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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.

As the average age of emergency physicians increases, the emergency physician becomes prone to the development of potentially disabling conditions that might affect his or her ability to practice emergency medicine. Emergency physicians may not have a full understanding of the assessment of disability or of the legal, financial, and technical issues involved. The authors report 3 cases of emergency physicians who experienced severe disabilities and were unable to return to the practice of emergency medicine. All 3 physicians had long-term disability insurance policies that enabled them to financially maintain their pre-disability standard of living, despite the devastating effects of the specific disability itself. The authors strongly advise emergency physicians to have a long-term disability policy in effect at all times and review the issues associated with the assessment of disability, as well as the legal, financial, and technical issues.

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.

Study objective We measured the frequency of unanticipated death among patients discharged from the emergency department (ED) and reviewed these cases for patterns of potential preventable medical error. Methods This was a retrospective cohort of ED patients who were discharged to home from an urban tertiary-care facility after their evaluation, with subsequent case review. Subjects were aged 10 years and older, representing 387,334 visits among 186,859 individuals, February 1994 through November 2004. The main outcome was mortality. Deaths were assessed for relatedness to the last ED visit, whether the death was expected, and whether there was possible medical error. Deaths that were unexpected and related to the ED visit were analyzed using grounded theory to identify common themes among these cases. Error cases were identified as a subset of this group. Results We identified and reviewed 117 patients, or 30.2 deaths within 7 days of discharge per 100,000 ED discharges home (95% confidence interval [CI] 25.2 to 36.2 deaths). Of the 117 cases, 58 (50%) were unexpected but related to the ED visit and 35 (60%) of these had a possible error. For the unexpected, related group, there were 15.0 deaths within 7 days per 100,000 discharges home (95% CI 11.6 to 19.4 deaths); for the possible error group, there were 9.0 (95% CI 6.5 to 12.6 deaths). Four themes repeatedly emerged: atypical presentation of an unusual problem, chronic disease with decompensation, abnormal vital signs, and mental disability or psychiatric problem or substance abuse that may have made it less likely that the patient would return for worsening symptoms. Conclusion Monitoring of death records can identify unanticipated deaths after health care encounters. Further hypothesis-driven research is needed to identify, prevent, or mitigate problems in care and reduce the rate of death after ED visit.

Chronic posttraumatic sleep disturbance may include sleep-disordered breathing (SDB), but this disorder of sleep respiration is usually not suspected in trauma survivors. Sleep breathing signs and symptoms were studied in 178 adults-all with SDB-including typical sleep clinic patients (N = 89) reporting classic snoring and sleepiness and crime victims (N = 89) with insomnia and posttraumatic stress. Significant differences (p < 0.0001) were common between groups. Sleep breathing complaints, loud snoring, marked obesity, and obstructive sleep apnea were prevalent in sleep clinic patients; crime victims reported more insomnia, nightmares, poor sleep quality, leg jerks, cognitive-affective symptoms, psychotropic medication usage, and less snoring but more upper airway resistance syndrome. Both groups reported high rates of fatigue or sleepiness, nocturia, morning dry mouth, and morning headaches. Awareness of these clinical features might enhance detection of SDB among trauma survivors.

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.

A nonconcurrent prospective cohort study was conducted to evaluate if National Resident Matching Program (NRMP) rank developed using multivariate regression followed by consensus group activity is associated with perceived general performance during emergency medicine residency. All residents graduating from a university hospital-based residency program between 1990 to 1993 were ranked by university faculty, private attendings, charge nurses, and a clerk. Each evaluator was asked to order (from the strongest to the weakest) a deck of cards that contained only each graduate's name and picture. NRMP ranks were scaled to adjust for differences in each year's match list length. Evaluators were unaware of the graduates NRMP ranks. Agreement among raters was analyzed using Kendall's coefficient of concordance. Perceived ranks were compared with actual NRMP ranks using the Spearman correlation procedure. Twenty graduates were evaluated by eight different individuals, yielding 160 pairs of ranks. There was moderately strong agreement among evaluators about the relative strength of the 20 residents (W = 0.67, P < .001). The association of perceived rank with NRMP rank was much greater than that expected by chance (r(s) = .35, P < .0001). Applicants with better NRMP ranks were perceived as stronger residents, which supports the strategy of using formal statistical modelling followed by consensus group activity as a method of generating NRMP rank lists.

Study objective We differentiate risk factors for future homicide victimization and offending, and we measure emergency department (ED) use among homicide victims, offenders, and controls. Methods The design was a matched case-control study conducted in Bernalillo County, NM, and its university-affiliated health sciences center and hospital. All Bernalillo County homicide victims (N=124) and offenders (N=138) identified between January 1996 and December 2001 who were linked to university physician billing records and who had health care use during the 3 years before the homicide incident were included as cases. Randomly selected age-matched (±1 year) and sex-matched subjects with health care use within 3 years of their matched pair's homicide were included as controls. Main outcome measures were the number and type of ED visits by cases and controls. Results Among the 124 victims and 138 offenders who used health care, most were men (80%) and averaged 27.7 years of age. Victims and offenders had similar health care use and were grouped for final analyses. Cases (victims and offenders) were more likely to have had an ED visit within 3 years of the homicide (85%) compared with controls (59%) (odds ratio [OR] 4.3; 95% confidence interval [CI] 3.0 to 6.2). Within previous ED visits, assault (OR 4.5; 95% CI 2.9 to 7.0), firearm injury (OR 13.6; 95% CI 4.9 to 37.7), and substance abuse (OR 3.7; 95% CI 2.2 to 6.0) were associated with future homicide. ED visits clustered closer to the homicide incident for cases (median days before the homicide −402 days; 95% CI −434 to −364) compared with controls (median −487 days; 95% CI −498 to −474). Conclusion Patients with ED visits for assault, firearm injuries, and substance abuse are at increased risk for homicide and often have an escalating number of visits leading up to the homicide event. ED-based identification and referral programs similar to those used for intimate partner violence or other preventive strategies should be considered for this high-risk population.

Objective: To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients. Method: In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use. Results: In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high. Conclusions: In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.

Study objective The use of managed care to decrease emergency department (ED) use has been reported with some success among Medicaid and insured populations. Our objective is to determine the effect of a managed care program (the "Program") for uninsured patients on their use of emergency, inpatient, and outpatient services. Methods This was a retrospective, observational study with 3 groups of patients at an urban, academic medical center: uninsured patients enrolled in the Program, uninsured patients not enrolled in the Program ("Uninsured"), and commercially insured ("Commercial") patients. All patients received services at least once annually during the 5-year study duration. Administrative databases provided data on ED visits, hospital discharges, hospital days, primary care visits, and specialty care visits during the preprogram and 4 postprogram years. Results There were 1,676 Program, 335 Uninsured, and 844 Commercial patients (2,855 total patients). Use of emergency, inpatient, and outpatient specialty clinics by all groups did not change significantly after program implementation. There was a modest increase in outpatient primary care use by Program members. Conclusion Implementation of a managed care program did not significantly alter ED or inpatient hospital use patterns in an uninsured, indigent population. Providing a primary care provider and health care benefits alone was insufficient to reduce ED use in this population.

The objective of this study was to determine the degree of association of self-estimated scholastic standing (self-rank) with an independent evaluation of the dean's letter (dean's letter score). Applicants to our emergency medicine residency program were asked to estimate their scholastic standing on the application form. A blinded independent review of the dean's letter for each applicant was performed, and the letter was scored. The final ranking of the applicant submitted to the National Resident Matching Program was also obtained. Analysis was carried out using the Spearman rank correlation procedure. One hundred forty-three medical students with self-rank, dean's letter, and final ranking from applications between 1991–1993 were analyzed. The association of self-rank with dean's letter score was highly significant. There was also an appreciable relationship between self-rank and final rank in the NRMP Match. Self-rank of scholastic standing by applicants to an emergency medicine residency is strongly associated with dean's letter information. Self-rank may be useful during early screening of applications before dean's letters are available.

The Fatality Analysis Reporting System (FARS) and the Web-based Injury Statistics Query and Reporting System (WISQARS) were used to compare fatal pedestrian crashes in American Indians and Alaskan Natives (AI/AN) between urban and rural locations for 2000–2001. There were significant differences between urban and rural crashes for driver, pedestrian, environmental, and engineering factors. Rural pedestrian crashes more often occurred on highways (p

Medical schools and specialty societies have struggled to define a core content for medical students and practitioners but, to date, have been stymied by both political considerations and the sheer burden of the innumerable decisions that must be made to define the essence of a medical specialty. Six professional organizations representing the field of emergency medicine recently collaborated with the National Board of Medical Examiners to accomplish this objective by developing a Model of the Clinical Practice of Emergency Medicine. This document will provide support for the development of medical school and residency curricula, training program accreditation standards, board certification test specifications, and organizational agendas for postgraduate education, research, and patient advocacy for the specialty of emergency medicine. The authors present a description of the model and the process that was used to develop it with the belief that other medical disciplines that face similar issues and challenges could benefit from a similar undertaking.

The current US health care system is expensive,1 provides an uneven quality of care,2 and leaves about 40% of US adults uninsured or underinsured.3 The medical education system in the United States may contribute to these problems through its emphasis on the treatment of disease rather than addressing patient safety, cost-effective health care delivery, and population health. Graduate medical education (GME) occurs at the fulcrum of clinical care delivery and medical school, and could play an important role in altering medical education to better address features of clinical quality, health care costs, and access to health services. In the process, GME could bring about needed improvements in the delivery of health care services and prevention of disease and injury. To accomplish these goals, GME will have to build bridges between the clinical and educational enterprises. GME could begin a radical reconceptualization of the medical education continuum through the blending of health services concepts and competencies with traditional biomedical, bioscience models. In doing so, the prioritization of time and effort for residents and faculty would have to change to allow excellence in clinical quality to become the driving force for GME, and ultimately for the continuum of medical education.

The Accreditation Council for Graduate Medical Education (ACGME)-identified core competency of systems-based practice requires the demonstration of an awareness of the larger context and system of health care, and the ability to call on system resources to provide optimum care. This article describes an approach to teaching and fulfilling the requirement of this core competency in an emergency medicine residency. Beginning residents are oriented to community resources that are important to the larger context of care outside the emergency department. Each resident completes a community project during his or her residency. Readings and discussions concerning community-oriented medical care and the literature of research and injury prevention in emergency medicine precede the project development. Several projects are described in detail. Such projects help to teach not only awareness of the community resources of the greater context of medical practice outside the emergency department, but also how to use those resources. Projects could be a main component of a resident portfolio. This approach to teaching the core competency of systems-based practice is proposed as an innovative and substantial contribution toward satisfying the requirement of the core competency.

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.

The authors propose a three-year curriculum for emergency medicine residents using human simulation both to teach and to assess the Accreditation Council for Graduate Medical Education (ACGME) core competencies. Human simulation refers to a variety of technologies that allow residents to work through realistic patient problems so as to allow them to make mistakes, learn, and be evaluated without exposing a real patient to risk. This curriculum incorporates 15 simulated patient encounters with gradually increasing difficulty, complexity, and realism into a three-year emergency medicine residency. The core competencies are incorporated into each case, focusing on the areas of patient care, interpersonal skills and communication, professionalism, and practice based learning and improvement. Because of the limitations of current assessment tools, the demonstration of resident competence is used only for formative evaluations. Limitations of this proposal and difficulties in implementation are discussed, along with a description of the organization and initiation of the simulation program.

[Hockberger RS, Binder LS, Graber MA, Hoffman GL, Perina DG, Schneider SM, Sklar DP, Strauss RW, Viravec DR, Koenig WJ, Augustine JJ, Burdick WP, Henderson WV, Lawrence LL, Levy DB, McCall J, Parnell MA, Shoji KT. The model of the clinical practice of emergency medicine. Ann Emerg Med. June 2001;37:745-770.]

A 22-month-old child had a generalized tonic-clonic seizure during attempted orotracheal intubation and broke the laryngoscope bulb with his teeth. The glass was swallowed but passed uneventfully through the gastrointestinal tract. The possibility of this unusual complication should be considered when patients at risk for seizures are intubated by the orotracheal route.

To determine if examiner gender affects men's perceived pain and embarrassment during an emergency department (ED) digital rectal examination, we prospectively studied male ED patients undergoing rectal examination. Each subject's perceived pain and embarrassment was gauged using 100 mm visual analog scales. Age, complaint, and examiner gender and training level were recorded. Two-tailed Mann-Whitney or Kruskal-Wallis tests examined significant differences among group mean pain and embarrassment scores. Of 126 subjects, 60 had female and 66 had male examiners. Mean pain scores were similar for patients of female (36.5 mm) and male (37.4 mm) examiners (95% CI −9.8 to 11.5, P = .73). Mean embarrassment scores were similar for female (36.6 mm) and for male (32.9 mm) examiners (95% CI −7.9 to 15.3, P = .67). Younger male patients experienced more pain and embarrassment (P < .027). Examiner training level and prostatic examination did not affect the score. (Am J Emerg Med 2000;18:676-678.

[Sklar DP. Letting go. Ann Emerg Med. August 2000;36:167-168.].

Objective: To compare pediatric patients transported by ambulance on more than one occasion (repeat) with those transported only once. Methods: The authors analyzed pediatric (patient < 21 years old) transports for 1992-1995 by the ambulance service that provides 99% of transports for a non-innercity metropolitan area. Repeat transports were compared with single transports with regard to patient age, gender, chief complaint, and payment source. Results: There were 17,448 transports involving 15,168 patients. Nearly half (49.0%) of the repeat transports involved patients in the oldest age category, 17 to 20.9 years, contrasted with 38.0% of single transports (p < 0.00001). Females comprised 51.4% of the repeat transports and 48.5% of the single transports (p = 0.0008). Traumatic complaints accounted for one-third (33.0%) of the repeat transports and half (51.1%) of the single transports (p < 0.0001). Chief complaints of the patients with repeat transports were more likely to be seizure, assault, abdominal pain, and respiratory problems, and less likely to be falls and motor vehicle-related complaints, than chief complaints of the patients with single transports (p < 0.0001). More than one-third (39.0%) of the repeat transports were funded by Medicaid, in contrast with 19.8% of the single transports (p < 0.0001). Conclusions: Compared with single transports, repeat transports were more likely to involve patients more than 16 years of age, female, and with a chief complaint of seizure, assault, abdominal pain, or respiratory distress, and more likely to be funded by public insurance (Medicaid). Repeat pediatric transports warrant further investigation. This information may be useful in designing interventions targeted at reducing emergencies and hence ambulance use.

The suicide death rate in New Mexico is consistently higher than the national rate. Among adolescents, suicide is the third leading cause of death nationally, but in New Mexico it is the second leading cause of death. This study describes the pattern of adolescent suicide deaths in New Mexico. We conducted a retrospective review of all medical examiner autopsies for adolescent suicides (ages 20 years and younger) in New Mexico from 1990-1994. Records were reviewed for demographics and possible contributing factors such as depression, previous attempts, and alcohol and drug use. We identified 184 suicide deaths among children and adolescents ages 9-20 years for an overall rate of 12.9 per 100,000. Our rates for ages 5-9 years (0.2), 10-14 years (3.8), and 15-19 years (22.3) are over twice the U.S. rates. Suicide deaths resulted primarily from firearms (67%), hanging (16%), poisoning (6%), inhalation (4%), and other methods (7%). Method varied by ethnicity (p = .01) and gender (p = .03); males and non-Hispanic Whites were overrepresented among firearm deaths. Firearm ownership was known in 60 (48%) of the firearm deaths. Of these, 53% of the firearms belonged to a family member, 25% to the decedent, and 22% to a friend. Over one-third of decedents (41%) experienced mental disorders, primarily depressed mood and clinical depression. Previous suicide attempts were noted for 15% of the decedents. Some 50% of the decedents had alcohol or drugs present at the time of death; among American Indians/Alaska Natives, 74% had drugs or alcohol present (p = .003). Targeted interventions are needed to reduce adolescent suicide in New Mexico. We suggest raising awareness about acute and chronic contributing factors to suicide; training physicians to look for behavioral manifestations of depression; and involving physicians, teachers, and youth activity leaders in efforts to limit firearm accessibility, such as advising parents to remove firearms from their households.

In this article we try to determine if the examiner's gender affects women's perceived pain and embarrassment during emergency department pelvic examination, using a prospective comparative study in a university teaching hospital. Test subjects were taken from a convenience sample of female emergency department (ED) patients undergoing pelvic examination as part of their evaluation. 100 mm visual analog scales were used to gauge each subject's perceived pain and embarrassment. Subject age and complaint, and the examiner's gender and level of training were collected. Two-tailed Mann-Whitney or Kruskal-Wallis tests were used to test for significant differences among group median pain and embarrassment scores. One hundred and sixty-seven subjects completed the study (median age = 25 y, interquartile range 20-33 y). Seventy-seven subjects had abdominal or pelvic pain, 49 complained of vaginal bleeding, and the rest had dysuria, pregnancy, genital lesions, or other conditions. Ninety-four examiners were female and 73 were male. The mean pain scores were similar for female (33.6 mm) and male (38.8 mm) examiners. The medians were 19.5 mm and 41.0 mm respectively (difference, 21.5 mm; 95% Cl, -3.5 to 34 mm; P = 0.385). The mean embarrassment score was lower for female (19.6 mm) than for male (37.4 mm) examiners. The medians were 5.0 mm and 28.0 mm respectively (difference, 23 mm; 95% Cl, 11.5 to 40 mm; P = 0.00012). The level of examiner training did not appear to affect either score (P > 0.6). Emergency department patients perceive pelvic examination by a male examiner as more embarrassing but not more painful than examination by a woman.

Background. There have been no population-based studies estimating the prevalence of intimate partner violence (IPV) in an insured population. There is also little information on how well routinely collected health status information predicts IPV risk. Many women now obtain health care from providers who are members of a managed care organization (MCO). To justify efforts to routinely screen for IPV, it is essential to know the prevalence of IPV in this growing population and to identify correlates of IPV among female MCO members. Methods. A telephone survey with questions on health status, behavioral risk factors, preventive services use, and the Conflict Tactics Scale was completed by 2,415 female members of a New Mexico MCO. Results. Overall, 13.5% of respondents reported experiencing major verbal aggression and 6.7% reported experiencing physical aggression. Younger age, degree of sadness, and inability to handle stress, and a perception of a poorer general health status were significantly associated with major verbal aggression. Race/ethnicity, degree of sadness, and average number of drinks consumed at one sitting were significantly associated with physical aggression. Conclusions. There is a low but important annual prevalence of IPV among female members of a MCO that occurs across all variables studied. This information is needed to develop appropriate screening protocols and interventions in this population.

To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints.An out-of-hospital database for the primary transporting service in an urban area was analyzed for patients 0-20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed.There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0-11-year-olds (4.2%); 11-16-year-olds (17.5%); and 17-20-year-olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p0.0001) compared with the overall group.A substantial proportion of pediatric emergency medical services transports are for high-risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.

About a year ago, after a patient had a cardiac arrest in the waiting room, we decided to bring all of the patients waiting for care into a big open area of the emergency department (ED). It reminded me of a huge open pit mine with its bustle and unstructured space. We named it Flex, put a television in the room, and assigned a paramedic to keep an eye on things. We really had no choice; the main ED was often filled with admitted patients waiting for hospital beds that seemed to be less and less available. Some of the admitted patients would stay for days in the ED. We generally had between 15 and 20 of these patients filling our beds every day. Flex was supposed to be a place where patients could get their treatment started without having to wait for an ED bed to open up. We could order a radiograph for someone with a cough, start an IV, and give a breathing treatment. Metal chairs lined the walls of the room, which was divided into halves by a piece of temporary office wall material someone had picked up for 15 dollars. We were actually supposed to do our history and physical examination in a corner of the room—with a reclining chair and a curtain up for privacy—but it didn’t always work out that way. Sometimes the room in the corner was occupied or dirty. Then we’d try to ask a few discreet questions to the patients where they sat in a chair and maybe poke our stethoscope under a shirt to listen to lungs or a heart. Residents and faculty would often complain about the Flex area (and tried to avoid it if at all possible), but I generally supported the concept and thought we could make it work. Anyway, it seemed better than leaving the patients in the waiting room for hours. One day, I was walking into Flex to examine a man’s ankle. The chart said, “twisted ankle while dancing.” I thought it would probably be a good story, even if the medical problem were straightforward. The paramedic grabbed me as I walked by. “Doc, I’ve got a low glucose of 30 on this guy over here.” He pointed to a middle-aged man wearing a straw cowboy hat with a blue feather in the band. The man was watching Jerry Springer. The print at the bottom of the screen said, “Wife slept with son’s best friend, now she’s pregnant.” “Hmm,” I thought, “Where do they find these people?” Then turning to the paramedic, I said, “He looks pretty good— are you sure about the glucose?”

To test the hypothesis that time series analysis can provide accurate predictions of future ambulance service run volume, a prospective stochastic time series modeling study was conducted at a community-based regional ambulance service. For all requests for ambulance transport during two sequential years, the time and date, total run time, and acuity code of the run were recorded in a computer database. Time series variables were formed for ambulance service runs per hour, total run time, and acuity. Prediction models were developed from one complete year's data (1994) and included four model types: raw observations, moving average, means with moving average smoothing, and autoregressive integrated moving average. Forecasts from each model were tested against observations from the first 24 weeks of the subsequent year (1995). Each model's adequacy was tested on residuals by autocorrelation functions, integrated periodograms, linear regression, and differences among the variances. A total of 68,433 patients were seen in 1994 and 32,783 in the first 24 weeks of 1995. Large periodic variations in run volume with time of day were found (P < .001). A model based on arithmetic means of each hour of the week with 3-point moving average smoothing yielded the most accurate forecasts and explained 54.3% of the variation observed in the 1995 test series (P < .001). Time series analysis can provide powerful, accurate short-range forecasts of future ambulance service run volume. Simpler, less expensive models performed best in this study.

Objective: To evaluate the association between ambulance transports for assault and those for alcohol intoxication. Methods: A retrospective analysis of emergency medical services (EMS) calls was performed. The authors used logistic regression models to compare patients transported for alcohol intoxication with a control group of patients transported for respiratory distress (asthma or shortness of breath) with respect to whether they had been transported on a separate occasion for a chief complaint of assault. Results: Patients transported for alcohol intoxication had 9 times the risk of transport for assault as compared with the control group (OR = 9.3; 95% CI = 6.4, 13.6). The odds of transport for assault among the alcohol patients increased 17.1% with each alcohol transport (OR = 1.17; 95% CI = 1.14, 1.20) but decreased for the control group (OR = 0.34; 95% CI = 0.26, 0.44). Repeat transports for assault were more common among the alcohol patients than among the control group (OR = 3.3; 95% CI = 1.1, 11.3). The mean number of assault transports was higher among the alcohol patients than among the patients never transported for alcohol intoxication (p < 0.0001). Conclusions: Patients transported on multiple occasions for acute alcohol intoxication are at relatively high risk for assault. This risk group should be targeted for focused assault prevention interventions that include components designed to reduce incidents of repeat alcohol intoxication.

Injury prevention has been identified as a component of emergency medicine. However, involvement of emergency physicians in injury prevention has been hindered by clinical responsibilities, lack of financial support, and limited expertise in skills necessary for effective injury prevention programs. This article describes the development and content of a statewide pedestrian safety plan prepared by the Department of Emergency Medicine at the University of New Mexico. The plan included a written document, community input through focus groups, and a public information campaign. The written document included a synthesis of published literature, state-specific data, information on community interventions, and recommendations for state agencies and other groups interested in reducing pedestrian injuries. This project can be modeled at other academic EDs with an interest in injury prevention and pedestrian safety.

A study was done to prospectively compare the pain and distress of urethral mini-catheterization (MC) with the pain and distress of intravenous (IV) catheterization in women. Ten-centimeter visual analog scales were used on which the left end represented "no pain" or "no distress" and the right "the worst pain imaginable" or "extreme distress." Distress was defined to include embarrassment, anxiety, or fear. A convenience sample of 40 adult women who presented to a university emergency department and were undergoing both procedures as part of their management appraised pain and distress after IV placement and urethral MC. The mean IV pain score was 4.2 cm, whereas the mean MC score was only 2.6 cm (P = .02). The IV and MC distress score means were similar (2.3 v 2.6 cm, P = .55). These results suggest that patients perceive urethral MC as less painful than IV placement. The distress scores of these two procedures did not differ and were low in both instances.

Objective: To identify patterns of nonfatal and fatal penetrating trauma among children and adults in New Mexico using ED and medical examiner data. Methods: The authors retrospectively sampled in 5-year intervals all victims of penetrating trauma who presented to either the state Level-1 trauma center or the state medical examiner from a 16-year period (1978–1993). Rates of nonfatal and fatal firearm and stabbing injury were compared for children and adults. Results: Rates of nonfatal injury were similar (firearm, 34.3 per 100,000 person-years; stabbing, 35.1). However, rates of fatal injury were significantly different (firearm, 21.9; stabbing, 2.7; relative risk: 8.2; 95% confidence interval: 5.4, 12.5). From 1978 to 1993, nonfatal injury rates increased for children (p = 0.0043) and adults (p < 0.0001), while fatal penetrating injury remained constant. The increase in nonfatal injury in children resulted from increased firearm injury rates. In adults, both stabbing and firearm nonfatal injury rates increased. Conclusions: Nonfatal injury data suggest that nonfatal violence has increased; fatal injury data suggest that violent death rates have remained constant. Injury patterns vary by age, mechanism of trauma, and data source. These results suggest that ED and medical examiner data differ and that both are needed to guide injury prevention programs.

A prospective comparative trial was conducted to determine the effect of a physician's visual assessment of emergency patients on triage categorization and ability at triage to predict admission. The setting was a university, county, referral center and residency training site. Participants were a consecutive sample of emergency department patients presenting between the times of 0700 and 2300 hours for 5 weeks. All patients were assigned a triage category by an emergency nurse (RN) who saw the patient and by an emergency physician (EP) who had the option of performing a visual assessment. Triage categorization was compared for interobserver agreement (Kappa [kappa] statistic) and by ability to predict admission (MacNemar's test). A total of 3,949 patients was entered. The patients that physicians visually assessed were triaged by nurses as more ill (P < .001). For triage categories visualized by the EP compared with RN categorization, interobserver agreement was 59.8%, kappa = .21. For triage categories not visualized by EP compared with RN categorization, interobserver agreement was 67.9%, kappa = .45 (P < .001). Sensitivity of EPs to predict admission is as follows: all RN triage, 41.3; not seen by EP, 54.9; seen by EP, 69.3. Specificity is as follows: all RN triage, 93.7; not seen by EP, 88.5, seen by EP, 83.9. When physician visual assessment was done, agreement between physicians and nurses decreased by more than half. Physicians who included visual assessment in patient triage were less likely to agree with RN categorization. A visual assessment by the physician improved the sensitivity for predicting admission with an only small cost in specificity.

To compare the initial emergency medical services (EMS) prehospital assessment of medical and traumatic cardiopulmonary arrest in the pediatric patient with that of the Office of the Medical Investigator (OMI) and assess differences and implications for EMS training and prevention.Retrospective review of ambulance run forms with the OMI autopsy confirmations.An urban EMS system and the state Office of the Medical Investigator.Patients 15 years of age or less who were treated by prehospital personnel from November 1, 1990, to October 31, 1991, for a medical or traumatic arrest.None.Ambulance runs were reported for 2,586 pediatric patients. Of these, 42 (1.6%) had suffered arrests, with 32 (76%) medical arrests and ten (24%) traumatic arrests. Children 1 year of age or less accounted for 75% of the medical arrests, while children more than 1 year of age accounted for 80% of the traumatic arrests (p = 0.003). Overall mortality was 81%. When EMS prehospital assessments of medical and traumatic arrests were compared with autopsy reports, there was good agreement for sudden infant death syndrome (SIDS) (kappa = 0.70), but poor agreement for child abuse (kappa = 0.37).The authors found good agreement between EMS prehospital assessments and autopsy diagnoses for identifying pediatric SIDS, but child abuse was not well identified prior to autopsy.