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Objectives. To determine the following: 1) whether a Domestic Violence Scene Assessment Screen (DVSAS) is accurate at predicting domestic violence (DV) when compared with results on the validated Abuse Assessment Screen (AAS), and 2) whether EMTs can perform accurately on a DVSAS after they have finished a transport so as not to interfere with routine care. Methods. All patients transported by ambulance from domestic environments (i.e., home) by an urban EMS system were included in the study. A ten-question screen was developed to assess whether a domestic environment had a high risk of having DV (DVSAS). A positive answer to any of the questions was considered to be a positive result on the screen. A trained observer with no clinical duties rode on the ambulance for randomized shifts during a two-month period. The observer completed the DVSAS while at the scene, then the patient, if able, completed the AAS. After finishing the transport, the EMT completed the DVSAS based on his or her memory of the scene...

Our purpose was to determine if core hypothermia influences physiological responses to norepinephrine (NE); and if rewarming reverses these effects. Animals were instrumented to measure mean arterial pressure (MAP) and cardiac output (CO). Core temperature was manipulated from 37.5 degrees C (normothermia), to 30 degrees C (hypothermia) and the back to 37.5 degrees C (rewarming) using an external arterial-venous femoral shunt. At each of these temperatures, baseline CO and MAP were measured. Norepinephrine (NE) was infused at rates to deliver 0.2, 1.0, or 5 microg kg(-1) per h. At each dose CO and MAP was measured again. Systemic vascular resistance (SVR) was calculated using the formula (SVR = (MAP/CO) x 80). Eight animals underwent all three phases of the protocol. The response to NE during normothermia was a significant increase in MAP to doses of 1 microg kg(-1) per min (P0.01) and 5 microg kg(-1) per min (P0.01) and SVR to doses of 1 microg kg(-1) per min (P0.01) and 5 microg kg(-1) per min (P0.01). The response to NE during hypothermia was a significant increase in MAP only at doses of 1 microg kg(-1) per min (P = 0.03) and 5 microg kg(-1) per min (P = 0.01). The response to NE after rewarming was a significant increase in MAP only at a dose of 5 microg kg(-1) per min (P = 0.03). This study shows that core hypothermia causes a change in physiological response to NE that rewarming does not reverse.

The purpose of a curfew is to decrease the amount of crime inflicted on minors during the late hours of the night. On June 1, 1994, a city curfew was instituted in New Orleans, requiring all persons 17 years of age or younger to be off the streets from 9 PM to 6 AM Sunday through Thursday, and from 11 PM to 6 AM on Friday and Saturday. This study evaluated the effect of the curfew on emergency medical services (EMS) transports for patients who were 17 years old or younger (pediatric).Data from all pediatric transports were included from the months before (5/94) and after (6/94) the institution of the curfew, and from the same two months one year earlier (5/93 and 6/93). A chi-square test was used to evaluate comparisons.The city EMS transports 48,000 patients per year in a one-tiered system (paramedic only) that acts as the sole provider of emergency EMS transport in the city. Approximately 10% of all transports are pediatric, and 40% of the pediatric transports are for trauma. A total of 1,642 transports were found that fit the inclusion criteria. In May 1993, there were 415 total pediatric transports; 234 were pediatric trauma. In June 1993, there were 406 total pediatric transports; 250 were pediatric trauma. In May 1994, there were 447 total pediatric runs; 243 were pediatric trauma. During the postcurfew month, June 1994, there were a significant decrease in pediatric transports to 370 (p0.01) and a significant decrease in pediatric trauma transport to 189 (p0.01).The institution of a curfew may lead to a drop in pediatric EMS runs during curfew hours. Another value of the curfew may be in the secondary effects of the curfew in preventing childhood injury during noncurfew hours.

Objectives: To compare four injectable anesthetics (buffered 1% lidocaine, buffered 1% lidocaine with epinephrine, plain 1% lidocaine with epinephrine, and 0. 5% diphenhydramine with epinephrine) for pain of infiltration and effectiveness of anesthesia during suturing of minor lacerations. Methods: A prospective, randomized, double-blind, comparison trial of the above agents was performed in an urban ED; adults with simple linear lacerations without vascular compromise were enrolled. Physicians and patients ranked the pain of injection and suturing according to a 10-cm visual analog scale (VAS). Fisher's exact and Kruskal-Wallis tests were used to compare demographic data, and Kruskal-Wallis and Newman-Keuls tests were used in analysis of VAS rankings. The power of the study was 0. 8 to detect a 1. 4-cm difference in VAS readings, and 0. 9 to detect a 1. 7-cm difference. Results: Seven of 200 enrolled patients were excluded due to improper data collection and 13 were removed from final statistical analysis due to need for additional anesthetic (treatment failures), leaving 180 subjects for final analysis. Demographic data were similar for the four groups (p > 0.05). Diphenhydramine with epinephrine was significantly more painful to inject than was buffered lidocaine or buffered lidocaine with epinephrine, according to both the patients (p = 0.0003) and the physicians (p = 0.0037). The two buffered compounds were slightly less painful to inject than was lidocaine with epinephrine, but statistical comparisons did not reach significance. For anesthesia effectiveness, lidocaine with epinephrine and buffered lidocaine with epinephrine were statistically better than buffered lidocaine or diphenhydramine with epinephrine (p = 0.0001 for the patients and the physicians). Conclusions: Buffered lidocaine with epinephrine and lidocaine with epinephrine were more effective anesthetics during suturing, according to both the physicians and the patients. There was a tendency toward less pain with infiltration in buffered solutions, compared with plain lidocaine with epinephrine, but the comparisons did not reach statistical significance. Diphenhydramine with epinephrine was more painful to inject than were buffered lidocaine with epinephrine and lidocaine with epinephrine, and was less effective anesthetically than the other three solutions.

Objective:To estimate the frequency of associated hypoglycemia in an ethanol-ingesting pediatric and adolescent population. Methods: The study was a retrospective review of nondiabetic pediatric and adolescent patients with measurable ethanol levels (i.e., >2 mmol/L) who had an ED serum glucose level determined. Results: Over the four-and-a-half-year study period, there were 254,234 pediatric visits. One hundred eleven had ethanol levels determined (0.044% of patients) due to suspected ingestion. Of these 111, 88 had glucose levels determined. The mean age of the 88 patients was 14 years, with a mean glucose level of 5.6 mmol/ L [101 mg/dL; interquartile range (IQR) 4.7-6.3 mmol/L] and a mean ethanol level of 30 mmol/L (IQR 15–43 mmol/L). Glucose levels were < 67 mg/dL (hypoglycemia) in three of the 88 (3.4%) ethanol-positive patients; all the hypoglycemic patients had significant behavioral changes. Conclusion: In this large retrospective series, the number of patients for whom the clinical suspicion of ethanol ingestion was confirmed was quite small. Hypoglycemia occurred in only 3.4% of these selected patients; all had altered behavior. Pediatric patients with presentations suggesting ethanol intoxication with altered behavior should be assessed for concurrent hypoglycemia.

Objective: To examine targeted screening and empiric treatment for syphilis in an urban ED. Methods: Screening of emergency patients during previously arranged shifts from July 1991 through January 1992 in a university-affiliated, inner-city ED. Emergency patients who perceived that they had high-risk factors for syphilis (i.e., cocaine or heroin use or sexual contact with a user of these substances) were compared with emergency patients denying high risk. All presumed high-risk patients and alternate patients in the group who denied high risk (control group) were screened in the ED with the rapid plasma reagin (RPR) test. Empiric antibiotic treatment was initiated if the patient was RPR-positive and gave no previous history of syphilis. In addition, serum was submitted to the state laboratory for VDRL and microhemagglutination-Treponema pallidum (MHA-TP) testing. Blinded serologic testing for HIV antibody was performed later on frozen serum. Results: Of 806 patients presenting to the ED, 276 (34%) admitted to high-risk behavior. Of 373 patients tested by RPR in the ED (216 high-risk and 157 control patients), no significant difference was found between the high-risk and the control patients in untreated syphilis [8 (4%) vs 4 (3%)] or positive MHA-TP [47 (22%) vs 25 (16%)]. In the high-risk group, the women were more likely than the men to be MHA-TP-positive (OR = 2.58, 95% CI 1.12–7.98, p = 0.04). Among the women, the MHA-TP was more often positive for the high-risk than for the control patients (34% vs 15%, OR = 2.27, 95% CI 1.12–4.67, p = 0.023). For the high-risk group, seven (3%) new cases of syphilis were managed empirically. vs three (2%) new cases for the control group. HIV antibodies were detected in 16 of 212 (8%) high-risk patients and five of 155 (3%) control subjects (p = 0.13). Conclusion: This inner-city ED population has a high frequency of positive syphilis and HIV serologies, regardless of acknowledged drug use risk factors. Therefore, in areas reporting high syphilis infection rates, consideration should be given to offering screening for syphilis to all emergency patients, along with establishment of adequate counseling and follow-up.

Goal of this study To compare outcomes of incision and drainage with packing to needle aspiration of purulent buboes in patients with presumed chancroid. The safety and efficacy of incision and drainage were compared with that of needle aspiration. Study design and methods The study was a prospective randomized, nonblinded clinical trial carried out from April 1992, to January 1994 in an inner city emergency department. A consecutive sample of 27 adults with fluctuant inguinal buboes presumed or proven to be chancroid or lymphogranuloma venereum were eligible for inclusion. Patients were excluded if they were believed to have buboes secondary to disease other than chancroid. After informed consent was obtained, patients had buboes drained by needle aspiration or by incision and drainage with packing according to a random numbers table. Results Twenty-seven patients were included in the study (22 men and 5 women), with 12 randomized to incision and drainage and 15 to aspiration. The mean age was 35.7 +/- 13 years. Genital ulcer or bubo pus cultures for Haemophilus ducreyi were positive in seven patients, negative in 15 patients, and not done in five patients. Follow-up was obtained for 23 (85%) patients, 11 of whom had incision and drainage and 12 of whom had aspirations. No adverse effects were reported in either group. Conclusion Incision and drainage is an effective method for treating fluctuant buboes and may be preferable to traditional needle aspiration considering the frequency of required re-aspirations in the study patients. Limitations of this study include lack of complete laboratory testing and lack of follow-up of all patients.

To estimate the rates of syphilis infection in inner-city patients managed by prehospital providers, a convenience sampling of prehospital patients who had intravenous lines initiated was screened for syphilis over a nine-month study period from February 1992 through October 1992. In a university-affiliated inner-city emergency department served by a city ambulance company, patients 18 years of age or older transported via ambulance who had had intravenous lines initiated at the scene or en route had a Venereal Disease Research Laboratory (VDRL) and microhemagglutination-Treponema pallidum (MHA-TP) drawn and performed by the state laboratory as a routine serological test. If the results were reactive with no previous history of syphilis recorded in the state registry, the state health department and/or one of the authors of this study contacted the patient for follow-up treatment. Age, race, sex, and diagnostic category (medical, surgical/obstetric, or neuropsychiatric) were recorded. Results were checked with the state syphilis registry. Latent syphilis was defined as a reactive VDRL and MHA-TP with no prior history of infection or record of infection in the state syphilis registry. Chi-squared test was used in statistical analysis for comparisons among ages, races, and sexes, with P > .05 considered significant. Three hundred two subjects 18 years of age and older consenting to a screening VDRL and MHA-TP had serum drawn. Two hundred seventy-nine patients were enrolled in the study after 23 patients were excluded because of improper data collection or insufficient serum collection. There were 174 men (63%) and 105 women (37%), with 73 white (26%) and 199 African-Americans (71%).(ABSTRACT TRUNCATED AT 250 WORDS)

The study objective was to compare the topical anesthetic LAT (4% lidocaine, 1:2,000 adrenaline, 1% tetracaine) to TAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine) for efficacy, adverse effects, and costs. The study design was a randomized, prospective, double blind clinical trial set in an inner-city emergency department with an emergency medicine residency program. Adults with linear lacerations of the face or scalp were eligible for inclusion in the study. Patients had lacerations anesthetized with topical TAC or LAT according to a random numbers table. A total of 95 patients were included in the study with 47 receiving TAC and 48 receiving LAT. Patients stated the number of sutures causing pain and patients and physicians rated the overall pain of suturing using a standard visual analog scale (VAS). The power of the study to determine a ranked sum difference of 15 was 0.8. Visual analog scale results and number and percentage of sutures causing pain were compared using Wilcoxon's Rank Sum Test. According to patients, the percentage of sutures causing pain was significantly fewer for LAT than TAC (P = .036, Interquartile Range 0.13 to 0.0 for LAT, 0.25 to 0 for TAC). Physicians found LAT statistically more effective than TAC (P = .0093, Interquartile Range 1 to 0 for LAT, 2 to 0 for TAC) but patients did not report a difference (P = .266, Interquartile Range 1 to 0 for both LAT and TAC). Our cost per application was $3.00 for LAT compared to $35.00 for TAC. Follow-up was accomplished in 91 of 95 patients (95%) with no reported complications for either medication.(ABSTRACT TRUNCATED AT 250 WORDS)

Study objective. The purpose of the present study is to compare LAT gel (4% lidocaine, 1:2000 adrenaline, 0.5% tetracaine) to TAC gel (0.5% tetracaine, 1:2000 adrenaline, 11.8% cocaine) for efficacy, side effects, and costs in children aged 5 to 17 years with facial or scalp lacerations. Design. Randomized, prospective, double-blinded clinical trial. Setting. Inner-city Emergency Department with an Emergency Medicine residency program. Patients or other participants. Children aged 5 to 17 years with linear lacerations of the face or scalp. Intervention. After informed consent was obtained patients had lacerations anesthetized with topical TAC or LAT gel according to a random numbers table. Measurements and main results. A total of 95 patients were included in the statistical analysis with 47 receiving TAC and 48 receiving LAT. Physicians and patients/parents separately rated the overall pain of suturing using a modified multidimensional scale for pain assessment specifically for children. Patients/parents also stated the number of sutures causing pain. The power of the study to determine a ranked sum difference of 15 was 0.8. Multidimensional rating scale results and number and percentage of sutures causing pain were compared using Wilcoxon's rank sum test. According to patients no difference could be detected in percent of sutures causing pain in the LAT versus TAC group (P = .51). Using the multidimensional scale, physicians and patients/parents found LAT statistically the same as TAC in effectiveness (P = .80 for physicians and P = .71 for patients). Cost per application was $3.00 for LAT compared to $35.00 for TAC. Follow-up was accomplished in 85 of 95 participants in the study with no reported complications for either medication. Conclusion. LAT gel worked as well as TAC gel for topical anesthesia in facial and scalp lacerations. Considering the advantages of a noncontrolled substance and less expense, LAT gel appears to be better suited than TAC gel for topical anesthesia in laceration repair in children.

Iontophoresis is a painless technique for topical anesthesia that uses an electric field to drive charged ions across an epithelial surface. The safety of this technique for laceration repair has never been demonstrated. The purpose of this study was to investigate the effect of iontophoretic fields on rapidly proliferating cells involved in laceration wound healing. The study was a prospective single-blinded animal study using a guinea pig model. Twelve guinea pigs each received four induced, uncontaminated lacerations. Each guinea pig was randomly assigned to 1 of 3 groups (4 guinea pigs in each group). One group received lidocaine via iontophoresis, one group received injected lidocaine, and one group received half iontophoresis and half injected lidocaine. After anesthetic treatment, wounds were then repaired in a standard fashion. The wounds were examined grossly on a daily basis and on day 10 the incised skin containing the laceration was examined by a pathologist blinded to the treatment group. A total of 48 wounds were assessed for wound healing, 24 of which received lidocaine via iontophoresis and 24 lidocaine via injection. The power of the study to determine a 40% difference between the two groups was 0.8. There was significantly more granuloma and granulation tissue formation in the iontophoresis group than in the injected lidocaine control group ( P = .0004, Fisher's exact test). There were no statistically significant differences in degree of inflammation between the two groups (lidocaine via injection v lidocaine via iontophoresis) measured by amount of dermal fibrosis ( P = .14, Fisher's exact test), giant cell formation ( P = .21, Fisher's exact test), and presence of acute and/or chronic inflammation ( P = .17, Wilcoxon's rank sum test). Wound healing proceeded normally with 100% in both groups having normal scar formation and healing at day 10. In conclusion, iontophoresis appears to be a safe method of anesthesia delivery in this guinea pig model with lacerations. Increased granuloma and granulation tissue formation may indicate an enhancement of wound healing via iontophoresis.

Our previous study demonstrated that 1% diphenhydramine is as effective as 1% lidocaine for anesthesia in minor laceration repair, but that it also is more painful to inject. The purpose of this study was to compare 0.5% diphenhydramine to 1% lidocaine for pain of injection and adequacy of local anesthesia.Randomized, double-blinded, prospective study from December 1991 through June 1992.University-affiliated, urban, inner-city emergency department.Ninety-eight adults with linear skin lacerations without end-organ involvement were included; 48 received lidocaine and 50 received diphenhydramine.Wounds were anesthetized with either diphenhydramine or lidocaine according to a random table. Both patients and physicians rated the pain of injection and suturing according to a standard, previously tested, visual analog scale.Patient and physician ratings were ranked without regard to treatment group, and rank sum scores were calculated for each group. General linear models and multivariate analysis of variance were used to analyze the ranked sum scores. The power of the study to detect a ranked sum difference of 15 was 0.8 with P.05 considered statistically significant. Lidocaine was found to be significantly more effective as a local anesthetic for facial lacerations according to both patients (P.002) and physicians (P.004). There was no statistically significant difference between 1% lidocaine and 0.5% diphenhydramine for pain of injection or suturing for all other locations according to both patients and physicians. Overall mean and median scores for injection and suturing with diphenhydramine corresponded to the mild pain category according to patients.Although not a replacement for lidocaine, diphenhydramine is a viable alternative for anesthesia in the repair of minor lacerations.

Neck pain is a common cause for presentation to an emergency department. Most causes are benign and often secondary to arthritis or injuries. We present a case of septic cervical facet arthritis, a very rare cause of neck pain. The clinical presentation of septic cervical facet arthritis includes fever, neck pain that is often unilateral that is worse with movement, nerve root symptoms, and radiation of pain to the shoulder. Consequences may be severe and include joint destruction and infection progression. Symptoms may be indolent, and a high index of suspicion is necessary to make this diagnosis.

OBJECTIVE: : To compare two brief randomized computer-based interventions about perpetration of intimate partner violence (IPV). METHODS: : The study was a prospective cross-sectional cohort study of patients during randomized 4-hour shifts in an urban hospital-based emergency department setting with an emergency medicine residency. The site is a level 1 trauma center emergency department with an annual census of 60,000 adults. A touch-screen computer program was developed in Visual Basic 2005 Studio with consecutive data entry screens. A series of questions to evaluative IPV knowledge, attitude, and practices (KAP) was given before and after the brief intervention. The subjects were randomized to one of two intervention groups. Both groups were shown a set of PowerPoint slides addressing IPV prevention, which was followed by either a control group with nothing further (control) or a five-minute simulation video depicting IPV perpetration in adults (SIM). The main outcome was the net improvement in KAP scores defined as number who improved minus number who did worse. Perpetrators and victims were assessed separately. Demographics were also obtained. For demographics, descriptive statistics and percentages were used. Wilcoxon signed rank test was used for pre-post test paired data. RESULTS: : A total of 239 patients, presenting during 52 randomized four-hour shifts, completed the study; 118 were in the control group, 121 in SIM; 115 (48%) were male and 124 (51 %) female (9 unknown). Most participants were from 21 to 30 years old (38%); 77 (32%) were Hispanic and 100 (42%) were white. There was an overall improvement in responses to KAP questions with correct answers to all questions in 46% before vs 59% after the computer intervention (Diff 13% 95% confidence interval [CI] 4-22). The net improvement in KAP score in the control group was 8% and in the SIM group it was 22% (Diff = 15%, 95% CI = 6-24). Forty subjects (17%, 95% CI = 12-21) were perpetrators and 52 subjects (22%, 95% CI = 17-27) were victims. KAP scores were not significantly improved in the SIM group over the control for either perpetrators or victims. CONCLUSION: : An IPV simulation video resulted in a greater percent of subjects showing improvement in knowledge, attitudes, and practices about IPV perpetration. A brief IPV simulation video intervention can be performed in a busy emergency department setting. Language: en

Objective The objective of the study was to compare errors in the emergency department (ED) with pharmacists present (PPs) for resuscitations and traumas vs with pharmacists absent (PAs). Our hypothesis was that errors would be significantly fewer during PP than PA times. We also hypothesized that times with PP would affect patients greater when disposition was to more critical areas (intensive care unit, or ICUs). Methods The study was conducted during a 3-month period in 2009 in a level 1 trauma center with an emergency medicine residency. This was a cross-sectional cohort study comparing a prospective analysis of patients during the time (10 hour/day) with PP and a retrospective review of the time on the same days (14 hours/day) with PA. Demographics of age, race, and sex were recorded. Patient disposition was either ICU, operating room, non-ICU wards, observation unit, or discharge. Main outcome was errors recorded including medications given but not ordered, medication ordered but not given, and time delays for medications. For demographics and prevalence, descriptive statistics and percentages were used. Percent differences and 95% confidence intervals (CIs) and χ 2 were derived. Logistic regression used predictor variables of age, race, sex, disposition, and presence or absence of pharmacists. An a priori power analysis was performed. The study was powered at 80% with 186 subjects per group (PP vs PA), to find a difference of 20% between the 2 groups in percent of medical errors. Results There were 694 patients included in the 3-month period. A total of 242 presented during PP times and 452 during PA times. There were 383 (55%) male, 301 (43%) female, and 10 (2%) unknown sex. Mean age was 45 ± 18 years in PP group and 48 ± 20 years in PA group ( P , nonsignificant). There was no difference in ethnicity between groups. There were 6 (3%) patients with errors recorded during PP times and 137 (30%) with errors recorded during PA times (difference, 27%; 95% CI, 23-32). Controlling for age, race, sex, and disposition, medical errors were 13.5 times more likely during PA than during PP times (adjusted odds ratio, 13.5; 95% CI, 5.7-31.9). Conclusion With pharmacists absent, over 13 times more errors are recorded in our ED than with pharmacists present. An on-site pharmacist in the ED may be helpful in reducing medical errors.

This prospective study compared the effectiveness of 1% diphenhydramine with 1% lidocaine for local anesthesia in repair of minor skin lacerations in adults with simple linear lacerations treated at our Emergency Department. Wounds were anesthetized with either lidocaine or diphenhydramine according to a random numbers table. Ninety-nine patients were included in the final analysis (51 received lidocaine; 48 diphenhydramine). Patients and physicians rated the pain of injection and suturing using a standard visual analog scale. Univariate and multivariate linear models were used on rank transformed scores of the patient and physician ratings of injection and suturing with p0.05 considered statistically significant. According to patient rating lidocaine was less painful for injection than diphenhydramine, with a statistically significant difference between the two anesthetics (p = 0.0017). There was no statistically significant difference in pain rating by physicians between the two anesthetics (p0.05). Pain with suturing was rated as minimal for both lidocaine and diphenhydramine with no statistically significant difference in the effectiveness according to either patients or physicians (p0.05). Lidocaine injection appears to hurt less than diphenhydramine injection according to the patients. Pain of suturing corresponding to anesthetic effectiveness appears to be equivalent for lidocaine and diphenhydramine according to both physicians and patients. Although diphenhydramine should not be substituted for lidocaine, it appears to be a viable alternative in the management of patients with allergy to amides or extremely large lacerations in which a maximum of amide anesthetic has been used.

Objectives Emergency physicians (EPs) and Juris Doctors (JDs) often disagree on the correct use of restraints for emergency department (ED) patients. The objective of the study was to compare EPs and JDs propensity to restrain patients given various scenarios. The study hypothesis was that EPs and JDs would agree on when to restrain emergency patients. Methods This was a prospective cross-sectional study. Twenty-two EPs and 27 JDs were asked to complete the Video Assessment of Propensity to use Emergency Restraints Scale (VAPERS). The VAPERS scale consists of 17 scenarios utilizing actors who were videotaped to produce a scale. Results obtained include overall likelihood to restrain and likelihood to restrain specific subgroups of patients such as those who are a danger to themselves, a danger to others, medically unstable, trauma patients, altered patients, belligerent patients, agitated patients, calm patients, and patients with normal mental status. A two-way mixed model average intraclass correlation coefficient (ICC) was used to determine scale reliability. Unpaired t-tests with confidence intervals (CI) were used to compare the two professions on VAPERS results and on individual scenarios. Results Overall, EPs were more likely to restrain patients than JDs (46% vs 37%), although this did not reach statistical significance. The statistically significant EP-JD disagreement, with EPs more likely to restrain patients, occurred if the patients were calm. Common themes in the differences emerged from evaluation of the two groups' comments. Conclusions EPs and JDs disagree on restraint use. These EP-JD differences were statistically significant in patients who were calm.

Background Agitated patients are the primary source of injury to patients and providers during ambulance transport. Objective Our primary hypothesis was that the addition of a chemical restraint agent (midazolam) to a restraint protocol would reduce agitation to a greater extent than a restraint protocol with physical restraint alone. Methods The local emergency medical services restraint protocol (RP) was implemented on October 1, 2006. It included a form for data collection about each restrained patient. On April 1, 2007, chemical restraint (CR) using midazolam in addition to physical restraints was made available through the RP, and paramedics were educated in its use. Transported patients were divided into pre-CR and post-CR. The post-CR group was split into those who received and those who did not receive midazolam. Agitation was measured on a validated agitation behavior scale with a parametric (Rasch) adjustment. Results There were 96 patients in the pre-CR group and 522 patients in the post-CR group. Forty-three percent of the pre-CR group and 49% of the post-CR group had a decrease in agitation during transport (NS). Of the 522 in the post-CR group, 110 were physically restrained and given midazolam (21%) and 412 were physically restrained without midazolam (79%). There was a significantly greater decrease in agitation scores (−17 ± 21 vs. −7 ± 17) in the subjects receiving midazolam compared to those who did not. Conclusion If available, CR is used in about 20% of restrained patients. When CR is used, there is a decrease in the subject’s agitation.

Introduction Emergency medical services (EMS) personnel attrition is a serious concern. Two fundamental psychological constructs linked to attrition are organizational and occupational commitment. Objective To determine if there is a relationship between a paramedic's degree of occupational/organizational commitment and the following: (1) levels of education and (2) type of employment. Methods This was a cross-sectional study of paramedics in 6 states that require continued paramedic national registration. The data collection instrument consisted of demographic and occupational and organizational commitment sections. For level of education, the primary independent variable, each subject was placed into 1 of 3 groups: (1) certificate, (2) associate's or bachelor's degree in EMS (degree), and (3) paramedic certificate or degree with a non-EMS postbaccalaureate degree. Type of employment (fire based vs non–fire based) was also used as an independent variable. Organizational and occupational commitment was measured using validated scales for each. Analysis of variance was used for the comparisons between levels of each of the independent variables. A P Results For occupational commitment, the participants with certificate level of education had a significantly higher score (88.9) than did those with either the degree (83.6) or postbaccalaureate (80.9) level of education. There were no significant differences for total organizational commitment. There were also no overall differences in occupational and organizational commitment between fire- and non–fire-based employees. Conclusion Paramedic occupational commitment shows a statistically significant decrease with increased level of education. Factors associated with commitment of more highly educated paramedics need to be explored.

This study was conducted to evaluate the blood urea nitrogen/creatinine (BUN/Cr) ratio for distinguishing an upper versus lower source of gastrointestinal (Gl) bleeding. Charts of patients who presented to the emergency department (ED) with the diagnosis of Gl bleeding from August 1995 to August 1996 were retrospectively reviewed for source of bleeding, initial BUN, Cr, BUN/Cr ratio, hematocrit (Hct), and need for transfusion. A total of 124 patients were eligible for inclusion, 71 (57%) of whom were male. A total of 63 (51%) presented with blood in stool and 53 (43%) with bloody emesis; 8 (6%) had blood in both emesis and stool. A total of 31 (25%) patients had a lower Gl bleed, 88 (70%) had an upper, and 5 (4%) had both upper and lower bleeding sources. The mean BUN level was 24 mg/dL, the mean Cr level 1.03 mg/dL, and the mean BUN/Cr ratio was 24. The mean hemoglobin (Hb) level was 11.3 g/dL, the mean Hct was 32 g/dL, and 51% required transfusion. Upper Gl bleeding was significantly correlated with age younger than 50 (P = .01) and male gender (P = .01; odds ratio, 3.13). Taking into account age and gender, the BUN/Cr ratio correlated significantly with an upper Gl source of bleeding (P = .03), with a ratio greater than 36 having a sensitivity of 90% and a specificity of 27%. The area under the receiver operating characteristic curve using age, gender, and BUN/Cr ratio was .73 (95% confidence interval, .62 to .84).

Objectives To evaluate compliance and safety of an emergency medical service (EMS) triage protocol that allows paramedics to transport patients directly to psychiatric emergency services. Methods A psychiatric patient diversion protocol was developed for our system. Protocol compliance was evaluated the following 3 ways: (1) psychiatric facility intake forms completed by mental health workers on patients transported by EMS directly to a psychiatric emergency service (PES) bypassing the ED, (2) hospital records for patients who were redirected from PES to the ED for medical evaluation, (3) retrospective analysis of ambulance charts. Study outcomes included protocol noncompliance rate, protocol failure rate, and any morbidity associated with either noncompliance or protocol failure. Data were analyzed using proportions and 95% confidence intervals (CI). Results A total of 174 patients were directly transported to PES bypassing ED medical clearance. The protocol effectively screened for medical issues in 96% of cases. Protocol noncompliance occurred in 51 cases for a frequency of 29% (CI, 22%-36%). One patient in the paramedic noncompliance group required hospital admission. There was protocol failure in 5 (2.9%; 95% CI, 0.9-6.6) of the patients who fit all protocol requirements for transport to PES but required secondary transport to the ED. All were subsequently transferred back to PES. Nine patients (5.2%; CI, 2.7%-9.5%) required secondary transfer to the ED. No patient had critical or life-threatening problems. Conclusions Emergency medical service providers showed a poor level of compliance with vital sign criteria, but the protocol provided a high level of safety.

Introduction Ambulance diversion is a problem in many communities. When patients are diverted prompt and appropriate medical care may be delayed. Objective Compare diversion hours and drop-off times before and after a dramatic change in diversion policy restricting each hospital to 1 hour out of every 8. Methods This study was a retrospective study in a county of 600 000 people and 10 hospitals from September 2004 to February 2006. A countywide diversion protocol was implemented in March 2005 that limited diversion hours to 1 hour out of every 8 (maximum of 90 h/mo). No other changes were implemented during the study period. Pretrial (9/04-2/05), interim (3/05-8/05), and posttrial (9/05-2/06) periods were compared. The main outcome measures were ambulance diversion hours and emergency medical service (EMS) drop-off times. Results were compared using analysis of variance and a Tukey post hoc analysis. P < .05 was considered significant. Results There was no significant difference in the number of monthly transports comparing the posttrial vs pretrial periods; however, a significant decrease in monthly ambulance diversion hours (difference, 251 hours; 95% CI, 136-368) and significant increase in additional time that EMS crews required to transport patients (drop-off times) (difference, 178 hours; 95% CI, 74-283) were observed. Posttrial diversion hours decreased to 18% of the pretrial values (from 305 to 54). Conclusion This novel ambulance diversion protocol dramatically reduced diversion hours at the cost of increasing EMS drop-off times in a large community.

Background:Emergency physicians (EPs) may disagree on when or whether patients need restraints. There is no good objective measure of the likelihood of EPs to restrain patients. Objectives:To 1) develop a scale to determine the likelihood that an EP would restrain a patient, 2) develop subscale scoring, and 3) determine a shortened version that correlates highly with the full scale. Methods:This was a prospective cross sectional study. The Video Assessment of Propensity to use Emergency Restraints Scale (VAPERS), consisting of 17 scenarios utilizing actors, was videotaped to produce a research video assessment tool. The VAPERS was designed by development experts to reflect the spectrum of patients who are considered for restraint in an emergency department. The VAPERS was piloted among a 22-member pilot panel of EPs (faculty and residents). The pilot panel was asked to determine the degree to which each video patient possessed the following patient characteristics: medical instability, trauma, belligerence, agitation, and altered mental status. Each “degree of characteristic” was measured on a separate 100-mm visual analog scale. Participants were then asked whether or not they would restrain each patient and whether the patient exhibited the potential to harm him- or herself or others. VAPERS subscales were developed for the likelihood to restrain patients with each of the patient characteristics. Spearman correlations were used for all comparisons. Linear regression was used to determine which patient characteristics were most related to likelihood to restrain and to develop a reduced scale to predict the overall likelihood to restrain. Results:The overall VAPERS score ranged from 0 to 100, with a median of 50 (interquartile range [IQR], 24–88). The visual analog scale results of how likely each video patient possessed specific characteristics were as follows: medical instability ranged from 0 to 100 (median, 32; IQR, 12–64), trauma ranged from 0 to 69 (median, 0; IQR, 0–31), belligerence ranged from 20 to 93 (median, 28; IQR, 14–63), agitation ranged from 3 to 84 (median, 52; IQR, 23–72), and altered mental status ranged from 1 to 93 (median, 29; IQR, 16–69). Linear regression indicated that two characteristic variables (danger to self and degree of agitation) in the video scenarios were highly correlated (0.87) with overall likelihood to restrain. Based on the results, the authors developed a shortened video assessment tool consisting of five of the original videos that were highly correlated (R= 0.94) with the full VAPERS scale on overall likelihood to restrain. Conclusions:The VAPERS scale covers a wide range of important variables in emergency situations. It successfully measured likelihood to restrain in this pilot study for overall situations, and for subgroups, based on patient characteristics. A shortened five-video VAPERS also successfully measured the overall likelihood to restrain.

Background: Emergency department (ED) crowding is just beginning to be quantified. The only two scales presently available are the National Emergency Department Overcrowding Scale (NEDOCS) and the Emergency Department Work Index (EDWIN). Objectives: To assess the value of the NEDOCS and the EDWIN in predicting overcrowding. The hypothesis of this study was that the NEDOCS and the EDWIN would be equally sensitive and specific for overcrowding. Methods: The NEDOCS, the EDWIN, and an overcrowding measure (OV) were determined every two hours for a ten-day period in December 2004. The NEDOCS is a statistically derived calculation, and the EDWIN is a formula-based calculation. The overcrowding measure is a composite of physician and charge nurse expert opinion on the degree of overcrowding as measured on a 100-mm visual analogue scale (VAS). The primary outcome, overcrowding, was based on the dichotomized OV VAS score at the midpoint of 50 mm (≥50, overcrowded

The objective of this survey was to determine the percentage of unfunded studies published in the four major emergency medicine journals and to examine the sources in funded studies. This study was a retrospective survey of all issues of the four general emergency medicine journals in 1994. Funding was categorized as public national, private, international, institutional, or unfunded. The total funding and sources were recorded for each of the four journals. Confidence intervals (CIs) were determined to compare the percent of funded versus unfunded articles. Overall, significantly more of the emergency medicine articles in the four journals were unfunded (63% unfunded [95% CI = 56.7-69.1]; 37% funded [95% CI = 30.9-43.3]). The sources of funding for each of the journals varied, with most being private (45%). In conclusion unfunded research remains a major source of emergency medicine literature in the four main emergency medicine journals.

Objective: We hypothesize that the number of patients who leave without being seen is correlated with the simple-to-use National Emergency Department Overcrowding Scale (NEDOCS). Methods: Results of a 6-item ED overcrowding scale (NEDOCS) were collected prospectively over a 17-day study period. The following additional data were extracted from records for each 2-hour study period: (1) number of registered patients, (2) number of ambulances that arrived, and (3) number of patients signed in that hour who eventually left without being seen. Spearman correlation coefficients were computed for the leaving without being seen (LWBS) rate with the NEDOCS score at the time of patient presentation and 2, 4, and 6 hours later. Results: The study period represents two hundred fourteen 2-hour periods. The LWBS rate was determined for 100% of the times; NEDOCS scores were determined for a sampling of 62% of the times spread equally over all hours of the day and days of the week. Correlation between the NEDOCS score and LWBS was 0.665. Conclusion: The NEDOCS score is well correlated with LWBS.

We wanted to prospectively evaluate the use of a brief screening tool for ongoing intimate partner violence (IPV), the OVAT, and to validate this tool against the present Index of Spouse Abuse (ISA). The design was a prospective survey during randomized 4-hour shifts in an urban emergency department setting. The scale consists of four questions developed based on our previous work. The ISA was compared as the gold standard for detection of present (ongoing) IPV. Of 362 eligible patients presenting during 75 randomized 4-hour shifts, 306 (85%) completed the study. The prevalence of ongoing IPV using the OVAT was 31% (95% CI 26% to 36%). For the ISA, the prevalence was 20% (95% CI 16% to 25%). Compared with the ISA, the sensitivity of the OVAT in detecting ongoing IPV was 86%, specificity 83%, negative predictive value 96%, positive predictive value 56%, with an accuracy of 84%. In conclusion, four brief questions can detect ongoing IPV to aid in identifying the victim.

Our ED at Louisiana State University developed a unique approach to airway management by having four diagnosis-based protocols for rapid sequence intubation (RSI). This study examines protocol use and outcome from RSI in an academic ED. The study objective was to identify variables that are predictive of adverse outcomes in patients requiring RSI. This was a 4-year prospective, observational, data-gathering study of all intubations in an academic ED setting with250,000 patient visits per year. Four protocols were established for 1) children10 years of age, 2) adults with increased intracranial pressure, 3) adults with chronic obstructive pulmonary disease/asthma, and 4) other adults not fitting B or C. A special continuing quality improvement (CQI) committee was established to examine each case of RSI. Prospective data were collected, including age, race, gender, protocol, diagnostic group, intubation indication, and preintubation oxygen saturation. Diagnostic group was categorized as medical, blunt trauma, or penetrating trauma. Adverse outcome was defined as any case with hemodynamic changes, those requiring surgical or bronchoscopic intervention, and those requiring more than three attempts at intubation. Data were analyzed using univariate analysis, logistic regression, and a binomial regression tree analysis with SPSS 9.0 (Chicago, IL) and Answer Tree (SPSS). A total of 1,320 consecutive intubated patients were included. Protocol A was used in 4%, B in 43%, C in 15%, and D in 38%. Significant differences in number of cases with adverse outcome were based on protocol (P =.03) and final diagnosis (P.03). Protocol C was less likely to be associated with adverse outcome than protocol D (odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1-0.7). Penetrating trauma was more likely to be associated with adverse outcome (OR = 1.8, 95%, CI = 1.1-3.2) than blunt trauma. A regression tree analysis yielded the following, all cases using protocol A or C or medical cases using B had an adverse event in 11 of 458 (2.4%), whereas nonmedical cases using protocols B or D and medical cases using D had adverse outcomes in 73 of 862 cases (8.5%). The decision rules lead to a better classification of cases with adverse outcomes (2.4 vs 8.5%, of = 6.1%, 95% CI = 3.7-8.4). Adult trauma patients who fit the protocols B or D or adult medical patients who fit protocol B were at higher risk for adverse outcomes with RSI. This could alert the physician to a population at higher risk for adverse outcomes. Variables available in a diagnosis-based protocol RSI system can be used to predict adverse outcome among patients requiring RSI.

Previous studies of injury prevention among the elderly have focused on care by community-based services for the elderly. The plan for this study was to determine whether emergency medical services (EMS) could be a valuable partner in an injury prevention program for the elderly. The purposes of the study were: 1) to determine whether it is feasible to gather injury prevention data prospectively, 2) to determine whether these data suggest the need for further intervention to aid the elderly, and 3) to determine whether retrospective chart data are comparable to prospectively gathered data for evaluating the elderly home environment.Trained fire/EMS chiefs gathered prospective data from the homes of all elderly falls. Patients were included if they were 65 years of age or older. Demographics extracted from the chart were gender, age, and average income based on zip code information from the city office. A 29-question survey was developed based on a literature review. Results were obtained representing information in six categories: environment, appearance, health, violence, access to help, and repeat medical care utilization. Retrospective data were obtained from run reports and from a computerized EMS database. Proportions and 95% confidence intervals were used. A p-value0.05 was considered statistically significant.There were 70 prospective elderly fall cases evaluated and 74 retrospective charts reviewed, each representing a two-to-four-month period. Prospectively, significant problems were found with the patient's environment in up to 53% of cases, appearance in up to 29%, health in up to 77%, abuse in up to 3%, access in up to 57%, and repeat use in 33-68%. Although there were no differences in the age, income, or percentage transported between the prospective and retrospectively obtained groups, a significantly higher percentage of females were entered prospectively. Retrospective chart review obtained reasonable amounts of data for only four of 29 questions.Prospective analysis is easily gathered and identifies elderly injuries and patterns. A significant number of elderly patients whose homes were visited by EMS need help. Retrospective analysis gleans little injury prevention information.

ED overcrowding is fast becoming a national crisis although no definition exists. The purpose of this study is to develop and pilot a sampling form that accurately reflects the concept of ED Overcrowding.A 26-question site-sampling form was designed based on input from academic physicians at 11 medical schools nationwide. The study was conducted at an inner city Academic medical center. Site-samplings were conducted at 20 times over a one-week period by an independent observer. These times ranged from very slow to severely overcrowded. Information was obtained by counting patients in the waiting room, ED rooms, ED halls and registration/triage, ancillary services, the charge nurse, and the attending physicians. The charge nurse, and ED physicians rated the degree of overcrowding and the ED physician rated the feeling of being rushed. A 'combined outcome variable' was created which consisted of the average responses of nurses and physician's opinion of ED overcrowding and physician's feeling of being rushed. All other data was compared to this outcome variable.Seven questions were significantly correlated with the combined outcome variable. These were the number of people in the waiting room, patients awaiting triage, patients awaiting registration, full patient rooms, hallway patient, patients awaiting beds, and total registered patients. According to this scale our ED was overcrowded 20% of the time.This analysis clarifies the definition of overcrowding, helps indicate the variance among responses to overcrowding questions, and provides the foundation for prospective analysis of overcrowding in multiple EDs.

The Americans With Disabilities Act (ADA) has been in effect since 1990. The present study shows response to this act for emergency medicine (EM) residents nationwide.A total of 121 surveys were mailed to the directors of American College of Graduate Medical Education (ACGME)-approved residency programs. A definition of disability was provided, and a second mailing was sent to those not replying.Ninety-two program directors (76%) responded, representing 4,644 residents. Of these, 62 residents (1.3%) were reported as having a documented disability. Programs with a known disabled resident were significantly more likely to have available resources for assistance. Forty-seven (52%) of the program directors suspected a resident might have an undiagnosed disability, and 40 (85%) of these recommended testing or referral.There is a wide array of disabilities among EM residents. Available assistance varies. This may apply to other residencies as well.

To evaluate a protocol for rapid sequence intubation (RSI) for pediatric patients in a Level 1 trauma center.Retrospective review of prospectively gathered Continuing Quality Improvement (CQI) data at an inner city Level 1 trauma center with an emergency medicine residency program. Protocols for RSI were established prior to initiating the study. All pediatric intubations at the center from February 1996 to February 2000 were included. Statistical analysis included descriptive statistics for categorical data and Chi-square for comparisons between groups.Over the 4-year study period there were 83 pediatric intubations ranging in age from 18 months to 17 years; mean age 8.6. All had data collected at the time of intubation. There were 20 (24%) females and 62 (76%) males (p0.001). Reasons for intubation were related to trauma in 71 (86%) and medical reasons in 12 (14%) (p0.001). Of the trauma intubations 7 (10%) were for gunshot wounds, 39 (55%) were secondary to MVCs, and the remainder (25; 35%) were from assaults, falls, and closed head injuries. The non-trauma intubations were for smoke inhalation, overdose, seizure, HIV related complications, eclampsia, and near drowning. Intubations were successful with one attempt in 65 (78%) cases. No surgical airways were necessary. Rocuronium was used in 4 cases. Protocol deviations did not lead to complications.This protocol based pediatric rapid sequence intubation method worked well in an EM residency program. More intubations were in males and more were necessary due to trauma in this group.

Active injury surveillance programs need to address 'ongoing' intimate partner violence (IPV). While the Abuse Assessment Screen (AAS) has been validated for 'present'(within a year) IPV it is not clear that it is valid for 'present' (ongoing) IPV. We have created an OAS (Ongoing Abuse Screen, OAS) by changing the AAS to specifically request information related to 'ongoing' IPV. The hypothesis of this study was that the OAS represents a construct that is different from either the original AAS or a single question asking about ongoing IPV.All patients presenting to the ED during a convenience sampling of shifts completed the survey. The survey included the OAS, the AAS, and the question 'Are you presently a victim of IPV?' Comparisons were made between these 3 using the kappa statistic for agreement.A total of 488 surveys were completed. The AAS was positive in 288/488 (59%, 95%CI= 55-63%), the OAS was positive in 78/488 (16%, 95%CI=13-19%), and the single question for DV was positive in 14/488 (3%, 95%CI=2-5%). Kappa was 0.28 for the AAS and the OAS. When compared to the single question about present DV, kappa was 0.05 for the AAS and 0.27 for the OAS.The OAS may be a useful tool for evaluating ongoing IPV. The OAS resulted in rates different from that of the AAS and may be more specific to ongoing IPV than the AAS and more sensitive than a single question about DV.

Previous studies of repeat care of the elderly have focused on trauma cases only. The purposes of this study were to identify repeat transports of elderly patients to the authors' emergency department (ED) by emergency medical services (EMS), to identify demographics, and to compare chief complaints.A population-based, retrospective cohort study was conducted. Data for this study were obtained from computerized registration files in an urban, university-affiliated ED with an annual census of approximately 60,000 visits. Patients were included if they were 65 years of age or older and they were transported by EMS in 1997. The repeater group included patients who had one or more EMS transports within the following 12 months. The comparison group was composed of all patients with no further EMS transport within the 12 months after the index visit. Demographics extracted from the database were gender, chief complaint, total number of visits, and time since previous visits. Repeats were characterized by frequency (number of visits in 12 months after the index visit), type (visit for same vs different complaint), and rate (time to the first return visit). Repeaters were defined as more than one visit within a 12-month period. Repeaters were subdivided as follows: "immediate" (within 72 hours), "short-term" (within 2 months), and "long-term" (within 12 months). Chi-square and 95% confidence intervals (95% CIs) were used. A p-value0.05 was considered statistically significant.There were 365 (23%) repeaters and 1,212 (77%) nonrepeaters. Repeaters accounted for 811 (40%) of the total of 2,023 elderly patients transported by EMS. Fifty-seven percent of all elderly patients transported by EMS were female, with no significant difference between the repeaters and nonrepeaters. There were significantly fewer transports for a chief complaint of trauma among the repeaters than among the nonrepeaters (14% vs 26%, diff = 12, 95% CI = 9-15%). Among the 365 repeaters, 186 (51%) had two transports, 92 (15%) had three transports, 36 (10%) had four transports, and 51 (14%) had five or more transports. Of the return transports by repeaters, 40 (12%) were "immediate," 191 (52%) were "short-term," and 134 (36%) were "long-term."Repeaters accounted for 18% of elderly ED patients transported by EMS and 40% of elderly transports to the authors' ED. There were significantly fewer trauma transports in the repeater group. One-half of the repeaters returned only once in a 12-month period and a third of these occurred more than three months apart. It is important to understand the characteristics of elderly EMS repeaters in order to use this opportunity for intervention.

Previous study has shown that the use of intramuscular (IM) steroid leads to improved symptoms in patients with group A beta-hemolytic streptococcus (GABHS).To compare oral with IM steroids as an adjunct to antibiotic therapy in the treatment of acute exudative pharyngitis. The null hypothesis was that there would be no difference in effectiveness of oral versus IM steroids.The study was a randomized, double-blind outpatient clinical trial. After consent was obtained, each patient was asked to rate his or her pain on a 10-cm numbered visual analog scale (VAS; 0-10). All of the patients received injectable benzathine penicillin or, if allergic to penicillin, a ten-day course of polyenteric-coated erythromycin. Each patient was randomized to receive either injectable steroid plus oral placebo or injectable placebo plus oral steroid. All medications were given in the emergency department. All patients were contacted by telephone at 24 hours (first follow-up) and 48 hours (second follow-up) by one of the study investigators and asked to rate their pain based on another VAS. If their pain was not resolved by 48 hours, they were called again daily for the third to seventh day after the initial visit. The time to total resolution of the sore throat was documented. The main outcome measures were time to complete relief of pain and VAS scores. Pain medication was not controlled; however, use of pain medications and amounts were recorded.A total of 78 patients were initially enrolled in the study. Eight patients were excluded from the statistical analysis because of inability to follow up. A total of 70 were entered, with 35 randomized to IM steroid plus oral placebo and 35 to IM placebo plus oral steroid. There was no difference in pain scores for the oral versus IM group at first follow-up (p = 0.13) and second follow-up (p = 0.82), and in number of hours to relief of pain (p = 0.06). Using repeated-measures analysis of variance, no difference in the effects of the two medications over time was detected (p = 0.83).The results of this clinical trial suggest that oral steroid and IM steroid provide similar levels of pain relief in acute exudative pharyngitis.

Understanding out-of-hospital transport demographics would clarify the opportunities for injury surveillance and prevention.To test the hypotheses that there are demographic differences in home vs. non-home emergency medical services (EMS) scene transports and that among age groups there are differences in demographics.Data were extracted from the EMS State Ambulance Transport database of all reported during 1995. Transports from patient homes were compared with transports from all non-home scenes. Data extracted included age, gender, race, and type of complaint. Subgroup analysis was performed based on age groups in nonvehicular cases, safety problems, and interpersonal violence. Results were compared using a two-tailed chi-square with significance at p0.05. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for significant differences.The study included 118,131 transported patients: 13% were children, 49% were adult between 18 and 64 years, and 38% were elder; 13% were African American, 82% were white, and 5% were other; 47% were male and 53% were female. Fifty-eight percent of the transports were for safety problems, and 17% were for interpersonal violence. Of the 118,131 transports, 56,812 (48%) were from patients' homes and 61,319 were not. Compared with EMS transports from non-home scenes, fewer home EMS transports were for injury (p0.01, OR = 0.18, 95% CI = 0.17-0.19) and more home EMS transports were for illness (p0.01, OR = 5.64, 95% CI = 5.49-5.79). There was no clinically significant difference in age, race, or gender. For all non-vehicular injury transports, the reason was more likely safety problems than interpersonal violence (58% vs. 17%); however, there was no difference in the percentages of type of call between the home and non-home transports. Home EMS transports were more likely interpersonal violence problems among adult patients less than 65 years old; however, among the old and young, the problems were more likely to be safety-related.Forty-eight percent of all EMS transports are from the home. Only 18% of these EMS home transports are for injury-related problems. In general, EMS injury transports are more likely related to safety than to interpersonal violence. Among the home EMS transports, more than 50% of transports for young and old patients are safety-related. A large proportion of the home EMS transports for adults less than 65 years of age, however, are for interpersonal violence.

Objectives To describe the extent of complementary and alternative medicine (CAM) use among emergency department (ED) patients, to evaluate patients' understanding of CAMs, and to determine gender differences in beliefs about CAMs. Methods This study was a convenience sampling of patients seen in an urban ED. Patient demographics were recorded. A questionnaire was administered that assessed patients' knowledge and use of CAMs. Patients were also asked about their beliefs on safety, medication interactions, and conveying information about these substances to their physicians. Results A total of 350 ED patients were included in the study; 87% had heard of at least one of the CAMs. There was no difference between genders or races concerning knowledge about CAMs. The most commonly known CAMs were ginseng (75%), ginkgo biloba (55%), eucalyptus (58%), and St. John's wort (57%). Forty-three percent of the responders had used CAMs at some time and 24% were presently using CAMs. The most commonly used CAMs were ginseng (13%), St. John's wort (6%), and ginkgo biloba (9%). All CAMs were considered to be safe by 16% of the patients. Only 67% would tell their doctors they were using CAMs. Females were more likely than males to believe that CAMs do not interact with other medications (15% vs 7%, difference 8%, 95% CI = 2% to 15%). Conclusions Complementary and alternative medicines are familiar to most patients and used by many of them. Despite this, a large percentage of patients would not tell their physicians about their use of alternative medications. Emergency medicine providers should be aware of the commonly used CAMs, and questions about their use should be routinely included in ED exams.

Study Objective: We sought to compare the use of anoscopy and colposcopy in examinations of male sexual assault victims and to characterize the demographics of male sexual assault victims. Methods: This is a case series of 67 male sexual assault victims evaluated over an 8-year period by the Sexual Assault Forensic Examination team. The setting is a university-based emergency department serving as the primary site for examination of sexual assault victims by trained nurse practitioners and physician's assistants. Police and victims' advocates are available at the time of the examination. Anoscopy was done routinely over the entire study period in all patients with any anal penetration or involvement. Colposcopy use started in 1994 to magnify and take pictures. Patients were categorized into 2 groups. Group 1 consisted of subjects receiving only anoscopy, and group 2 consisted of subjects receiving initial colposcopy. Anoscopy in group 1 and colposcopy in group 2 were compared for positive results. A positive result was defined as an additional finding to those obtained by means of gross examination by using the test being evaluated (anoscopy versus colposcopy). Colposcopy and anoscopy were also compared among the subjects receiving both tests. Groups were compared by using a Pearson χ 2 test. Results: Sixty-seven male sexual assault victims were evaluated between 1991 and 1998. The average age was 26±8 years, and the distribution of races was 30% black, 62% white, and 8% Hispanic. Results of gross examination were positive in 42 (63%) subjects. Four patients did not receive either anoscopy or colposcopy. Of the remaining 63, 25 patients had anoscopy only (group 1), and 38 patients had initial colposcopy (group 2). There were no significant differences in age, race, or rate of positive gross examination results between groups. Findings in addition to those obtained by means of gross examination were revealed by means of anoscopy in 8 (32%) of 25 subjects in group 1 and colposcopy in 3 (8%) of 38 subjects in group 2 ( P =.03, difference 24%, 95% confidence interval 4% to 44%). In the 36 subjects who had both examinations, the gross examination revealed at least one finding in 22 (61%). The combination of anoscopy and colposcopy yielded positive findings in 17 subjects, including 4 subjects who had no findings on gross examination (increasing the positive rate to 26/36 [72%]). Conclusion: In male sexual assault victims with anal penetration, anoscopy is significantly better for gathering evidence than is colposcopy. The addition of colposcopy and anoscopy increased the rate of cases with positive findings from 61% to 72%. These 2 methods together may be a valuable adjunct in gathering evidence of damage. [Ernst AA, Green E, Ferguson MT, Weiss SJ, Green WM. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med. November 2000;36:432-437.]

Study Objective: Nausea and vomiting related to gastritis or gastroenteritis are common complaints in the emergency department. The most effective antiemetic agent is yet undetermined. This study was conducted to compare the efficacy of prochlorperazine versus promethazine for uncomplicated nausea and vomiting in the ED. Methods: The study was a randomized, double-blind comparison of prochlorperazine (Compazine) and promethazine (Phenergan) for acute ED treatment of gastritis or gastroenteritis. We studied patients 18 years or older with presumed uncomplicated gastritis or gastroenteritis who presented to 2 academic EDs. Patients were randomly assigned to receive either prochlorperazine, 10 mg intravenously, or promethazine, 25 mg intravenously. Visual analog scale readings of patient comfort were obtained at baseline and at 30- and 60-minute intervals. The primary endpoint was degree of relief at 30 and 60 minutes. Secondary endpoints were time to complete relief, need for further antiemetic medication (treatment failures), and side effects. Statistical analysis was performed using the Mann-Whitney U test for nonparametric analysis and repeated-measures analysis of variance (ANOVA). Results: Eighty-four patients were enrolled in the study; 42 received prochlorperazine and 42 received promethazine. There were no differences in demographics in the 2 groups. At baseline (time 0), there was no difference in symptoms ( P =.23). At 30 and 60 minutes after receiving medication, prochlorperazine worked significantly better than promethazine ( P =.004 and P P P =.002). Time to complete relief was significantly shorter with prochlorperazine ( P =.021). There were significantly fewer treatment failures with prochlorperazine ( P =.03, 9.5% versus 31%; difference 21%, 95% confidence interval 5 to 38). There was no difference in incidence of extrapyramidal effects. Prochlorperazine caused significantly fewer complaints of sleepiness ( P =.002, 38% versus 71%; difference 33%, 95% confidence interval 13 to 53; P =.002). Conclusion: Prochlorperazine works significantly better than promethazine for relieving symptoms of nausea and vomiting more quickly and completely in ED patients with uncomplicated nausea and vomiting. [Ernst AA, Weiss SJ, Park S, Takakuwa KM, Diercks DB. Prochlorperazine versus promethazine for uncomplicated nausea and vomiting in the emergency department: a randomized, double-blind clinical trial. Ann Emerg Med. August 2000;36:89-94.]