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Both professionalism and interpersonal communication are core competencies for emergency medicine residents as well as residents from other specialties. The authors describe a weekly, small-group seminar lasting one year for emergency medicine residents that incorporates didactic materials, case studies, narrative expression (stories and poems), and small-group discussion. Examples of cases and narrative expressions are provided and a rationale for utilizing the format is explained. A theoretical model for evaluation measures is also included.

Objective. To evaluate the effect of a new protocol allowing paramedics to administer morphine without a physician order to patients with extremity trauma with respect to time of morphine administration, scene time, morphine amount and number of doses per patient, and proportion of patients receiving morphine. Methods. Data were abstracted from transport forms for a ten-month period prior to the implementation of the new protocol and for nine months after implementation. Data elements included patient age and sex, date, time of EMS arrival on scene, amount and number of morphine doses, and total number of patients transported. Results. Implementation of the new protocol was associated with a decrease in time between emergency medical services (EMS) arrival on scene and administration of the first dose of morphine from 18.8 to 16.7 minutes, a difference of 2.1 minutes [95% confidence interval (95%CI) 1.3, 2.9]. The proportion of patients receiving analgesia at the scene, rather than during transport, incre...

Study Objective: We identify health variables associated with a history of intimate partner violence (IPV) using self-reported and laboratory measures. Methods: This study used a cross-sectional design. Participants were a randomized sample of English-speaking women between the ages of 18 and 50 years who presented to a large urban emergency department. Potential participants were screened in the ED for a history of physical abuse and coded as having experienced no IPV (No IPV), as having a recent history of IPV (occurring in the previous 12 months; IPVA), or as having a remote history (most recent occurrence >12 months ago; IPVHx). Participants were interviewed several days later in an outpatient setting regarding demographics, medical care use, and physical and mental health variables. Participants also received urine and blood tests and a pelvic examination. Results: Self-reported health was poorest among women reporting IPVA and best among women reporting no IPVA. Women in the IPVA group differed from women with no IPV history with respect to cocaine use (odds ratio [OR] 4.8; 95% confidence interval [CI] 1.4 to 17.3), sexually transmitted diseases (OR 5.1; 95% CI 1.5 to 20.3), and nightmare frequency (OR 11.6; 95% CI 2.3 to 83.4). Women reporting IPVHx were more likely to report a history of sexually transmitted diseases than women with no IPV history (OR 4.1; 95% CI 1.6 to 11.4) and had more frequent nightmares (OR 5.0; 95% CI 1.3 to 24.9). Urine and blood tests identified only 2 variables (hemoglobin levels, mean corpuscular volume) that differed significantly between groups by IPV history; these differences were not clinically significant. Conclusion: Women with a recent history of IPV reported a poorer health status than women with no IPV history; laboratory testing detected few differences. [Brokaw J, Fullerton-Gleason L, Olson L, Crandall C, McLaughlin S, Sklar D. Health status and intimate partner violence: a cross-sectional study. Ann Emerg Med. January 2002;39:31-38.]

This commentary discusses the forces behind the formation of a resident union at the University of New Mexico School of Medicine and the union's evolution over its first three years. Because unions exist primarily to provide an avenue for advocacy to their members, they could have a negative impact on resident professionalism and on the faculty-resident mentor relationship. Resident unionization could also adversely impact the perceived balance between education and clinical service, to the detriment of the professional identity development of resident physicians. Despite this concern, the authors express their initial, cautious optimism that the union is instead currently promoting resident professionalism. The resident union has provided a forum for a unified resident voice, the engagement of the residents in safety and quality improvement activities, and advocacy for, and direction of, additional patient care funds, all of which has encouraged resident professionalism. Residents who have been active in the union also seem to have maintained altruistic professional attitudes as well as engagement in their educational activities. However, as the environment changes from one of increasing resources to one of stagnant or decreasing institutional resources, inevitable conflicts will arise between advocacy for resident salaries and benefits and patient care needs, and the manner in which the resident union will balance these conflicting needs and what impact it will have on the residents' professional identity development is unclear.

A curriculum in sonoanatomy was piloted in the Human Structure, Function and Development (HSFD) block at the University of New Mexico. This 10-week block combines anatomy, histology and embryology ...

To assess the efficacy of occupant protection systems, the authors measured the mortality reduction associated with air bag deployment and seat belt use for drivers involved in head-on passenger car collisions in the United States. They used a matched case-control design of all head-on collisions involving two passenger cars reported to the Fatality Analysis Reporting System in 1992-1997, and driver mortality differences between the paired crash vehicles for air bag deployment and seat belt use were measured with matched-pair odds ratios. Conditional logistic regression was used to adjust for multiple effects. There were 9,859 head-on collisions involving 19,718 passenger cars and drivers. Air bag deployment reduced mortality 63% (crude odds ratio (OR) = 0.37, 95% confidence interval (CI): 0.32, 0.42), while lap-shoulder belt use reduced mortality 72% (OR = 0.28, 95% CI: 0.25, 0.31). In a conditional logistic model that adjusted for vehicle (rollover, weight, age) and driver (age, sex) factors, air bags (OR = 0.71, 95% CI: 0.58, 0.87) and any combination of seat belts (OR = 0.25, 95% CI: 0.22, 0.29) were both associated with reduced mortality. Combined air bag and seat belt use reduced mortality by more than 80% (OR = 0.18, 95% CI: 0.13, 0.25). Thus, this study confirms the independent effect of air bags and seat belts in reducing mortality.

We developed a statistical model that would identify and quantify the relative contributions of different factors hypothesized to impact the frequency of emergency center (EC) patients who leave without being seen (LWBS). We performed an analysis of the daily counts of patients that registered in our EC during a 21-month period who then LWBS. Candidate predictor variables included the number of patients seen, and the number admitted to the hospital, for each area of our EC, as well as the hours of faculty double coverage, and the day of the week. Univariate analyses were performed using standard methods. Multivariate analysis was performed using the general linear model. A backward selection procedure was used to eliminate statistically insignificant variables until all remaining independent variables had P-values < or = .05. External validation and analysis of the stability of the estimated regression coefficients of the model were evaluated using bootstrap methods. Two-tailed tests and a type I error of 0.05 were used. During the period studied, 133,666 patients were registered in the EC and 9,894 (7.4%) left. Multivariate analysis identified six variables that were significantly associated with LWBS. The fitted model containing all six variables explained 52.8% of the variability observed in LWBS frequency. The most powerful predictor of LWBS was total number of patients cared for in the main ED. This accounted for 46.4% of the observed variation in LWBS. The total number of trauma and resuscitation patients, and the total number of observation unit admissions to the hospital were also associated with increased LWBS. More pediatric cases seen in the main ED, weekends, and additional faculty coverage were associated with fewer patients leaving. Efforts to decrease the LWBS rate will be most successful if they address the issue of main ED volume.

Three chronic conditions were examined—acute alcohol intoxication, seizure disorder, and respiratory illness—to quantify the extent of repetitive emergency medical services (EMS) use in a defined population. Urban EMS system ambulance data from 1992 to 1994 were analyzed for the three designated conditions with respect to transports by condition and individual patient. Analysis by χ 2 was used for comparing proportions. Analysis of variance after square root transformation was used to evaluate differences among means. The total number of transports analyzed was 15,541: 7,488 for acute alcohol intoxication, 4,670 for respiratory illness, and 3,383 for seizure disorder. These transports involved 8,692 patients who were transported at least once for one of the three designated conditions. The mean number of transports for alcohol was 1.96 (95% confidence intervals [CI]: 1.92, 2.01), seizure 1.32 (95% CI: 1.27, 1.36), and respiratory 1.18 (95% CI: 1.15, 1.21). Of 369 patients transported five or more times during the study period, 260 (70.5%) were for alcohol, 56 (15.2%) for seizure, and 53 (14.4%) for respiratory complaints. This group comprised only 4.3% of patients, but 28.4% of all transports. Acute alcohol intoxication resulted in more repetitive ambulance transports than either seizure disorder or respiratory illness. A small number of patients were responsible for a large number of transports. Focused intervention for patients with high ambulance transport deserves further study.

The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care, which will benefit not only the patients emergency physicians serve but also, ultimately, the nation's health.

Question Does utilization of hospital beds by people aged over 65 years differ in the NHS in England, Kaiser Permanente in California and Medicare in California and the USA? Study Design Retrospective cohort study. Main results For all 11 causes of hospital admissions, standardised length of hospital stay for people aged >65 years was highest in the NHS (3.5 times as long as Kaiser, twice as long as Medicare California, and nearly 50% higher than Medicare in the United States). Standardised hospital admission rates for 11 leading causes of hospital admissions in people aged >65 years are generally highest for Medicare recipients in the United States and California, followed by the NHS in England and then Kaiser Permanente in California (see Table 1). However, there are important limitations to the reliability of these findings (see notes). Authors’ conclusions For 11 leading causes of acute hospital admissions in people aged >65 years, the NHS has generally lower hospital admission rates and longer hospital stays compared with Medicare recipients in the United States and California, and Kaiser Permanente in California. Table 1 Number of hospital admissions (per 100,000 population) and length of stay (days) in people aged >65 years, standardised for English population data. Clinical Diagnosis NHS Kaiser Medicare California Medicare United States Admissions Stay Admissions Stay Admissions Stay Admissions Stay Stroke 823 27.08 788 4.26 1155 5.84 1183 6.53 Chronic obstructive pulmonary disease 699 9.87 558 3.79 1067 5.35 1256 5.37 Bronchitis or asthma 531 11.73 141 3.09 225 4.22 310 4.41 Coronary bypass 144 13.27 97 9.60 296 8.63 321 9.98 Acute myocardial infarction 550 9.39 893 4.35 675 5.14 923 5.46 Heart failure/shock 556 12.42 1118 3.70 1893 5.28 2272 5.37 Angina pectoris 783 5.88 152 2.21 176 2.58 203 2.56 Hip replacement 342 12.60 256 4.54 602 5.41 644 5.46 Knee replacement 344 11.32 367 4.17 479 4.54 557 4.40 Hip fracture 315 26.88 388 4.89 489 5.97 535 6.47 Kidney or urinary infection 396 15.19 526 3.80 726 5.11 708 5.32

Study objective: To examine specific risks for occupational injury deaths in New Mexico. Design: Retrospective review of state medical investigator reports from 1980 through 1991 with regard to industry, agent of death, gender, ethnicity, location, and alcohol and other drug involvement. Participants: New Mexico residents who were fatally injured while on the job. Results: We identified 613 deaths: 87.1% unintentional, 10.6% homicides, and 2.3% suicides. Industries with the most fatalities were construction (11.8%), oil/gas (10.6%), and farming (8.6%). The primary agents of death were motor vehicles (41.7%), firearms (10.1%), and falling objects (10.0%). Almost all (95.6%) of the decedents were male. However, females were overrepresented among homicide deaths ( P Conclusion: New Mexico has a high rate of occupational injury death, which appears to be associated with rural location and use of motor vehicles and alcohol. [Fullerton L, Olson L, Crandall C, Sklar D, Zumwalt R: Occupational injury mortality in New Mexico. Ann Emerg Med October 1995;26:447-454.]

Background Dyspnea is among the most common reasons for emergency department (ED) visits by patients with cardiopulmonary disease who are commonly asked to recall the symptoms that prompted them to come to the ED. The reliability of recalled dyspnea has not been systematically investigated in ED patients. Methods Patients with chronic or acute cardiopulmonary conditions who came to the ED with dyspnea (N = 154) completed the Multidimensional Dyspnea Profile (MDP) several times during the visit and in a follow-up visit 4 to 6 weeks later (n = 68). The MDP has 12 items with numerical ratings of intensity, unpleasantness, sensory qualities, and emotions associated with how breathing felt when participants decided to come to the ED (recall MDP) or at the time of administration (“now” MDP). The recall MDP was administered twice in the ED and once during the follow-up visit. Principal components analysis (PCA) with varimax rotation was used to assess domain structure of the recall MDP. Internal consistency reliability was assessed with Cronbach’s alpha. Test–retest reliability was assessed with intraclass correlation coefficients (ICCs) for absolute agreement for individual items and domains. Results PCA of the recall MDP was consistent with two domains (Immediate Perception, 7 items, Cronbach’s alpha = .89 to .94; Emotional Response, 5 items; Cronbach’s alpha = .81 to .85). Test–retest ICCs for the recall MDP during the ED visit ranged from .70 to .87 for individual items and were .93 and .94 for the Immediate Perception and Emotional Response domains. ICCs were much lower for the interval between the ED visit and follow-up, both for individual items (.28 to .66) and for the Immediate Perception and Emotional Response domains (.72 and .78, respectively). Conclusions During an ED visit, recall MDP ratings of dyspnea at the time participants decided to seek care in the ED are reliable and sufficiently stable, both for individual items and the two domains, that a time lag between arrival and questionnaire administration does not critically affect recall of perceptual and emotional characteristics immediately prior to the visit. However, test–retest reliability of recall over a 4- to 6-week interval is poor for individual items and significantly attenuated for the two domains.

The authors used a multipronged approach to gain resident involvement in institutional quality improvement over a 3-year period; the initiative included a survey, a retreat, workgroups, a resurvey, and another retreat. Survey results (from 2007 compared with those of 2010) demonstrated significant improvement in almost all the top issues concerning patient safety for residents-emergency department boarding and crowding, adequacy of patient flow through the institution, adequacy of nursing and technical support staffing, and laboratory specimen handling (initial overall mean concern level was 2.87, and final concern level was 2.19; P < .01). This perceived improvement in patient safety concerns for residents was associated with observable improvements in areas of high concern for hospital leaders. By surveying residents and students, prioritizing concerns, convening a hospital-wide retreat with key leaders, and implementing accountable plans, the authors have demonstrated that resident perceptions of quality and safety can help drive quality improvement and engage residents in improvement efforts at an institutional level.

Hantavirus infection with respiratory involvement is a new clinical entity. The respiratory and cardiovascular abnormalities associated with hantavirus infection define the hantavirus pulmonary syndrome (HPS). We present two cases of HPS and discuss the presentation, epidemiology, emergency department management, and differential diagnosis. Treatment of HPS involves intensive care monitoring, airway management, and cardiovascular support. Because human hantavirus infection with respiratory involvement has been recognized recently in all geographic regions of the United States, it is important for emergency physicians to recognize this syndrome's characteristic symptoms and laboratory abnormalities. The fulminant clinical course of HPS and its 65% mortality rate underscore the importance of early recognition if potentially life-saving interventions are to be initiated.

The selection of emergency medicine residents requires review of medical school performance and, usually, an interview in which applicants and program directors exchange important information. Computer technology is available to assist programs in the analysis of information about applicants. Ethnic diversity and minority recruitment should also be considered as 40% of all emergency medicine residencies have no minority residents. Suggestions for developing a valid, humane, and fair selection process are made.

A medical student advisee recently met with me to plan his fourth-year rotations. He ranked near the top of his class after his third-year rotations, and I anticipated we would be discussing which residency programs he should consider and how he could best use the fourth year to prepare for his internship. I suggested a subinternship experience in critical care and emergency medicine, and electives in medical and surgical subspecialties. However, as I looked at the preliminary schedule he had prepared, I was surprised to see several away rotations in the same specialty—all audition rotations for the specialty into which he hoped to match. “Why are you taking all these away rotations?” I asked. “Everyone has told me I need to do this so that the programs will get to know me. It is very competitive for the good programs. I want to be sure to match. I don’t feel like I have any other choice.” “But you have excellent grades and board scores. I don’t think you need to do this. You will almost certainly match into one of your top choices. The fourth year should be an opportunity for you to explore other topics and learn skills that you may not have a chance to during residency,” I said. “What else would you like to learn this year?” But he remained focused on his original concern and replied, “Can we talk about programs where I should apply?” We went back and forth discussing elements of the fourth year—the uncertainty of the Match interview process, the benefits of exposure to fields that would broaden his perspective, and the need for flexibility to complete scholarly projects and to solidify skills that would be needed before the start of internship. We also discussed several residency programs I was familiar with and how they might fit his interests. It was an excellent discussion about the fourth year. However, I realized that my perspective on the fourth year was heavily influenced by my experience as a former program director, and that students might have very different views. What are some of those views? In this month’s Academic Medicine, Wolf et al1 describe graduating students’ perspectives on the fourth-year curriculum at the University of Colorado School of Medicine. This mixed-methods study, using focus groups and a survey, suggests that students look to the fourth year for career identification and professional development as well as for the opportunity to explore diverse practice settings and personal interests. They also seek flexibility and individualization. In addition, students referred to the role of emotions, like fear and anxiety about competence, in motivating fourth-year course selection. This is valuable information for those of us who advise medical students. Cosgrove et al2 from the University of Washington School of Medicine, in their Commentary on Wolf and colleagues’ report,1 reinforce many of these themes as they describe the goals for their school’s new fourth-year curriculum. That curriculum will stress preparing for residency and national board exams, making career choices, exploring practice settings and topics of personal interest, and engaging in socially responsive service-oriented learning. Residency program directors describe somewhat different goals for the fourth year. Lyss-Lerman et al3 interviewed 30 program directors about the fourth year at one institution and found that the program directors recommended a subinternship in the student’s chosen career area as well as internal medicine rotations, internal medicine subspecialty rotations, and critical care, emergency medicine, and ambulatory medicine rotations. They suggested minimizing additional time in the student’s chosen field. Walling and Merando4 present another view. In their review of the literature about the fourth year from 1974 to 2009, they note an overemphasis on the Match and a lack of focus in the fourth-year curriculum. They suggest that the goals of the fourth year should reflect the medical school’s mission, address the transition to residency, and complete the medical school experience. They also recommend that the fourth year be designed to accommodate the residency application process and medical licensing examinations. Stevens5 suggested using the fourth year to address reform of the health care delivery system by training students in interdisciplinary teams and presenting required educational experiences in evidence-based medicine, patient safety, and quality improvement. He also advised reducing elective time to make room for this new curricular experiences. What conclusions can we draw from these articles? There is a consensus that the fourth year should have the flexibility to accommodate the residency selection process. Students must be able to present themselves well to prospective programs with completed application materials, and have the opportunity to interview to their best advantage. Although the residency selection process diverts the attention of students away from their training goals, the practical considerations of an increasingly competitive Match cannot be ignored. Except for cases in which students have entered a joint medical school–residency program with guaranteed acceptance into residency, any reform of the fourth year will be limited by the important interruptions caused by residency applications. If the number of medical students continues to increase and the number of residency slots remains relatively stable, the Match will become even more stressful for students and will encroach upon other options for reform of the fourth year. Students will also need increased emotional and logistic support from their institutions. There is also general agreement that during the fourth year, students should become prepared for the activities of internship. Some promising initiatives that can help to smooth the transition of education from the undergraduate to the graduate medical education program include “boot camps,”6 in which specific skills that will be needed in internship are identified and students learn and practice the skills. Finally, there are many who would agree that the fourth year could also help to fulfill the unique focus of the medical school’s program, such as emphasizing community service to underserved populations, as in the example described by Cosgrove et al,2 or by encouraging research and other scholarly activities. But at many medical schools, there continues to be discontent with the fourth year and concern that there is much wasted time. Why is this? I believe the problems with the fourth year of medical school may reflect a larger problem—the failure to articulate a vision for the outcome of medical school education. If we do not have a consensus for the end product of medical school education, is it any wonder we would have confusion about identifying when a student has reached this goal? Although students progressively attain expertise during their undergraduate and graduate medical educations, we have not identified the competencies for medical school graduates the way we have for residents. Fortunately, there is a promising project currently under development that attempts to describe core behaviors that would be expected of all medical school graduates. These behaviors, called core entrustable professional activities for entering residency,7 would provide a road map for students about which minimum outcomes they should achieve before starting their residencies. If these proposed guidelines are adopted by all medical schools, there will be an opportunity to identify the placement of educational experiences to meet these outcomes and the inclusion of options that would go beyond minimum requirements. Reform of the fourth year could occur in the context of overall medical school curriculum reform. The current reexamination of the fourth year of medical school also comes at a time of renewed interest in shortening medical education. Emanuel and Fuchs8 have suggested that medical education could be shortened by 30%, including reductions in the clinical experience. If we do not have a clear vision of the value of the fourth year of medical school, it could become a target for elimination. I believe that at a time of great change in our health care system and with the enormous growth in science, medical knowledge, and information systems, the training of our future physicians may need to become more intensive, require more resources, and in most cases require more time than what we have needed in the past. There may be some students who can master all the necessary core entrustable professional activities and the other skills and knowledge needed to pass licensing exams in three years, but I suspect that for most students, four years or more may be required. However, we will not know how much time is needed until we agree upon the desired outcomes. I also hope that we can look beyond minimal requirements and consider what we aspire to for our educational programs. The students studied by Wolf et al1 reported that they would like the opportunity to explore new ideas and experience personal growth. In addition to these goals, we could also encourage students to partake of the excitement and joy of scholarship, critical thinking, and the development of their professional identities. The fourth year of medical school could be a unique opportunity for growth that sets a medical student on a path to a fulfilling and productive medical career. As we consider how we advise our upcoming clinical medical students, we should pause to imagine what a pleasure it would be to discuss how each student could begin to meet his or her potential as a physician during fourth-year rotations, rather than focusing our advice only on the residency application process or passing of board exams. The current limitations are of our making, and we owe it to our students to create a better final year of medical school.

This article reflects the proceedings of a breakout session, "Beyond ED Categorization-Matching Networks to Patient Needs," at the 2010 Academic Emergency Medicine consensus conference, "Beyond Regionalization: Integrated Networks of Emergency Care." It is based on concepts and areas of priority identified and developed by the authors and participants at the conference. The paper first describes definitions fundamental to understanding the categorization, designation, and regionalization of emergency care and then considers a conceptual framework for this process. It also provides a justification for a categorization system being integrated into a regionalized emergency care system. Finally, it discusses potential challenges and barriers to the adoption of a categorization and designation system for emergency care and the opportunities for researchers to study the many issues associated with the implementation of such a system.

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.

Emergency medicine (EM) has grown rapidly over the past 50 years, evolving from a specialty defined by its locational identity--a hospital receiving room--to the specialty picked fourth-most-frequently by graduating U.S. medical students and to being the focal point of clinical care and of research on time-sensitive medical conditions. The authors review the forces that led to the growth of EM and those that will shape its future--in particular, cost, quality, and technology. A balancing of cost and quality considerations will likely drive EM education and research endeavors. The future of the field will be determined in part by resolution of the tension between the current inefficient conditions of emergency departments (EDs), which are crowded because of the temporary boarding of admitted patients for whom a bed is not yet ready, and the desired provision of quality care under emergent conditions. That is, patients with stroke, myocardial infarction, sepsis, or severe injuries from trauma require a working diagnosis and interventions that are initiated shortly after presentation, but ED personnel distracted by the demands of caring for boarded patients are unable to deliver optimal ED care. The reduction or elimination of boarding will enhance education and research within EDs and will contribute to an efficient system of high-quality EM services.

To determine the relationship among helmet use, alcohol use, and ethnicity in people killed on motorcycles.Retrospective review of all motorcycle fatalities in New Mexico from 1984 through 1988.Office of the Medical Investigator, State of New Mexico.All decedents of motorcycle crashes in New Mexico from 1984 through 1988.Review of all autopsies, medical investigator reports, traffic fatality reports, and toxicological studies on fatally injured motorcyclists.Nine of the helmeted drivers (18%) were legally intoxicated compared with 67 of the nonhelmeted drivers (51%) (chi 2 = 15.7, P less than .0001); 42 of the white nonHispanic decedents (37%), ten of Hispanic decedents (12%), and none of the Native-American decedents were wearing helmets. The head and neck region was the most severely injured body region in 42 of the nonhelmeted cases (84%) and in eight of the helmeted cases (50%) (Fisher's exact test, P less than .02).There is an association between nonuse of helmets and alcohol intoxication in fatally injured motorcyclists in New Mexico. Strategies for preventing motorcycle fatalities should address alcohol abuse and ethnicity in conjunction with helmet use.

The objective of this study was to determine which airway maneuvers cause the least cervical spine movement. A controlled laboratory investigation was performed in a radiologic suite, using eight human traumatic arrest victims who were studied within 40 minutes of death. All subjects were ventilated by mask and intubated orally, over a lighted oral stylet and flexible laryngoscope, and nasally. Cinefluoroscopic measurement of maximum cervical displacement during each procedure was made with the subjects supine and secured by hard collar, backboard, and tape. The mean maximum cervical spine displacement was found to be 2.93 mm for mask ventilation, 1.51 mm for oral intubation, 1.65 mm for guided oral intubation, and 1.20 mm for nasal intubation. Ventilation by mask caused more cervical spine displacement than the other procedures studied (ANOVA: F = 9.298; P = .00004). It was concluded that mask ventilation moves the cervical spine more than any commonly used method of endotracheal intubation. Physicians should choose the intubation technique with which they have the greatest experience and skill.

Study objective: To compare the diagnostic processes of experienced emergency physicians with those of novices. Design: Prospective, convenience sample of patients. Setting: Emergency department of a county university medical center in a large southwestern urban community. Participants: Experienced emergency physicians (attending and senior residents) and novice clinicians (junior residents and senior medical students). Interventions: Participants developed initial diagnostic impressions after reviewing the chief complaint, nurse triage notes, and vital signs. Tests were then selected, and a final diagnostic impression was identified after results were known. Clinicians also marked a visual analog scale corresponding to their estimate that each diagnostic possibility was correct. Results: Experienced physicians increased their certainty more than novices ( P = .014). They deviated from a standard history-physical-laboratory sequence more often than novices ( P = .008). Conclusion: Expertise in medical decision making is characterized by a moderate initial level of certainty concerning a diagnosis that significantly increases as the experienced clinician follows a flexible strategy of testing to arrive at a final diagnosis.

Study hypothesis: Risk factors associated with unintentional gunshot fatalities among children include gender and race of the decedent, type of firearm used, and whether loaded guns are stored within the home. Study population: All New Mexico children 0 to 14 years old unintentionally killed by a firearm between 1984 and 1988. Methods: The New Mexico Office of the Medical Investigator master mortality file was reviewed retrospectively to identify all unintentional firearm fatalities occurring in New Mexico children during a five-year period. Medical investigator, autopsy, and police reports were analyzed to identify epidemiologic factors associated with these deaths. Chi-square and Fisher's exact tests were used to analyze the data. Results: Twenty-five unintentional firearm fatalities were identified. These deaths occurred most frequently among children playing with loaded firearms found within the home. A disproportionate number involved handguns. Conclusion: The study results provide a basis for preventive strategies that limit accessibility or decrease lethality of loaded firearms within the home.

Crowding is an increasingly common occurrence in hospital-based emergency departments (EDs) across the globe. This 2-article series offers an ethical and policy analysis of ED crowding. Part 1 begins with a discussion of terms used to describe this situation and proposes that the term "crowding" be preferred to "overcrowding." The article discusses definitions, measures, and causes of ED crowding and concludes that the inability to transfer emergency patients to inpatient beds and resultant boarding of admitted patients in the ED are among the root causes of ED crowding. Finally, the article identifies and describes a variety of adverse moral consequences of ED crowding, including increased risks of harm to patients, delays in providing needed care, compromised privacy and confidentiality, impaired communication, and diminished access to care. Part 2 of the series examines barriers to resolving the problem of ED crowding and strategies proposed to overcome those barriers.