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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.annemergmed.2008.07.001 Byline: Jonathan A. Edlow, Peter D. Panagos, Steven A. Godwin, Tamara L. Thomas, Wyatt W. Decker Author Affiliation: American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department with Acute Headache Article Note: (footnote) Approved by the ACEP Board of Directors, June 24, 2008, Supported by the Emergency Nurses Association, July 29, 2008

Byline: Kathleen J Clem, Tamara L Thomas, Yi-Tang Wang, Darlene Bradley Abstract: Emergency medicine is growing rapidly as a specialty and is beginning to be recognized as an essential component of medicine in China. Traditional Chinese medicine and modern technology exist together. A description of the US authors' experience as consultants at a new emergency department and in establishing an emergency medicine residency program in Hangzhou, China is provided. A total of 7 months were spent in the observation, identification, and development of a basic framework of emergency care at a new hospital. The practice of emergency medicine in China was researched by direct observation at several Chinese cities and by literature review. China is taking the parts of the Western system it can use and implementing its own methods in the overall practice of emergency medicine. [Clem KJ, Thomas TL, Wang Y-T, Bradley D: United States physician assistance in development of emergency medicine in Hangzhou, China. Ann Emerg Med July 1998;32:86-92.] Article History: Received 4 August 1997; Revised 1 January 1914; Revised 19 February 1998; Accepted 23 March 1998 Article Note: (footnote) [star] From the Department of Emergency Medicine, Loma Linda University Medical Center,* Loma Linda, CA, Chinese Association of Emergency Medicine and Nanjing Medical University,a People's Republic of China., [star][star] Reprint no. 47/1/90883 , a Address for reprints: Kathleen J Clem, MD, Department of Emergency Medicine, Loma Linda University Medical Center, Loma Linda, CA 92354, 909-824-4344, Fax 909-478-4121, E-mail kathleen_clem@ccmail.llumc.edu

Byline: Steven M Green, Steven G Rothrock, Jeffrey D Ho, Roger D Gallant, Rodney Borger, Tamara L Thomas, Grenith J Zimmerman Abstract: Study objective: Although adjunctive intravenous bicarbonate therapy is commonly recommended for children with severe diabetic ketoacidosis (DKA), no studies assessing clinical outcome with this therapy have ever been performed. Our objective was to determine whether bicarbonate therapy influenced outcome for pediatric DKA. Methods: The study was a retrospective consecutive case series of 147 admissions for severe DKA (initial pH [less than or equal to]7.15 and glucose concentration [greater than or equal to]300 mg/dL [16.7 mmol/L]) in 106 children during a 16-year period at a tertiary university medical center. Descriptive statistics were applied to the 147 admissions. The first patient admitted with DKA was then selected for each of the 106 children, and clinical and laboratory data were compared between subjects who did and did not receive bicarbonate. Multivariate and matched pair analyses were performed to control potentially confounding variables. Results: Fifty-seven of the 147 patients admitted with DKA (39%) were successfully treated without bicarbonate, including 9 with a pH of 7.00 or less and one with a pH of 6.73. The frequency of complications was comparable between bicarbonate and nonbicarbonate groups (4% versus 2%, P=1.00). The mean duration of hospitalization for children receiving bicarbonate was 23% (16 hours) longer than children who did not receive bicarbonate in the multivariate analysis (P=.07) and 37% (22 hours) longer in the matched pair analysis (P=.01). The mean rate of metabolic recovery by three distinct measures was similar between groups, and the sample had 80% power to detect differences of 14% to 29% in these measures. Conclusion: We found no evidence that adjunctive bicarbonate improved clinical outcome in children with severe DKA. The rate of metabolic recovery and complications were similar in patients treated with and without bicarbonate, and prolonged hospitalizations were noted in the bicarbonate group. We conclude that adjunctive bicarbonate is unnecessary and potentially disadvantageous in severe pediatric DKA. [Green SM, Rothrock SG, Ho JD, Gallant RD, Borger R, Thomas TL, Zimmerman GJ: Failure of adjunctive bicarbonate to improve outcome in severe pediatric diabetic ketoacidosis. Ann Emerg Med January 1998;31:41-48.] Article History: Received 18 March 1997; Revised 23 July 1997; Accepted 2 August 1997 Article Note: (footnote) [star] From the Departments of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, CA, and Riverside General Hospital, Riverside, CA;* Orlando Regional Medical Center, Orlando, FL;a Hennepin County Medical Center, Minneapolis, MN;As. West Virginia University, Morgantown, WV;a[yen] and the Loma Linda University School of Allied Health Professions.A[paragraph] , [star][star] Reprints not available from the authors. , a 47/1/87347

A 33-year-old woman presented to a community emergency department with a 4-day history of monocular orbital pain, photophobia and pain on extraocular movement. Findings included chemosis, conjunctival injection and restricted [...]

International emergency medicine continues to grow and expand. There are now more than 30 countries that recognize emergency medicine as a specialty. As the field continues to develop, many physicians are reaching across borders and working with their colleagues to improve patient care, education, and research. The future growth and success of the specialty are based on several key components. These include faculty development (because this is the key driver of education), research, and curriculum development. Each country knows what resources it has and how best to utilize them. Countries that are developing the specialty can seek consultation from successful countries and develop their academic and community practice of emergency medicine. There are many resources available to these countries, including distance learning and access to medical journals via the Internet; international exchanges by faculty, residents, and medical students; and physicians who are in fellowship training programs. International research efforts require more support and effort to be successful. This report discusses some of the advantages and hurdles to such research efforts. Physicians have a responsibility to help one another succeed. It is the hope of the authors that many more emergency physicians will lend their skills to further global development of the specialty.

Guatemala has recently undergone many advances in emergency medical services (EMS) training and disaster management. Industrialization and demographic changes have led to a continuing decline in the prevalence of infectious disease, while trauma and cardiovascular-related deaths have become increasingly important. Trauma now accounts for the nation's single greatest cause of productive years of life lost, a major indicator of a disease's impact on society. This "demographic transition" has dramatically increased the number of incidents where early prehospital intervention can have a positive impact on morbidity and mortality. However, until recently, prehospital medical care was provided by firefighters, who lacked formal medical training. Responding to a perceived need, increased collaborative efforts between prehospital care providers and governmental and nongovernmental agencies have rapidly improved provider training, initiated care standardization, and improved disaster preparedness. These efforts may serve as a model to other developing nations seeking to improve their EMS systems.

Manmade disasters have risen over the past decaFde. Specifically, chemical weapons used in acts of aggression pose an increasing threat to our society. These potential disaster situations raise concerns regarding preparedness for both adults and children. This article's purpose is to review general principles of chemical exposure and treatment of specific chemical agents, and to identify specific pediatric considerations involved.

Abstract. Objectives: To present suggestions on planning for development of emergency medicine (EM) and out‐of‐hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already familiar with EM. Methods: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. Conclusions: Some aspects of EM system development have applicability to most countries, but other aspects must be decided by planners based on country‐specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the efficacy of these efforts. Further studies are needed on the relative effectiveness and cost‐benefit of different EM development efforts.

Abstract. This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs’ content would be “observational” rather than involving direct “hands‐on” clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs.

A functional analysis of noncompliance, aggression, and disruptive behavior during instruction was conducted with a 10-year-old boy with severe disabilities. We studied the relation between participant responsiveness and the rate and function of problem behavior. Results showed that unresponsiveness before difficult instruction was associated with higher rates of problem behavior negatively reinforced by termination of that instruction. A neutralizing routine, called precorrection, was then applied before difficult instruction when the participant was rated as not responsive. Results showed that the neutralizing event increased responsiveness and reduced problem behavior during difficult instruction. The study demonstrates a promising assessment and treatment method for problematic behavior that begins prior to instruction.

The objective of this article is to identify and describe Chinese emergency medical services (EMS) components. Chinese EMS system development began in the 1980s with “importing” of EMS principles from other systems. China is now attempting to unify these principles. Chinese EMS systems are absent in most rural areas. Urban ambulance dispatch or “rescue” centers provide both transport and inpatient care. Ambulances are staffed with either a physician or a driver. There is not extensive overlap between hospital emergency physicians and ambulance physicians and no out‐of‐hospital providers at the paramedic or emergency medical technician level exist. Access to EMS is accomplished by dialing 1‐2‐0. Emergency calls go directly to the rescue center and a physician is dispatched. No on‐line radio communication between hospitals and ambulances typically takes place. China has assimilated both traditional and unique EMS components and is undergoing development. It remains unclear whether a systematized EMS structure will emerge.

Objective. To evaluate the experience of prehospital care providers with violence. Methods. A survey addressing experiences with prehospital violence was administered to a convenience sample of emergency medical services (EMS) providers in a southern California metropolitan area. Descriptive statistics are reported. Results. Of 774 EMS providers surveyed, 522 (67%) returned the questionnaire. Members of law enforcement were excluded because their experience with violence, weapons, and tactics is not typical of most paramedics. This left a sample of 490 for further analysis. These prehospital care providers had a median of ten years' experience on the job. They tended to be male (93%) and white (80%). All together, 61% recounted assault on the job, with 25% reporting injury from the assault. Respondents reported a median of three episodes, and the number of assaults for each individual was unrelated to the number of years of experience on the job (r= 0.068). Of those injured, 37% required medical attention. On the other hand, 35% reported that their company had a specific protocol for managing violent situations and 28% stated ever having received formal training in the management of violent encounters. This limited training notwithstanding, nearly all (95%) providers described restraining patients. Use of protective gear was reported (73%), and some (19%) admitted to ever carrying a weapon on the job. Conclusions. By their own report, EMS providers encounter a substantial amount of violence and injury due to assault on the job. Formal training and protocols to provide a standardized safe approach for such encounters are lacking. Although the limitations of survey data are recognized, further research characterizing the level of violence and potential interventions seems warranted.

Relates a story of a couple that was destined to be together. Hospital where the couple was born; Similarities of the couple; Family plans.