Stephen R. Hayden

Rapid sequence intubation in the field versus hospital in trauma patients.

We conducted a retrospective review of all adult trauma patients who underwent prehospital field rapid sequence intubation (RSI) by aeromedical crews from 1988 through 1995 and compared them to all trauma patients who arrived by ground transportation and underwent RSI in the trauma suite from 1992 through 1995 at a University hospital. Of the 47 field RSI patients, 46 (97.9%) were successfully intubated, whereas 263 of the 267 (98.5%) hospital RSI patients were successfully intubated. There were no statistical differences in success rates, number of attempts, or immediate intubation events in the procedure between the two groups. There were no differences in delayed events with the exception of pneumonia, which occurred more frequently in the field RSI group (28% vs. 6%, respectively). We performed a subgroup analysis on isolated head injury patients to evaluate outcome. There was no difference in total hospital days, length of ICU stay, mortality or final disposition in the two head injury groups. Though this study is limited by small sample size, we conclude that field RSI is equally successful and safe as hospital RSI.

Likelihood ratio: A powerful tool for incorporating the results of a diagnostic test into clinical decisionmaking.

Abstract [Hayden SR, Brown MD: Likelihood ratio: A powerful tool for incorporating the results of a diagnostic test into clinical decisionmaking. Ann Emerg Med May 1999;33:575-580.]

Domestic violence in the emergency department: How do women prefer to disclose and discuss the issues?

The purpose of this study was to survey women presenting to the emergency department (ED) and determine from them how best to identify and discuss issues of domestic violence (DV). An anonymous 10-question survey was given to ambulatory females presenting to the ED. It was conducted at two affiliated university hospital EDs, one an urban trauma center (ED 1) and the other an ED in an affluent suburban setting (ED 2). Two hundred forty-three women responded (73% response), 153 (63%) from ED 1 and 90 (37%) from ED 2. There were 21 women (9%) currently being abused, and 109 (45%) were past victims. Of all victims, 40 (36%) would only divulge DV if asked directly, 28 (25%) would volunteer this information without being asked, and 12 (11%) would not report DV even if asked. Of women who would reveal DV only if asked directly, 52 (45%) felt very comfortable disclosing this to an ED physician, although only 27 (24%) would reveal DV at a triage encounter. Of past or current victims, 43 (39%) would not disclose DV if they knew that ED personnel were required to report it. In conclusion, the ED is an appropriate setting to discuss DV issues. A significant percentage of women will disclose DV only if asked directly about it. Many victims of DV feel very comfortable discussing DV with ED physicians and nurses, although they may be less likely to reveal DV incidents at a triage encounter. Mandatory reporting laws may be an impediment to identifying cases of abuse.

Effect of surgical cricothyrotomy on the unstable cervical spine in a cadaver model of intubation.

Cricothyrotomy is indicated for patients who require an immediate airway and in whom orotracheal or nasotracheal intubation is unsuccessful or contraindicated. Cricothyrotomy is considered safe with cervical spine (c-spine) injury; however, the amount of c-spine movement that occurs during the procedure has not been determined. In this experimental study, an established cadaver model of c-spine injury was used to quantify movement during cricothyrotomy. A complete C5--6 transection was performed by using an osteotome on 13 fresh-frozen cadavers. Standard open cricothyrotomy was performed on each cadaver, with c-spine images recorded in real time on fluoroscopy, then transferred to video and Kodachrome still images. Outcome measures included movement across the C5--6 site with regard to angulation expressed in degrees of rotation and linear measures of axial distraction and anterior-posterior (AP) displacement expressed as a proportion of C5 body width. Data were analyzed by using descriptive statistics to determine mean change from baseline in each of three planes of movement. Significance was assumed if 95% confidence intervals did not include zero. A significant amount of movement was observed with regard to AP displacement (6.3% of C5 width) and axial distraction (-4.5% of C5 width, indicating narrowing of the intervertebral space). These correspond to 1--2 mm AP displacement and less than 1 mm axial compression. No significant angular displacement was observed. In conclusion, cricothyrotomy results in a small but significant amount of movement across an unstable c-spine injury in a cadaver model. This degree of movement is less than the threshold for clinical significance.

Accuracy of Leukocyte Count in the Diagnosis of Acute Appendicitis

Abstract [Snyder BK, Hayden SR: Accuracy of leukocyte count in the diagnosis of acute appendicitis. Ann Emerg Med May 1999;33:565-574.]

Cerebral Gas Embolism Resulting From Inhalation of Pressurized Helium

Loss of consciousness, a generalized tonic-clonic seizure, rightside weakness, and pneumomediastinum developed suddenly in a 13-year-old boy who had inhaled helium directly from a pressurized helium tank. His condition improved dramatically with hyperbaric oxygen treatment, and he had apparently regained complete neurologic function by the time of follow-up 2 weeks later. On the basis of the boys clinical presentation and his response to hyperbaric oxygen therapy, we diagnosed a cerebral gas embolism.

EMERGENCY DEPARTMENT AIRWAY MANAGEMENT BEFORE AND AFTER AN EMERGENCY MEDICINE RESIDENCY

To determine whether the start of an Emergency Medicine (EM) training program affects the appropriateness, timeliness, and safety of Emergency Department (ED) intubations, all ED intubations performed 12 months before and after the start of an EM residency were reviewed. In addition, all patients intubated within 12 h after being admitted through the ED were reviewed. We found that all ED intubations before and after the start of a residency program were deemed appropriate. Of patients intubated after admission, 13 of 20 (65%) were felt to have warranted intubation while in the ED for the pre-residency group, compared with 9 of 29 patients (31%) for the post-residency group. There were no differences between the complication rates of these groups. We conclude that an EM residency program did not increase the number of inappropriate intubations or complications, and reduced the number of patients who required but did not receive intubation in the ED.

Patients' satisfaction when denied authorization for emergency department care by their managed care plan.

We conducted a survey of managed care plan (MCP) patients who presented to the emergency department (ED) but were denied insurance authorization during a 3-month period. Patients were identified by triage or registration records, contacted by telephone after their visit, and surveyed regarding their satisfaction with the ED and MCP, follow-up care, and future behavior. We surveyed 72 (73.4%) of 98 subjects who were denied authorization. Forty-nine (68.1%) were redirected to a clinic or primary physician, 14 (19.4%) to an urgent care or other ED, and 9 (12.5%) were given no follow-up. Fifty-five respondents (76.4%) stated they had followed-up as directed, but 34 (47.2%) felt the delay had a negative impact. Thirty-nine (54.2%) were dissatisfied with their MCP. If their problems were to recur, 27 (37.5%) stated they would go to a clinic or call their MCP, but 34 (47.2%) would return to the ED. Many patients who are denied authorization are dissatisfied with their MCP and will return to the ED in the future, despite previous denials.

Becoming an Emergency Medicine Resident: A Practical Guide for Medical Students

A medical student interested in Emergency Medicine (EM) will find acceptance into residency to be competitive and possibly difficult. An applicant should become aware of the qualities valued by EM residency directors. In the pre-clinical years, an applicant should do well in the basic sciences, perform well on the United States Medical Licensing Examination (USMLE) Step 1, and find an appropriate EM mentor. In the clinical years, excellence in the third-year core clerkships and the EM rotations, as well as the USMLE Step 2, are very important. The student must then acquire strong letters of recommendations from supervisors and a Deans letter that accurately reflects the students academic record. Preparation for a residency interview involves an understanding of both opportunities and challenges in the specialty. Coupled with a strong academic record, this gives the best chance for a favorable match.

Preparing for the Transition to Practice: A Compilation of Advice from Program Directors to Residency Graduates

Each year, a graduating class of senior emergency medicine (EM) residents enters the workplace, marking an important milestone in the development of practicing physicians. This transition from senior resident to attending physician is an exciting time, but bears with it daunting challenges for even the most seasoned resident. Financial decisions, personnel management, clinical autonomy, and patient care are just a few of the challenges with which new graduates are faced. Although residency training programs strive to prepare residents for these challenges, there remains a gap between the theory of medicine and the practice of health care. This gap represents the ‘‘transition to practice.’’ Program Directors serve as important guides during the development of resident physicians. As mentors, Program Directors help shepherd residents through the challenges of residency training and help prepare these residents for their transition to practice. Not only have Program Directors made this transition themselves, but they have witnessed hundreds of residents make the same journey. The collective experience of Program Directors serves as an invaluable resource and helps new graduates navigate this challenging period.