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On December 2, 2015, a terror attack in the city of San Bernardino, California killed 14 Americans and injured 22 in the deadliest attack on U.S. soil since September 11, 2001. Although emergency personnel and law enforcement officials frequently deal with multi-casualty incidents (MCIs), what occurred that day required an unprecedented response. Most of the severely injured victims were transported to either Loma Linda University Medical Center (LLUMC) or Arrowhead Regional Medical Center (ARMC). These two hospitals operate two designated trauma centers in the region and played crucial roles during the massive response that followed this attack. In an effort to shed a light on our response to others, we provide an account of how these two teaching hospitals prepared for and coordinated the medical care of these victims. In general, both centers were able to quickly mobilize large number of staff and resources. Prior disaster drills proved to be invaluable. Both centers witnessed excellent teamwork and coordination involving first responders, law enforcement, administration, and medical personnel from multiple specialty services. Those of us working that day felt safe and protected. Although we did identify areas we could have improved upon, including patchy communication and crowd-control, they were minor in nature and did not affect patient care. MCIs pose major challenges to emergency departments and trauma centers across the country. Responding to such incidents requires an ever-evolving approach as no two incidents will present exactly alike. It is our hope that this article will foster discussion and lead to improvements in management of future MCIs.

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Background Women in medicine continue to experience disparities in earnings, promotion, and leadership roles. There are few guidelines in place defining organization-level factors that promote a supportive workplace environment beneficial to women in emergency medicine (EM). We assembled a working group with the goal of developing specific and feasible recommendations to support women's professional development in both community and academic EM settings. Methods We formed a working group from the leadership of two EM women's organizations, the Academy of Women in Academic Emergency Medicine (AWAEM) and the American Association of Women Emergency Physicians (AAWEP). Through a literature search and discussion, working group members identified four domains where organizational policies and practices supportive of women were needed: 1) global approaches to supporting the recruitment, retention, and advancement of women in EM; 2) recruitment, hiring, and compensation of women emergency physicians; 3) supporting development and advancement of women in EM; and 4) physician health and wellness (in the context of pregnancy, childbirth, and maternity leave). Within each of these domains, the working group created an initial set of specific recommendations. The working group then recruited a stakeholder group of EM physician leaders across the country, selecting for diversity in practice setting, geographic location, age, race, and gender. Stakeholders were asked to score and provide feedback on each of the recommendations. Specific recommendations were retained by the working group if they achieved high rates of approval from the stakeholder group for importance and perceived feasibility. Those with >80% agreement on importance and >50% agreement on feasibility were retained. Finally, recommendations were posted in an open online forum (blog) and invited public commentary. Results An initial set of 29 potential recommendations was created by the working group. After stakeholder voting and feedback, 16 final recommendations were retained. Recommendations were refined through qualitative comments from stakeholders and blog respondents. Conclusions Using a consensus building process that included male and female stakeholders from both academic and community EM settings, we developed recommendations for organizations to implement to create a workplace environment supportive of women in EM that were perceived as acceptable and feasible. This process may serve as a model for other medical specialties to establish clear, discrete organization-level practices aimed at supporting women physicians.

The Society for Academic Emergency Medicine (SAEM) convened a taskforce to study issues pertaining to women in academic emergency medicine (EM). The charge to the Taskforce was to "Create a document for the SAEM Board of Directors that defines and describes the unique recruitment, retention, and advancement needs for women in academic emergency medicine." To this end, the Taskforce and authors reviewed the literature to highlight key data points in understanding this issue and made recommendations for individuals at four levels of leadership and accountability: leadership of national EM organizations, medical school deans, department chairs, and individual women faculty members. The broad range of individuals targeted for recommendations reflects the interdependent and shared responsibility required to address changes in the culture of academic EM. The following method was used to determine the recommendations: 1) Taskforce members discussed career barriers and potential solutions that could improve the recruitment, retention, and advancement of women in academic EM; 2) the authors reviewed recommendations in the literature by national consensus groups and experts in the field to validate the recommendations of Taskforce members and the authors; and 3) final recommendations were sent to all Taskforce members to obtain and incorporate additional comments and ensure a consensus. This article contains those recommendations and cites the relevant literature addressing this topic.

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

Interest in international emergency medicine (EM) has grown steadily over the last ten years. This growth has been fueled by increased demand for emergency services abroad and the proliferation of emergency physicians (EPs) working in international relief and development. As a response, several academic EM programs have developed international EM fellowships for the purpose of providing formal training to EPs interested in international health. Although there have been preliminary articles describing fellowship curricula, to the authors' knowledge no recommendations have been proposed by national consensus that suggest emphasis or required components of a fellowship program. Therefore, a group of EPs interested in fellowship training convened for the purpose of developing goals and objectives for a postgraduate training program in international EM. To that end, this article proposes guidelines for a fellowship training program for international EM.

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

Emergency medicine is growing rapidly as a specialty and is beginning to be recognized as an essential component of medicine in China. Traditional Chinese medicine and modern technology exist together. A description of the US authors' experience as consultants at a new emergency department and in establishing an emergency medicine residency program in Hangzhou, China is provided. A total of 7 months were spent in the observation, identification, and development of a basic framework of emergency care at a new hospital. The practice of emergency medicine in China was researched by direct observation at several Chinese cities and by literature review. China is taking the parts of the Western system it can use and implementing its own methods in the overall practice of emergency medicine.

Objectives: Despite the influx of female physicians in academic medicine departments, there are a small number of women in faculty and departmental leadership positions in emergency medicine (EM). The objective of this study was to determine if the gender of the chairperson of an academic EM department is associated with the gender of the residency program director (RPD) and gender proportion of its faculty. Methods: This was a retrospective analysis of 133 academic EM departments using the Society for Academic Emergency Medicine online residency catalog, program Web site, or e-mail. Main outcome measures were proportion of female EM faculty and gender of the RPD. Results: Data were available for 133 academic departments. Women chaired 7.5% (n= 10) of departments and comprised 22.3% of all faculty and 15.0% (n= 20) of RPD positions. EM departments that were chaired by women had a significantly higher percentage of female faculty compared with those led by men (31% vs. 22%; p = 0.01). Similarly, departments that were chaired by women had a significantly higher proportion of female RPDs compared with those chaired by men (50% vs. 12%; p < 0.01). Compared with departments chaired by men, the RPD was 5.0 times (95% confidence interval = 1.9 to 27.8; p < 0.01) more likely to be a woman if the chairperson was also a woman. Conclusions: An academic EM department was more likely to have a higher proportion of female faculty and a female RPD when the department chairperson was female.

Emergency physicians (EPs) are increasingly participating in international medicine in regions that are chronically medically underserved. In August 1994, a ten-member emergency medicine team from the Loma Linda University School of Medicine staffed a 70-bed bush hospital in the primitive highlands of Papua New Guinea, providing both outpatient and inpatient medical care. Typhoid fever, malaria, polio, and numerous other infectious diseases were encountered. Rampant local tribal warfare resulted in regular penetrating injuries from arrows, spears, and machetes. The expedition was judged highly successful, in that 1) substantial medical service was provided to tribespeople accustomed to minimal care, 2) education was provided to local health care providers, and 3) team participants became adept at managing medical conditions uncommon in industrialized societies, and gained valuable ethical and utilitarian perspectives regarding health care delivery in underserved areas. In this article the objectives, organization, and experiences of the team members are described. This information may encourage other EPs to participate in medical expeditions to the developing world, and to provide general principles to assist in their organization and implementation.

Objective To evaluate the safety profile of ketamine when used to facilitate surgical procedures in the less controlled setting of developing world, rural hospitals. Methods A survey addressing clinical experience with ketamine in the developing world was administered to a convenience sample of missionary physicians. Descriptive statistics are reported. Results Of the 172 surveyed physicians, 122 (71%) responded; 55 reported experience with ketamine. These physicians estimated a total of 12,844 administrations. The format of one procedural physician and a second trained anesthesiologist/anesthetist was unavailable in the practice of 59% of the responding physicians, and 34% routinely performed procedures while simultaneously supervising ketamine administration and monitoring its clinical effect. Pulse oximetry was used "often" or "always" by only 10% of the physicians. Cardiac monitoring and intermittent vital signs were used in only 19% and 45%, respectively. One unexplained pediatric death occurred during an unmonitored, unobserved ward recovery. An adult suffered cardiac arrest after a failed intubation attempt. Seventeen other complications possibly related to ketamine were apnea (n = 10), laryngospasm (n = 6), and aspiration (n = 1), all of which were transient and without sequelae. Physicians believed that recovery hallucinations and agitation were frequent in adults and unusual in children. Conclusions Death and other serious complications were rare in this survey reporting > 12,000 estimated ketamine administrations in the developing world. Although the limitations of survey data are recognized, the margin of safety with ketamine appears to be high, even when administered by non-anesthesiologists in settings lacking basic mechanical monitoring. These findings have important implications for the use of ketamine outside the controlled operating room environment in developed countries.

Objective. It is frequently taught that lumbar puncture is a mandatory procedure in many or all children who have fever and a seizure, because the convulsion may represent the sole manifestation of bacterial meningitis. We attempted to determine the incidence of this occult manifestation of meningitis. Design. Retrospective case series. Setting and patients. 503 consecutive cases of meningitis in children aged 2 months to 15 years seen at two referral hospitals during a 20-year period. Main outcome measures. Signs and symptoms of meningitis in patients having associated seizures. Results. Meningitis was associated with seizures in 115 cases (23%), and 105 of these children were either obtunded or comatose at their first visit with a physician after the seizure. The remaining 10 had relatively normal levels of consciousness and either were believed to have viral meningitis (2) or possessed straightforward indications for lumbar puncture: nuchal rigidity (6), prolonged focal seizure (1), or multiple seizures and a petechial rash (1). No cases of occult bacterial meningitis were found. Conclusion. In our review of 503 consecutive children with meningitis, none were noted to have bacterial meningitis manifesting solely as a simple seizure. We suspect that this previously described entity is either extremely rare or nonexistent. Commonly taught decision rules requiring lumbar puncture in children with fever and a seizure appear to be unnecessarily restrictive.

Patients who present to the emergency department (ED) with return of spontaneous circulation after cardiac arrest generally have poor outcomes. Guidelines for treatment can be complicated and difficult to implement. This study examined the feasibility of implementing a care bundle including therapeutic hypothermia (TH) and early hemodynamic optimization for comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest. The study included patients over a 2-year period in the ED and intensive care unit of an academic tertiary-care medical center. The first year (prebundle) provided a historical control, followed by a prospective observational period of bundle implementation during the second year. The bundle elements included (a) TH initiated; (b) central venous pressure/central venous oxygen saturation monitoring in 2 h; (c) target temperature in 4 h; (d) central venous pressure greater than 12 mmHg in 6 h; (e) MAP greater than 65 mmHg in 6 h; (f) central venous oxygen saturation greater than 70% in 6 h; (g) TH maintained for 24 h; and (h) decreasing lactate in 24 h. Fifty-five patients were enrolled, 26 patients in the prebundle phase and 29 patients in the bundle phase. Seventy-seven percent of bundle elements were completed during the bundle phase. In-hospital mortality in bundle compared with prebundle patients was 55.2% vs. 69.2% (P = 0.29). In the bundle patients, those patients who received all elements of the care bundle had mortality 33.3% compared with 60.9% in those receiving some of the bundle elements (P = 0.22). Bundle patients tended to achieve good neurologic outcome compared with prebundle patients, Cerebral Performance Category 1 or 2 in 31 vs. 12% patients, respectively (P = 0.08). Our study demonstrated that a post-cardiac arrest care bundle that incorporates TH and early hemodynamic optimization can be implemented in the ED and intensive care unit collaboratively and can achieve similar clinical benefits compared with those observed in previous clinical trials.

Objectives: To present suggestions on planning for development of emergency medicine (EM) and out-of-hospital care in countries that are in an early phase of this process, and to provide basic background information for planners not already fa- miliar with EM. Methods: The techniques and pro- grams used by the authors and others in assisting in EM development in other countries to date are de- scribed. Conclusions: Some aspects of EM system de- velopment have applicability to most countries, but other aspects must be decided by planners based on country-specific factors. Because of the very recent initiation of many EM system development efforts in other countries, to the authors' knowledge there have not yet been extensive evaluative reports of the effi- cacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts. Key words: emergency med- icine development; international emergency medi- cine; system development; EMS systems. ACA- DEMIC EMERGENCY MEDICINE 2000; 7:911-917

Medical resources routinely used for intravenous hydration and resuscitation of critically ill patients may be limited in remote regions of the world. When faced with these shortages, physicians have had to improvise with the available resources, or simply do without. We report the successful use of coconut water as a short-term intravenous hydration fluid for a Solomon Island patient, a laboratory analysis of the local coconuts, and a review of previously documented intravenous coconut use.

Many developing countries are experiencing a greater need for prehospital systems because of urbanization and changing population demographics, leading to greater death rates from trauma and cardiac illnesses. While emergency medical services (EMS) systems may take a variety of forms, they usually contain some system components similar to those found in the United States. In evaluating EMS abroad, it may be useful to compare the developing system type to one of five models of EMS delivery: hospital-based, municipal, private, volunteer, and complex. Using community-based services and available health providers can enable a developing system to function within a primary health network without overtaxing scarce resources. Developing such an approach can lead to creative and effective solutions for prehospital care in developing countries.

By Gregory A. Baldwin. Baltimore, MD: Lippincott Williams & Wilkins, 2000, 736 pp, $39.95 (softcover).

Study objectives The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established. Methods The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included. Results A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles). Conclusion There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.

The off-service rotation in Neurosurgery is included in some programs training emergency medicine residents. It may also be offered as an elective. The experience on this rotation can lack opportunity and educational content if structured guidance is not available. We have addressed this problem by developing a written curricula containing subject content listing, objectives, and references for the Neurosurgery off-service rotation for emergency medicine residents. This is the 23rd in a series of objectives for off-service rotations for emergency medicine residents.

Study objective Attrition rates in emergency medicine have been reported as high as 25% in 10 years. The number of women entering emergency medicine has been increasing, as has the number of female medical school graduates. No studies have identified factors that increase female emergency physician career satisfaction. We assess career satisfaction in women emergency physicians in the American College of Emergency Physicians (ACEP) and identify factors associated with career satisfaction. Methods The survey questionnaire was developed by querying 3 groups: (1) ACEP women in the American Association of Women Emergency Physicians, the (2) Society for Academic Emergency Medicine Mentoring Women Interest Group, and (3) nonaffiliated female emergency physicians. Their responses were categorized into 6 main areas: schedule, relationships with colleagues, administrative support and mentoring, patient/work-related issues, career advancement opportunities, and financial. The study cohort for the survey included all female members of ACEP with a known e-mail address. All contact with survey recipients was exclusively through the e-mail that contained a uniform resource locator link to the survey itself. Results Two thousand five hundred two ACEP female members were sent the uniform resource locator link. The Web survey was accessed a total of 1,851 times, with a total of 1,380 surveys completed, an overall response rate of 56%. Most women were satisfied with their career as an emergency physician, 492 (35.5%) very satisfied, 610 (44.0%) satisfied, 154 (11.1%) neutral, 99 (7.1%) not satisfied, and 31 (2.3%) very unsatisfied. Significant factors for career satisfaction included amount of recognition at work, career advancement, schedule flexibility, and the fairness of financial compensation. Workplace factors associated with high satisfaction included academic practice setting and sex–equal opportunity for advancement and sex–equal financial compensation. Conclusion Most of the ACEP female physicians surveyed were satisfied with their career choice of emergency medicine. Opportunities for career advancement, fairness in financial compensation, and schedule flexibility were key factors in career satisfaction among female emergency physicians.