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Objective: To examine the scope of alcohol use among a population of injured adolescents., Methods: A convenience sample of injured patients aged 12-18 years seen at a pediatric ED was tested for the presence of alcohol. Injured patients seen within 6 hours of their injuries were asked to submit urine samples for testing using reagent strips. Data were collected from the patient, out-of-hospital emergency care personnel, and parents regarding the circumstances of the injury., Results: Of the 243 injured patients who were tested during an 8-month period, 231 were included in the final analysis. Ninety patients (39%) were alcohol-positive. The mean age of the alcohol-positive group was 16.0 +/- 1.64 years, compared with 15.3 +/- 1.8 years for the alcohol-negative group (p < 0.003). There was no significant difference between the 2 groups based on race, gender, or injury characteristics. A positive urine alcohol test was found for 18 (33%) of motor vehicle crash victims, 9 (38%) of the motor vehicle drivers, 10 (37%) of the patients who attempted suicide, and 49 (44%) of the assault victims., Conclusions: A substantial percentage of injured adolescent patients were alcohol-positive. The authors recommend the use of alcohol screening when treating injured adolescents.

Three cases are reported of hypoglycemia manifested by profound sinus bradycardia and fatigue, which responded to i.v. dextrose with prompt normalization of the cardiac rhythm. The cases involved 3 different patients and disease processes: a young female who had anorexia nervosa and profound malnutrition; an elderly, nondiabetic male who subsequently experienced a transient ischemic attack: and a patient who had diabetes mellitus managed with chronic, subcutaneous insulin administration. It is vitally important that the emergency physician recognize unusual clinical manifestations of hypoglycemia and fully evaluate such scenarios when hypoglycemia may occur. Untreated, hypoglycemia may result in significant chronic morbidity, and rarely, in death. Bradyarrhythmias--particularly sinus bradycardia--should be added to the list of potential clinical manifestations of hypoglycemia.

Study Objective: To assess the effectiveness of an international emergency medical services (EMS) train-the-trainer program., Participants: Seven bilingual Polish physicians attended a 350-hour US-based EMS training program. The physicians returned to Poland to train Polish-speaking EMS personnel., Interventions: The Polish training was assessed by means of a pretest, a final examination, a series of skill stations, and a retrospective self-assessment instrument created by the authors. The retrospective self-assessment instrument, using a six-point Likert scale, measured the degree of self-reported competence before and after training in three areas: basic trauma, advanced medical, and basic medical., Results: One hundred seventy-nine Polish students were assessed. Pretest scores ranged from 17% to 100% (mean, 74% +/- 11%). Ninety-one percent passed the final examination (mean, 91% +/- 4.0%; range, 74% to 99%). All students passed all skill stations. The before-and-after instrument indicated that the Polish students' prior competence ranged from not competent (Likert score 1) to fully competent (Likert score 6). Mean scores were: basic trauma, 2.6 +/- 4; advanced medical, 2.5 +/- 7; and basic medical, 2.8 +/- 7. After-course scores demonstrated improved competence. Before-and-after instrument score differences were significant for each area (P < .0001)., Conclusion: Despite differences in language, culture, technology, and resources, an international train-the-trainer program can be evaluated. In addition to standard testing, a retrospective before-and-after self-assessment instrument provides corroborative evidence of program success.

Wrist injuries occur commonly. Significant wrist injuries such as perilunate dislocation and scapholunate dissociation may occur without carpal bone fracture. The emergency physician can recognize these ligamentous wrist injuries by noting abnormalities of the shapes, joint spaces, and alignments of the carpal bones. Early diagnosis allows for prompt referral and optimal outcome.

Study Objective: To determine the rate and cause of death of patients who were evaluated in the emergency department and discharged and how the cause of death related to the ED visit., Design: Retrospective chart review of medical examiner cases from July 1, 1990, to June 30, 1991., Setting: Urban county served by 13 hospital EDs with 383,416 visits in 1991. Eighty-five percent of these patients were discharged., Participants: Medical examiner cases of patients who had been evaluated and released from an ED within 8 days prior to death., Results: Forty-two of the 2,665 medical examiner cases met inclusion criteria. Death was classified as expected or unexpected based on the patient's clinical status at the time of discharge, and directly related or not directly related to the ED visit, based on review of all records and the cause of death as listed on the death certificate. Six deaths (14%) were considered expected and directly related. Three deaths (7%) were considered expected and not directly related. Twenty-four deaths (57%) were considered unexpected and not directly related. Nine deaths (21%) were considered unexpected and directly related; the most common cause was ruptured aortic aneurysm, occurring in three of these nine cases. The death rate was 13 per 100,000 discharged patients., Conclusion: Death after discharge from the ED is uncommon. The most common cause of unexpected, directly related death is ruptured aortic aneurysm.

Study Objective: To determine the incidence, demographics, clinical indicators of survival, and frequency of cervical-spine fractures to define appropriate emergency airway management in hanging victims., Design: Medical examiner records, paramedic reports, and emergency department and hospital medical records were reviewed retrospectively for the period January 1, 1978, to January 1, 1990., Setting: Urban paramedic system with nine receiving hospitals., Participants: A total of 160,724 medical examiner and paramedic records were reviewed to identify a total study population of 306 hanging victims. One hundred eighty-two victims (59%) were found dead at the scene, and the emergency medical system was not notified. An additional 57 (19%) were seen by paramedics and declared dead at the scene. Sixty-seven (22%) were treated and transported to nine receiving EDs; 39 of these 67 received oral or nasal endotracheal intubation., Results: The incidence of hanging was 0.19% of all medical examiner cases and paramedic runs during the 12-year study. Those hanging victims who survived to receive paramedic transport and treatment by physicians were typically male and attempted suicidal hanging in a public place (most frequently jail) with available bedding or clothes. No hanging victim treated and transported by paramedics had documentation of cervical-spine or spinal cord injury., Conclusion: In nonjudicial hanging victims seen by paramedics and transported to an ED, cervical-spine injury is rare. Cerebral hypoxia rather than spinal cord injury is the probable cause of death and should be the primary concern in treatment of this patient population. Following external stabilization of the neck, nasal or oral endotracheal intubation is appropriate emergency airway management in hanging victims.

Study Objective: To study emergency physician documentation of seat belt use, practice patterns, and charges for patients with different restraints involved in motor vehicle crashes., Design: Retrospective examination of 2,239 emergency department records during a 5-month period., Participants: Patients from four community EDs and one Level I trauma center ED., Results: Documentation of seat belt use for motor vehicle crash occupants was reported in 70% of the ED records reviewed. Only 64.5% of the records from the four community hospital EDs recorded seat belt use, compared with 81.7% of the records from the trauma center ED (P < .001). The unbelted group had a greater mean number of physician procedures performed (1.4 versus 1.2; P < .001) and more radiographs of the face and skull ordered (11.9% versus 8%, P < .01). Seat belt users had a higher average number of cervical-spine radiographs ordered than did nonusers (71.5 versus 65.7; P < .05). Physician charges for unbelted patients were higher compared with those for belted patients, averaging $22.00 more per patient (P < .001)., Conclusion: Emergency physician practice patterns reflect the distribution of injuries associated with seat belt use and nonuse. Reduced physician charges for belted patients contributed to health care cost savings. Emergency physicians should be encouraged to consistently obtain and record whether an individual was wearing a seat belt during a motor vehicle crash.

Motor vehicle crash (MVC) deaths in Wisconsin have steadily declined since the 1970s. Multiple prevention strategies have been applied resulting in the lowest MVC death rate in 30 years. If current trends continue, firearms will exceed MVCs in Wisconsin by the year 2001. Multiple prevention strategies based on the public health model need to be applied to firearms.

Study Objective: To ascertain the nature and extent of motorboat propeller injuries in Wisconsin., Design: Retrospective study of deaths and injuries from outboard motor propellers reported to the Wisconsin Division of Health, Vital Statistics, and reported by a statewide retrospective survey of emergency departments., Results: For the study period 1987 through 1989, three fatalities were found in Vital Statistics and Emergency Department records and 14 nonfatal injuries reported by respondents to the Wisconsin emergency department survey. Thirty-six percent (5 of 14) of the nonfatal injuries occurred in water skiers. Injuries involved the lower extremities in 10 of 14 nonfatal cases (71%), frequently in association with other anatomic areas. At least three cases involved very severe injuries, with mean acute care medical charges of more than $100,000 per case., Conclusions: Where boating is common, fatal and severe injuries from propellers occur with regularity. These injuries are often severe, requiring complicated and expensive treatment. The authors urge improved documentation of the incidence of propeller injuries, and an active exploration of prevention strategies including fitting motorboat propellers with guards.

This paper focuses on the implications of an inadequate public health/preventive health care system for emergency medicine (EM), the role that EM providers can play in remedying critical health problems, and the benefits gained from a public health approach to EM. A broad definition of public health is adopted, suggesting shared goals of public health and EM. Critical problems posed for EM include alcohol, tobacco, and other drug abuse; injury; violence; sexually transmitted diseases and human immunodeficiency virus (HIV) infection occupational and environmental exposures; and the unmet health needs of minorities and women. A blueprint for future merging of public health issues with EM is presented that includes the application of public health principles to 1) clinical practice; 2) public education, community involvement, and public policy advocacy; 3) development of medical school and residency public health/prevention curricula and teaching methods; and 4) research opportunities and surveillance. Finally, recommendations are proposed that require restructuring the present health care system to provide resources, incentives, and organizational changes that promote an integration of public health and preventive services in the practice of EM.

Study Objective: To describe fatal childhood injury patterns in an urban county and evaluate the use of the emergency medical services system., Design: Retrospective chart review of medical examiner files, prehospital and hospital records, and police and fire personnel reports., Setting: Milwaukee County, Wisconsin, an urban county with a population of approximately 1 million., Participants: All children 15 years old or younger who sustained a fatal injury in 1989 or 1990 (70)., Results: House fires were the leading cause of death by injury (34%), followed by firearms (19%), and drowning (11%). Motor vehicle occupant deaths occurred less frequently (7%). One-third of deaths were homicides (48% firearms and 30% assault). Twenty-four percent of deaths were pronounced at the scene, 12% were dead-on-arrival (no emergency department resuscitative efforts), and 37% were dead-on arrival ED resuscitations. Only 27% of victims survived to become inpatients (84% died within 72 hours). Mean scene time (16.1 +/- 7.9 minutes), transport time (9.5 +/- 5.1 minutes), and success rates for prehospital peripheral IV insertion (72%), endotracheal intubation (91%), and intraosseous line (86%) were not significantly different among those who were dead-on-arrival, dead-on-arrival failed resuscitations, or eventual inpatients., Conclusion: Fatal childhood injury patterns in this urban setting differed from reported national injury patterns. This study found a higher percentage of deaths from fire, gunshot wounds, and homicides but a lower percentage of motor vehicle-related deaths. Prevention strategies need to address the injury patterns of a particular community. Only a small percentage of victims survived to receive inpatient care following their injuries, suggesting that primary prevention of injury may be the most effective intervention.

Study Objective: To study the epidemiology of U.S. citizens who become ill or injured while on vacation outside the United States and are transported back to the United States by emergency air medical transports., Design: A retrospective self-reported survey covering a study period of three years (1988-1990) of air medical transport services in the United States., Setting and Type of Participants: All members of the Association of Air Medical Services (AAMS) who operate either rotorcraft within range of non-U.S. territories (excluding Canada) or who operate fixed-wing aircraft in the United States., Interventions: None., Results: There were a total of 796 cases reported by AAMS members during the study period. Males comprised 61% of the cases. Unintentional injury accounted for 44% (n = 351) of the patients transported. Acute myocardial infarctions, angina and post-cardiac arrest cases comprised 15% (n = 141) of the total cases. Infectious diseases other than pneumonia comprised slightly more than 1% (n = 11) of the total cases. There were 12 gunshot wounds and one stab wound, comprising 1.6% (n = 13) of the total cases. Mexico, the Virgin Islands, and the Bahamas were the top three sites of transport origin, accounting for 59% of the cases. Fixed-wing transport accounted for 90% of the reported flights., Conclusions: This survey reveals a previously undescribed portion of travel-related morbidity and mortality. Injury prevention needs greater emphasis when travel advice is given by physicians and other travel medical services. Air medical transport is an important aspect of the care of acutely injured or ill U.S.-citizen tourists.

We have briefly described the theoretic and strategic concepts of injury control and suggested ways for emergency medicine to be more broadly involved. It is not enough for emergency physicians to be active solely in the acute management of injured patients. Emergency physicians need to "look upstream" and balance their focus on the acute management of injuries with a focus on the prevention of injuries.

Volar metacarpal phalangeal joint dislocations are rare injuries. We could find only eight cases reported, with none in the emergency medicine literature. We present a case report and describe the biomechanics and radiographic findings of this injury.

Emergency departments are intended to be the location of entry into the health care system for patients with acute problems, such as injuries and myocardial infarctions. In contrast, cancer should optimally be detected during periodic health examinations, either through screening procedures or by early detection from signs and symptoms which prompt a routine visit to a primary care physician. This study was undertaken to describe patients who present to an emergency department with urgent symptoms and signs, are hospitalized, and subsequently diagnosed with cancer (ED group). One hundred twenty-nine patients were retrospectively studied. When compared with patients diagnosed in a primary care setting (tumor registry patients), the ED group was significantly older, more often male, had a significantly lower survival rate, and more frequent metastatic disease at diagnosis (P less than .001). The ED group accounted for 5.3% of the new tumor registry patients for the study years. Only 3.1% of the ED group had no insurance, and 21% reported no personal physician. Strategies are needed for patients and physicians to reduce the number of late-diagnosed cancer cases presenting in emergency departments.

Difficulties in adjustment frequently accompany severe hand injuries. The purpose of this study was to determine whether presurgical screening could predict long-term adjustment problems. One hundred thirteen patients with severe hand injuries completed a presurgical questionnaire evaluating flashbacks, avoidance, and causal factors pertaining to the injury. Patients were evaluated by a psychologist within 5 days after surgery and again 6 months later. Flashbacks initially occurred with equal frequency in occupationally and nonoccupationally injured groups. At 6-month follow-up 50% of the occupationally injured patients and 25% of the nonoccupationally injured patients had flashbacks. Avoidance of the activity at which patients were injured was also assessed. Among occupationally injured patients, 52% initially reported no avoidance compared with 17% at follow-up. Patients with nonoccupational injuries showed more initial avoidance (68%), with slightly less at follow-up (61%). Of the occupationally injured patients, 46% initially reported personal error or fatigue as the cause of their injury, but only 6% reported this as the cause at follow-up; it is interesting that at 6-month follow-up 81% of this group reported machine failure or lack of safeguards. Among nonoccupationally injured patients, 71% reported personal error as the cause of injury presurgically and 66% at 6-month follow-up. Presurgical screening appears to be a valid means of identifying persons at risk of ongoing adjustment problems after hand injury. A screening interview can easily be conducted in less than 5 minutes.

The Federal Government, U.S. physicians, their patients who travel, insurance companies, the travel industry, and multinational corporations should know the health hazards facing Americans overseas. However, the deaths overseas of almost 5,000 Americans every year have never been analyzed. A previously unreported, unexamined data source is analyzed by cause, sex, age, length of stay, and country of death of Americans dying overseas. The major findings are 1. Most Americans who die overseas die in the developed countries of Western Europe, where most Americans live or visit. The patterns of deaths in these countries are similar to death patterns in the United States. 2. Surprisingly, the deaths of Americans in less developed countries are not from infectious and tropical disease, as many health professionals would expect, but are from chronic diseases, injuries, suicides, and homicides. The importance of these findings for the Federal Government, travelers' clinics, insurance companies, multinational corporations, and Americans living and traveling overseas is discussed.

Study Objective: Studies of travel-related mortality and morbidity have been limited to nonfatal events. Causes of travel-related mortality may differ significantly from morbidity and thus have different prevention strategies., Design: We examined the overseas fatalities of US citizen travelers for the years 1975 and 1984. The death certificates were abstracted; all deaths under age 60 and a 20% sample of deaths 60 and older were examined., Setting and Type of Participants: All overseas travel fatalities of US citizens were examined excluding those occurring in Canada., Interventions: None., Results: Cardiovascular events (including myocardial infarctions and cerebrovascular accidents) and injuries accounted for 49% and 25% of the overseas deaths of US citizen travelers, respectively. Infectious diseases other than pneumonia accounted for only 1% of the deaths. Eighty percent of injury deaths occurred outside of hospitals. Injury death rates for male travelers were greater than US age-specific death rates., Conclusions: Greater emphasis on the prevention of fatal events, especially those resulting from injury, must be given by physicians and other individuals and organizations who advise travelers. Further studies are needed to explore the issues of preventable injury deaths, emergency medical services, and overseas travel.

Malaria continues to be a significant cause of travel related morbidity and mortality for US citizens. Yet there have been no previous analyses of malaria cases reported in Wisconsin. To provide timely information to Wisconsin physicians, the authors present a review of reported malaria cases in Wisconsin for the years 1981 through 1989, and an update of current Center for Disease Control malaria chemoprophylaxis.

All-terrain vehicles (ATVs) have resulted in over 1,400 deaths and 400,000 injuries in the United States since their introduction in the 1970s. Analysis of deaths due to ATVs have been limited to a few states. Death certificates for ATVs were abstracted for the years 1983 through 1989 in Wisconsin. Fifty-two deaths were analyzed; 44 (85%) were male, and 26 (50%) were under age 18. Head injuries accounted for 33 (63%) of the deaths. Thirty-one of the deaths (60%) were "immediate", occurring in "seconds", "minutes", or "immediately". Following the model developed by Haddon, there are several promising injury-control strategies: limiting the use of ATVs to those sixteen or older, increasing visibility of vehicles through means such as flags, increasing helmet usage, and improving emergency medical systems services. Many of these strategies are best promoted through statewide legislative policy changes. This injury study model of ATV deaths suggest that a more balanced approach towards injury reduction should have an equal emphasis on improving injury prevention and acute care.

About 3 to 4 million Americans travel to Mexico every year, yet their mortality experience has never been analyzed. Fatalities among US travelers to Mexico during the years 1975 and 1984 were examined using a previously unanalyzed data source. The leading cause of death to all US travelers to Mexico was injuries (51%), with 18% of deaths resulting from motor vehicle crashes. Of all travelers' deaths, 37% were due to circulatory diseases and less than 1% were due to infectious diseases. While the proportion of all deaths from motor vehicle crashes was similar for US citizens traveling in Mexico and US residents, travelers had significantly higher proportions of injury deaths due to aircraft crashes and drowning. Injury, rather than infectious diseases, appears to pose the greatest risk of death to travelers to Mexico. Physicians and travel clinics need to place greater emphasis on injury prevention when giving advice to clients traveling to Mexico.