analgesia during period A vs 75% and 51%, respectively, during period B (all P < .001). Furthermore, in the latest study period, there were no differences in the frequency of analgesic administration for LBF with respect to race (blacks, 43%; whites, 48%; Hispanics, 43.8%; P > .1).nnnCONCLUSIONnThere is evidence that previously described racial inequalities in analgesic use have decreased over time.

Fast education: a comparison of teaching models for trauma sonography.

This studys objective was to evaluate the peritoneal dialysis and mannequin simulator models for the hands-on portion of a 4-h focused abdominal sonography for trauma (FAST) course. After an introductory lecture about trauma sonography and practice on normal models, trainees were assigned randomly to two groups. They practiced FAST on one of the two simulator models. After the didactic and hands-on portions of the seminar, FAST interpretation testing revealed mean scores of 82% and 78% for the peritoneal dialysis and mannequin simulator groups, respectively (p = 0.95). Post-course surveys demonstrated mean satisfaction scores for peritoneal dialysis and mannequin simulator models of 3.85 and 3.25, respectively, on a 4-point Likert scale (p = 0.317). A FAST educational seminar, which provides both didactic and hands-on instruction, can be completed in 4 h; the hands-on instruction phase can incorporate both normal models and abnormal simulation models, such as the peritoneal dialysis model and the multimedia mannequin simulator.

Does wearing a necktie influence patient perceptions of emergency department care

We conducted a prospective study of discharged emergency department (ED) patients to determine the effect of wearing a necktie by emergency physicians (EPs) had on patients impression of their medical care. All male EPs were assigned randomly by dates to wear a necktie or no necktie, and the attire worn was otherwise similar in all respects. The study was conducted at a community teaching hospital with an Emergency Medicine residency and an annual census of 40,000. A total of 316 patients were surveyed. There were no statistically significant differences between patient groups in any of the five areas surveyed, including patient perception of physicians appearance. Nearly 30% of patients incorrectly identified their doctor as wearing a necktie when no necktie was worn, and the perception of tie wearing was correlated with a positive impression of physician appearance. Wearing or not wearing a necktie did not significantly affect patients impression of their physician or the care they received. However, patients seemingly preferred the appearance of physicians who were perceived to wear neckties.

Transnasal butorphanol in the emergency department management of migraine headache.

Transnasal butorphanol (TNB) is a mixed agonist-antagonist opioid that has recently been released for the treatment of painful conditions. Patients with a history of migraine diagnosed in either of two emergency departments (EDs) with a moderate or severe migraine were eligible for this prospective study. Patients received 1 mg of TNB at time zero and again in 45 minutes if needed. Twenty-five patients were studied. Pain intensity was measured on a 10-cm visual analog scale. Mean pain intensity was significantly decreased at 15 minutes and declined from 7.9 +/- 1 cm initially to 2.5 +/- 3.3 cm at 90 minutes. Sixty percent of the patients required no further treatment. Thirty-six percent experienced side effects, with all but 1 being mild or moderate. Seventy-five percent rated the treatment as good, very good, or excellent, and 71% would prefer to receive TNB for future migraines over other treatment options. TNB offers rapid, effective pain relief to the majority of ED migraine patients.

Patient andPhysician Perspectives on Ambulance Utilization

Objective. The objective of the current study was to define the clinical anddemographic characteristics of ED patients who used ambulance transport (USERS) compared to contemporaneous non-ambulance users (NON) andto determine the reasons users gave for their choice to use ambulance transport. Methods. A single researcher queried a convenience sample of consenting ED patients regarding reasons for choice of transport to the ED, knowledge of ambulance cost, andself-estimation of illness or injury severity on a (1 most severe, 5 least severe) five-point Likert scale. We also asked if the treating physician agreed with transport choice. Results. Of 311 participants (97% response rate), USERS (N = 71, 22.8%) were older than NON (53 vs. 35, p < 0.0001) andwere more sick according to self-rated illness severity (mean rank 128 vs. 156, p = 0.02), nurse triage score (mean rank 103 vs. 153, p < 0.0001), andadmission rate (37% vs. 15%, p < 0.0001). Patient decision regarding ambulance use was associated with both having someone who called an ambulance for them andself-estimation of illness severity (or lack thereof). Physicians agreed with transport method in 68% of USERS and92% of NON (overall kappa = 0.6, p < 0.0001). Conclusions. Ambulance users were more likely to be more sick as determined by commonly used measures than nonusers. ED physicians almost always agreed with nonuse of ambulance transport andtwo-thirds of the time agreed that a patients decision to use ambulance transport was appropriate.

Impact of emergency medicine resident training in ultrasonography on ultrasound utilization

Training programs in bedside ultrasound for emergency physicians often encounter considerable resistance, partly because of concern that the number of radiology-interpreted studies ordered from the ED may decrease. This study attempted to determine the effect of instituting an ED training program in ultrasound on the ordering of formal studies from a department of radiology. This retrospective, computer-assisted review compared all abdominal sonograms ordered from the ED of a busy community hospital in the 3 years before introduction of an ultrasound training program (1992 through 1994) with those ordered in the 2 years after the programs inception (1995, 1996). The number of formal studies significantly increased after institution of the training program, both in terms of absolute numbers (annual mean 181 v 95, P < .001) and as a percentage of all outpatient sonograms ordered at the institution (9.8% v 5.1%, P < .001). Introduction of a teaching program in emergency ultrasound appears to increase utilization of formal ultrasound services, at least during the training period.

Short- and Long-term Effects of Emergency Medicine Sonography on Formal Sonography Use A Decade of Experience

Objectives. It has been reported that use of formal sonographic studies by departments of radiology initially increases after inception of an emergency medicine (EM) sonography training program, but there are no data on whether this trend continues as the training program matures. The purpose of this study was to evaluate the effect of an ongoing EM sonography program on formal sonography use after more than a decade of experience. Methods. This retrospective, computer‐assisted review compared emergency department (ED) abdominal sonographic studies ordered in the 3 years before inception of an EM sonography program (1992–1994) with those ordered in the 8 years after its inception (1995–2002). To determine the relative change, all abdominal sonograms ordered by ED physicians were compared with equivalent outpatient formal sonograms by all other physicians in the hospital. The study site is a community teaching hospital with a current ED census of 50,000. Results. In the initial 4 years (1995–1998), the number of formal studies increased significantly in both absolute numbers (annual mean, 95 versus 162; P < .002) and as a percentage of all outpatient sonograms ordered at the institution (5.1% versus 8.5%; P < .0001). However, in the following 4 years (1999–2002), the absolute number of formal studies remained constant but decreased when adjusted for an increased ED census. Emergency department–ordered formal studies also decreased as a percentage of all sonograms ordered (5.1% versus 4.1%; P = .002). Conclusions. Emergency department use of formal sonography services increases with the introduction of ED sonography but decreases markedly as the program matures.

Noninvasive measurement of carbon monoxide levels in ED patients with headache.

ObjectivesCarbon Monoxide (CO), the third most common cause of acute poisoning death, is easily overlooked in the emergency department (ED). Nonspecific complaints such as headache, weakness, or malaise may easily result in misdiagnosis. The objectives of this study are to determine the frequency of CO poisoning in patients presenting to the ED complaining of headaches and to determine the feasibility of using noninvasive CO analyzers as a screening tool.MethodsThis prospective controlled study examined, during the winter months, adult patients presenting with a complaint of atraumatic, afebrile headaches. All subjects submitted a sample for a CO breath analyzer. Participants with elevated carboxyhemoglobin (COHb) levels (nonsmoker > 2%, smokers > 5%) underwent venous COHb testing. Control patients, without headaches, presenting to the ED were similarly studied.ResultsWe enrolled 170 subjects and 98 controls. Of the 170 subjects, 12 (7.1%) had elevated COHb levels confirmed by venous COHb levels. Of the 98 controls, 1 (1.0%) had an elevated COHb level (p<0.05). There were no differences in demographic factors between the two groups (p > 0.16).ConclusionsNoninvasive measurement of CO levels in ED patients with headaches is rapid and specific. During winter months, elevated CO levels are present in over 7% of ED patients with headaches.

Bedside ultrasound to determine prandial status

The prandial status of ED patients is often unknown. Because a full stomach predisposes patients to aspiration during a variety of urgent interventions, a method of determining the degree of gastric fullness would be of potential clinical importance. The purpose of this single-blind interventional trial was to determine if bedside ultrasound, performed by EPs, could accurately determine prandial status. We enrolled 20 subjects who were randomized to either a fasting or nonfasting group. Three emergency sonographers scanned each subject in both the supine and right lateral decubitus (RLD) positions and independently recorded their determination of the prandial status both before and after ingestion of water. We found that the technique was specific in identifying a full stomach but only moderately reliable in identifying an empty one. Best results (sensitivity S + 86%, specificity S- 70%, accuracy A+ 78%) were achieved only after water ingestion with the patient in the RLD position. We conclude that bedside ultrasound is of only limited value for determining prandial states in the ED setting.