Nicholas Jouriles

Survey of Out-of-hospital Emergency Intubations in the French Prehospital Medical System: A Multicenter Study

STUDY OBJECTIVE To determine the clinical characteristics of endotracheal intubation in the French emergency prehospital medical system and compare these data with those of other systems. METHODS This study was performed in lle de France (Paris Region) in mobile ICUs staffed by physicians. This prospective, descriptive study involved completion of a questionnaire by the operator just after endotracheal intubation was performed. RESULTS Six hundred eighty-five (99.1%) of 691 consecutive prehospital intubations were performed successfully in the field. The orotracheal route was used in 96.0%, and no surgical approaches such as cricothyroidotomy were used. Mechanical complications occurred in 84 patients, at a rate of 15.9% for nonarrest patients and 8.1% for arrest patients. A wide variety of sedation protocols were used. Difficult intubations (10.8%) were comparable in incidence to the number seen in US emergency departments, not US prehospital systems. By the same token, intubation success rates (99.1%) were comparable to US EDs and much higher than US prehospital results. CONCLUSION The characteristics of French prehospital airway management differ significantly from those of other countries. These differences may be explained by differences in approach to prehospital management rather than differences of skill.

Effectiveness of a 2-Specialty, 2-Tiered Triage and Trauma Team Activation Protocol

STUDY OBJECTIVE To determine the effectiveness, safety, and resource allocation of a 2-specialty, 2-tiered triage and trauma team activation protocol. METHODS We conducted a 6-month retrospective analysis of a 2-specialty, 2-tiered trauma team activation system at an urban Level I trauma center. Based on prehospital data, patients with a high likelihood of serious injury were assigned to triage category 1 and patients with a low likelihood of serious injury were assigned to category 2. Category 1 patients were immediately evaluated by both emergency medicine and trauma services. Category 2 patients were evaluated initially by emergency medicine staff with a mandatory trauma service consultation. Main outcomes measured included mortality, need for emergency procedures, need for emergency surgery, complications, and discharge disposition. Potential physician-hours saved were calculated for category 2 cases. RESULTS Five hundred sixty-one patients were assigned a triage classification (272 to category 1 and 289 to category 2). Category 1 patients had a higher mortality rate (95% confidence interval [CI] for difference of 15.9%, 11.1% to 20.7%, P < .0001), need for emergency surgery (10.7% versus 1.4%, 95% CI for difference of 9.3%, 5.2% to 13.4%; P < .0001), need for emergency procedures (89% of total procedures, 95% CI 83% to 95%; P < .0001), and discharges to rehabilitation facilities (95% CI for difference of 15.1%, 9.3% to 21.0%; P < .0001). The 2-tiered response system saved an estimated 578 physician-hours of time for the trauma service over the study period. CONCLUSION This evaluation tool effectively predicts likelihood of serious injury, mortality, need for emergency surgery, and need for rehabilitation. Patients with a low likelihood of serious injury may be initially evaluated by the emergency medicine service effectively and safely, thus allowing more efficient use of surgical personnel.

Severe rhabdomyolysis with renal failure after intranasal cocaine use

A case of acute renal failure due to rhabdomyolysis in a patient who used cocaine on a daily basis is presented. In contrast to many prior reports of renal failure occurring with cocaine-associated rhabdomyolysis, our patient did not use intravenous cocaine and did not have any evidence of trauma, seizure, hypotension, hyperthermia, hyperactivity, or coma. His creatine phosphokinase peaked at 448,000 U/liter. He was treated initially with forced diuresis and i.v. furosemide, but he became oliguric, developed pulmonary edema, and required hemodialysis. He recovered fully after 3 weeks of dialysis. The literature is reviewed in an attempt to delineate a rational approach to evaluating cocaine users at risk for rhabdomyolysis.

The Impact of Two Freestanding Emergency Departments on a Tertiary Care Center

BACKGROUND Freestanding emergency departments (FEDs) have become increasingly popular as the need for emergency care continues to grow. OBJECTIVE To analyze the impact of two FEDs on a local tertiary care centers patient volume and admission rates. METHODS A retrospective analysis examined monthly volume and admission rates for the main ED and two FEDs located 9.6 and 12 miles away. Main ED census records were divided into three distinct time frames: period A (control) was January 2007 through June 2007. Period B was July 2007 through July 2009 when one FED was open. Period C was August 2009 through June 2010 when both FEDs were open. A two-factor analysis of variance was used to analyze admission rates while adjusting for monthly variation. RESULTS The mean monthly patient volume for the main ED was 4709 for period A, but dropped significantly (p<0.01) to 4447 for period B, and again dropped significantly (p<0.01) to 4242 during period C. The volume for all facilities increased throughout the study period. A combined monthly volume increase to 5642 occurred in Period B, and increased to 6808 in Period C. The adjusted mean admission rate at the main ED for period A was 0.221, which dropped somewhat, though not significantly (p=0.3505) to 0.213 for period B, and then significantly (p<0.01) to 0.189 for period C. CONCLUSION Opening two FEDs decreased the volume and admission rates for the main ED and increased the overall ED volume for the health care system.

International Federation for Emergency Medicine model curriculum for medical student education in emergency medicine

There is a critical and growing need for emergency physicians and emergency medicine resources worldwide. To meet this need, physicians must be trained to deliver time-sensitive interventions and life-saving emergency care. Currently, there is no internationally recognized, standard curriculum that defines the basic minimum standards for emergency medicine education. To address this lack, the International Federation for Emergency Medicine (IFEM) convened a committee of international physicians, health professionals, and other experts in emergency medicine and international emergency medicine development to outline a curriculum for foundation training of medical students in emergency medicine. This curriculum document represents the consensus of recommendations by this committee. The curriculum is designed with a focus on the basic minimum emergency medicine educational content that any medical school should be delivering to its students during their undergraduate years of training. It is not designed to be prescriptive, but to assist educators and emergency medicine leadership in advancing physician education in basic emergency medicine content. The content would be relevant, not just for communities with mature emergency medicine systems, but also for developing nations or for nations seeking to expand emergency medicine within current educational structures. We anticipate that there will be wide variability in how this curriculum is implemented and taught, reflecting the existing educational milieu, the resources available, and the goals of the institutions’ educational leadership.

The Future of Emergency Medicine

BACKGROUND The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care. SUMMARY In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to-and will continue to contribute to-a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EMs future; 7) It is important that all providers of emergency care receive continuing postgraduate education.

Posted emergency department wait times are not always accurate.

OBJECTIVES Hospitals around the United States are advertising emergency department (ED) wait times. The objective was to measure the difference between publicly posted and actual ED wait times and to compare these between ED site volumes. METHODS This study was a retrospective consecutive sample of ED patients at one hospital system with four EDs. The wait times of 8,889 patients were included in this analysis. One ED was in a large teaching hospital with 5,000 ED patients per month; the other three were freestanding or community EDs without teaching and with fewer than 2,000 ED patients per month each. The publicly posted ED wait times at the time of patient arrival were recorded and compared to the actual wait times as retrieved from the ED tracking system. The difference between posted and actual wait times for each site was calculated. Separate one-way analysis of variance (ANOVA) tests with post hoc testing were conducted to assess actual wait time and wait time difference between ED sites. RESULTS Mean and standard deviation (SD) wait time difference at the main ED with a volume of 5,000 patients per month was 31.5 (±61.2) minutes. At the facilities with fewer than 2,000 ED patients per month each, the differences in wait times were 4.2 (±21.8), 8.6 (±23.8), and 1.3 (±11.9) minutes. ANOVA results revealed that the main ED had significantly different actual wait time and wait time differences (p < 0.05) when compared to the other three EDs. CONCLUSIONS In one hospital system, publicly posted ED wait times show better accuracy in EDs that see 2,000 or fewer patients per month and less accuracy for an ED that sees 5,000 patients per month, likely due to flow confounders.

Regionalization of Emergency Care Future Directions and Research: Workforce Issues

The provision of emergency care in the United States, regionalized or not, depends on an adequate workforce. Adequate must be defined both qualitatively and quantitatively. There is currently a shortage of emergency care providers, one that will exist for the foreseeable future. This article discusses what is known about the current emergency medicine (EM) and non-EM workforce, future trends, and research opportunities.

A comparison of acuity levels between 3 freestanding and a tertiary care ED.

INTRODUCTION Freestanding emergency departments (FEDs) have grown in popularity. They often provide emergent care in areas distant from other EDs. Investigations and research to characterize the operation and dynamics of FEDs are needed. This study characterizes the severity of illness seen at FEDs and compares it with a hospital-based urban tertiary care ED using the emergency severity index (ESI), a quantification of patient acuity. METHODS Patient ESI levels were analyzed retrospectively over 1 year for a single hospital system with 1 main urban hospital-based ED and 3 FEDs. Data analysis was completed using analysis of variance with and without time as a factor. RESULTS The average ESI level at the main ED (3.04) was lower than the FEDs, respectively (3.42, 3.22, and 3.38) (P < .001). Patient ESI levels were significantly different between FEDs (P < .001). CONCLUSION The main ED demonstrated lower ESI levels and thus higher acuity than the 3 affiliated FEDs. There were significantly different acuity levels between the main ED and 3 FEDs as well as between individual FEDs.

The future of emergency medicine.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem. In July 2009, representatives of the leading emergency medicine organizations met in Dallas, TX, for the Future of Emergency Medicine Summit. This consensus document, agreed to and cowritten by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty.