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To evaluate the daily output measures of the emergency department (ED) in association with seasonality and the day of the week. A retrospective cohort of ED visits to tertiary medical centers between 2016 and 2020. The research unit was each day during the study period. The independent variables were season and day of the week. The dependent variables were ED visits, admission and dropout rates, and duration of ED discharge. The comparison of means was evaluated using ANOVA. Statistical significance was set at P.05. There were 1826 days, 792 thousand visits, 58% were female. Admission rate 28%, duration to discharge 3.8 h, dropout rate 2%. The average daily visits by season ranged from 101% of the overall average in autumn to 97% in spring. Average daily visits by day of the week were significantly different, with the highest on Sunday (Israel's first working day of the week), 124% of the overall daily average, and the lowest on Saturday (weekly day off) with 70%. Saturdays had the highest admission rate of 30% and 28% of the overall rate. There was a moderate dependency between the ED duration and discharge, with a dropout rate of r2 = 0.19. The average daily visits were not affected by season but differed considerably by day of the week. Admission rates varied slightly by season but were similar by day of the week apart from Saturdays. This may be attributable to the case mix on Saturdays or less restriction to admit when the number of visits is low. We recommended each Emergency Department to evaluate its daily output measures dependency with seasonality and day of the week for operational optimization.

The growing popularity of E-bikes and P-scooters has led to their increasing involvement in injuries. This study sought to evaluate the impact of drug and alcohol consumption on hospitalization rates for electric-vehicle-associated injuries. A retrospective cross-sectional study design was used, including patients evacuated to the emergency department (ED) of a tertiary medical center in 2014–2020 for injuries sustained while riding E-bikes or P-scooters. Data on clinical characteristics were collected from the medical files, including pre-accident usage of alcohol or drugs. Of the 1234 patients (75.7% male) who met the inclusion criteria, 90 (7.3%) were hospitalized. The mean (SD) number of admission days was 5.44 (±0.12). Alcohol consumption was associated with 2.2% of injuries and drug use with 0.6%. Patients who rode under the influence of alcohol were significantly more likely to be hospitalized than discharged (6.7% vs. 1.8%, χ2 (2) =19.25, p < 0.001); the odds ratio was 14.1. A similar association with hospitalization was found for drug use (χ2 (2) = 7.83, p = 0.02). Riding an E-bike or P-scooter under the influence of alcohol or drugs increases the probability of severe injury requiring hospital admission. These results should prompt the relevant authorities to initiate effective legislation of alcohol and drug use.

Background Electric bikes (E-bikes) and powered scooters (P-scooters) have become increasingly popular modes of public transportation, but they have been associated with injuries of all kinds, including dental trauma. Helmet use is promoted as a means of reducing injuries in accidents involving motorized and unmotorized vehicles. The aim of the study was to evaluate the impact of helmet use on the number and severity of oral and maxillofacial injuries caused by E-bikes and P-scooters. Methods A retrospective cross-sectional study design was used. The cohort included all patients referred to the emergency department of a tertiary medical center in 2014–2020 with oral and maxillofacial injuries involving E-bikes or P-scooters. Data were collected from the medical files on demographics, types of injuries, circumstances of occurrence, work-up, treatment, and outcome. Use of a helmet was recorded in each case. Results Of the total 1417 patients referred to the emergency department for E-bike and P-scooter-related trauma, 62 had oral and maxillofacial injuries, including 57 riders and 5 pedestrians. All had hard- or soft-tissue injuries; 20 (32.2%) had head injuries and 22 (35.5%) had dentoalveolar injuries. Eleven riders had worn a helmet at the time of injury (17.7%). Helmet use was associated with time of injury (weekday/weekend, daytime/night-time), type of motorized vehicle (E-bike or P-scooter), head injury, and number of bone fractures. Head injuries occurred more often on the weekend (57.9%) than during the week (20.9%) and were more likely to occur in riders who were not protected by a helmet (37.3% vs 18.2%). Patients who used helmets also had a lower rate of fractured bones (18.2%) and dentoalveolar injuries (23.7%) than patients who did not (68.8 and 37.3%, respectively). Interestingly, helmet use had no protective effect on soft-tissue injuries. Conclusions Helmet use by E-bike and P-scooter riders decreased the probability of head injury and of hard tissue and dentoalveolar injuries. These results may provide guidance for effective legislation and regulation of helmet use and improved treatment protocols for general and dental physicians.

Background and Aims. Plasma levels of soluble triggering receptor expressed on myeloid cells (sTREM-1) reflect innate immune cell activation. We sought to evaluate sTREM-1 levels in patients with acute coronary syndrome (ACS) and their predictive value for disease severity and outcome. Methods. Plasma sTREM-1 levels were prospectively measured by ELISA in 121 consecutive patients with new-onset (≤24 h) chest pain at arrival to the emergency department (ED) and 73 healthy controls. Secondary endpoints were the association of plasma levels of sTREM-1 with day 30 and month 6 major adverse cardiovascular events (MACE) defined as death, ACS, stroke, and need for coronary revascularization, as well as with CAD severity. The primary endpoint of the study was the association of plasma sTREM-1 level at the time of admission to the ED with a diagnosis of ACS at day 30. Results. Fifty-nine patients (48.7%) were diagnosed with ACS and 62 (51.3%) with nonspecific chest pain (NSCP). Median plasma sTREM-1 level at admission was significantly higher in the ACS group than the NSCP group and the control group ( 539.4 ± 330.3 pg/ml vs. 432.5 ± 196.4 pg/ml vs. 230.1 ± 85.5 pg/ml, respectively; P < 0.001 ) and positively correlated with the number of stenosed/occluded coronary arteries on angiography ( P < 0.001 ). On logistic regression analysis, higher sTREM-1 levels predicted definite ACS vs. NSCP determined on day 30 (OR 1.29, 95% CI 1.07-1.54, P = 0.01 ) as well as with recurrent ACS ( P = 0.04 ) and stroke ( P = 0.02 ) at 6 months. Conclusions. Plasma sTREM-1 levels are significantly elevated in patients with ACS and might serve as a biomarker differentiating ACS from NSCP in the ED as well as an inflammatory biomarker for coronary artery disease severity and outcome.

Background: Daboia (Vipera) palaestinae envenomation (DPE) is the most common snake-bite in Israel. Current practice has supported antivenom treatment, including those with local or systemi...

Author(s): Drescher, Michael J.; Fried, Jeremy; Brass, Ryan; Medoro, Amanda; Murphy, Timothy; Delgado, Joao | Abstract: Introduction: Computerized decision support decreases the number of computed tomography pulmonary angiograms (CTPA) for pulmonary embolism (PE) ordered in emergency departments, but it is not always well accepted by emergency physicians. We studied a department-endorsed, evidence-based clinical protocol that included the PE rule-out criteria (PERC) rule, multi-modal education using principles of knowledge translation (KT), and clinical decision support embedded in our order entry system, to decrease the number of unnecessary CTPA ordered. Methods: We performed a historically controlled observational before-after study for one year pre- and post-implementation of a departmentally-endorsed protocol. We included patients g 18 in whom providers suspected PE and who did not have a contraindication to CTPA. Providers entered clinical information into a diagnostic pathway via computerized order entry. Prior to protocol implementation, we provided education to ordering providers. The primary outcome measure was the number of CTPA ordered per 1,000 visits one year before vs. after implementation. Results: CTPA declined from 1,033 scans for 98,028 annual visits (10.53 per 1,000 patient visits (95% CI [9.9-11.2]) to 892 scans for 101,172 annual visits (8.81 per 1,000 patient visits (95% CI [8.3-9.4]) pl0.001. The absolute reduction in PACT ordered was 1.72 per 1,000 visits (a 16% reduction). Patient characteristics were similar for both periods.Conclusion: Knowledge translation clinical decision support using the PERC rule significantly reduced the number of CTPA ordered.

Background Medical treatment of hunger-strike patients, especially those in incarceration facilities, may pose clinical and treatment challenges for the treating physicians. Objective The aim of our study is to describe the epidemiology and clinical and laboratory characteristics of hunger-strike prisoners presenting to the emergency department (ED) and to describe etiologies of hospitalization and complications among this group. Method We retrospectively examined clinical and laboratory manifestations of 50 hunger-strike prisoners who were referred for evaluation to the ED after a longstanding fast. Results After a mean of 38 (28-44) days of a hunger strike, the most common complaints were chest pain and abdominal pain (14/60 [23.3%], 13/60 [21.6%], respectively). Mean weight loss percentage was 18.5%, and most patients were bradycardic (25/40 [62.5%]), and some hypothermic (16/50, [32%]). We describe several laboratory disturbances observed in these patients; leukopenia was the most common hematologic manifestation (31/50 [62%]), and a prolonged international normalized ratio was observed in 12/29 (41.3%) patients. We hospitalized 12% of the patients; the most common hospitalization cause was bradycardia (3/6 [50%]). Conclusions Our study found that the most common clinical symptom was chest pain, which has not been previously reported among hunger strikers. We observed a substantial number of laboratory disturbances due to muscle wasting and protein loss and due to presumed vitamin and micronutrient deficiencies. We suggest monitoring electrocardiograms for heart rate, blood count, chemistry, coagulation tests, and vitamin levels.

Background Despite evidence-based recommended weight-based (WB) dosing of diltiazem for the initial treatment of atrial fibrillation (AF) with rapid ventricular response (RVR), many providers utilize lower initial doses of diltiazem. Objective We sought to determine whether a low, standard dose of diltiazem is noninferior to WB diltiazem as an initial bolus dose in the treatment of AF with RVR. Methods This retrospective review included patients who presented to the emergency department (ED) of an urban, academic tertiary medical center experiencing AF with RVR from November 2010 to August 2014. Adult patients were categorized by the dose of diltiazem received; 10 mg standard dose or 0.2−0.3 mg/kg WB dose. The primary outcome of successful treatment was defined as a composite of the following parameters 15 min after the initial bolus dose: heart rate (HR) Results Four hundred and fifty-six patients who received diltiazem were included for study evaluation (standard dose: n = 255 patients, WB: n = 201 patients). Baseline characteristics, medical history, and medication use before ED presentation were similar between the groups. Significant differences at baseline between the groups included weight and HR at presentation. The primary outcome of successful treatment was attained in 60.8% of the standard dose patients and 68.7% of the WB patients (p = 0.082). Conclusions In patients presenting to the ED, we found that standard dose diltiazem was noninferior to WB dosing in the initial treatment of AF with RVR.

Introduction: A family history of appendicitis has been reported to increase the likelihood of thediagnosis in children and in a retrospective study of adults. We compare positive family history with thediagnosis of acute appendicitis in a prospective sample of adults. Methods: We conducted a prospective observational study of a convenience sample of 428 patients.We compared patients with surgically proven appendicitis to a group without appendicitis. The latterwere further grouped by their presenting symptoms: those presenting with a chief complaint ofabdominal pain and those with other chief complaints. Participants answered questions regarding theirfamily history of appendicitis. Family history was then compared for the appendicitis group versus thenonappendicitis group as a whole, and then versus the subgroup of patients without appendicitis butwith abdominal pain. The primary analysis was a v2 test of proportions and the calculation of odds ratio(OR) for the relationship between final diagnosis of appendicitis and family history. Results: Of 428 patients enrolled, 116 had appendicitis. Of those with other diagnoses, 158 hadabdominal pain and 154 had other complaints. Of all patients with appendicitis, 37.9% (confidence interval [CI]=29.1–46.8) had positive family history. Of those without appendicitis, 23.7% (CI=19.0–28.4) had positive family history. In the subgroup without appendicitis but with abdominal pain, 25.9%(CI=19.1–32.8) had positive family history. Both comparisons were significant (P=0.003; OR=1.97;95% CI=1.2–3.1; and P=0.034; OR=1.74; 95% CI=1.04–2.9, respectively). By multivariate logisticregression analysis across the full sample, family history was a significant independent predictor (P=0.011; OR = 1.883) of appendicitis. Conclusion: Adults presenting to the emergency department with a known family history ofappendicitis are more likely to have this disease than those without. [West J Emerg Med.2012;13(6):468–471.]

Study Objectives Time counts in thrombolytic therapy for stroke. An international normalized ratio (INR) greater than 1.7 may preclude its use. We studied whether the use of point-of-care testing (POCT) for INR in the emergency department (ED) may substitute for the same test done in the central hospital laboratory, thereby reducing time to treatment. Methods We performed a prospective observational study comparing a POCT analysis of INR (i-STAT-1; Abbott Inc, Abbott Park, Ill) with a simultaneously drawn sample sent to the central laboratory. We tested a convenience sample of adult patients taking warfarin who presented to the ED of a tertiary teaching hospital. Results Thirty-two patients were enrolled. A receiver operator curve analysis was performed. Sensitivity and specificity were calculated for laboratory INR cutoff of 1.7. The area under the curve was 0.979 (95% confidence interval [CI], 0.843-0.991). When POCT INR was 2.1, the sensitivity for laboratory INR being higher than 1.7 was 100% (CI, 62.9%-100.0%), and the specificity was 90.5 (CI, 69.6-98.5). When POCT INR was 1.8, the specificity for laboratory INR being lower than 1.7 was 100% (CI, 83.7%-100%), and the sensitivity was 62.5% (CI, 24.7%-91.0%). The regression coefficient (r) value was 0.9648. Conclusion Correlation of POCT INR with that of the central laboratory and receiver operator curve characteristics are excellent. In general, POCT INR is about 0.3 higher than the laboratory INR. This is not generally of clinical importance, but when using cutoff of 1.7 (central laboratory), it may be. We describe a 3-tiered system for use of POCT INR in determining use of tissue-type plasminogen activator.

Objective In 2003, we published a study on the Israeli workforce in emergency medicine (EM). We repeated the study in 2012 to assess changes in the workforce that have occurred in the interval decade. Methods This is an observational cross-sectional study of the physician workforce in EM in Israel in 2012. An online survey was sent to the ED medical directors of all general hospitals in Israel querying the numbers of physicians working in the ED, as well as the specialty and level of training of those manning the ED at various times during the day. The workforce in 2012 was compared to that of 2003. Results Twenty-four of 28 (86 %) EDs responded. Certified EM specialists have increased from 59 to 164 since 2003. Disparities continue regarding their presence in the ED. Most EM specialists are scheduled during the day whereas they are virtually absent during the night. A total of 58 EM specialists were scheduled countrywide for the weekday day shift and only one overnight. The preponderance of EM specialists working during the day and the large number of supervised and unsupervised residents working at night has not changed substantially since 2003. Eleven departments reported having an EM specialist present during the evenings whereas in 2003, only two departments reported so. Conclusion Since 2003, there are more certified EM specialists and more specialist coverage in the ED into the evening hours. Most ED providers are still not emergency physicians, and there is still a preponderance of EM specialist coverage during the day and a lack thereof overnight.

UNLABELLED Aortic dissection (AD) is the most common acute aortic condition requiring urgent surgery. AD, if not diagnosed in the emergency department (ED), is frequently fatal. AD is a difficult antemortem diagnosis. OBJECTIVES To determine if acute AD is associated with an elevation of fibrin degradation products, D-dimers. METHODS This was a retrospective chart review of patients diagnosed as having AD in the ED in whom a D-dimer determination was obtained in the ED, prior to any therapeutic intervention. The study was conducted in an urban Level I trauma center between October 1996 and September 2000. Exclusion criteria were referred patients with known diagnosis of AD. The D-dimer assay used was the semiquantitative latex agglutination assay, with a normal range up to 0.5 micro g/mL. RESULTS One hundred fifty-six patients were diagnosed as having AD in the ED. Seven patients had a D-dimer assay during their workup. All seven had a positive test. CONCLUSIONS All seven patients with an AD who had D-dimer assays performed in the ED had positive results by latex agglutination.

OBJECTIVE Emergency medicine practitioners (EMPs) often provide 'medical clearance' before evaluation by a psychiatry practitioner (PP). We set out to determine the level of agreement between EMP impression and disposition as determined by PPs. PATIENTS AND METHODS This was a prospective observational study in an urban tertiary teaching hospital emergency department. We collected data from February to April 2011. We used a convenience sample of patient encounters evaluated by EMPs and subsequent referral for psychiatric evaluation. We asked EMPs whether they thought the patients would be admitted or discharged following psychiatric evaluation, and if discharged, whether to outpatient psychiatric follow-up or to no follow-up. EMPs were asked to base their opinion upon their general impression following their brief medical evaluation. They were not given guidelines on which to base their decision. The EMPs were blind to PP decisions. The κ-statistic was used to calculate agreement between the EMP's impression and disposition decision by the PP. We excluded patients who were acutely intoxicated, in police custody, or lived in an extended care facility. RESULTS We included 156 patient encounters over the study period and had complete data for 152 encounters. Of these, 86 (55%) were admitted, 46 (30%) were discharged with no specific psychiatric follow-up, and 20 (13%) were discharged with a follow-up plan. EMPs predicted the exact disposition in 77/152 (51%) cases (κ=0.264, 95% confidence interval 0.77-0.333). Agreement was higher for admitted patients, with EMPs predicting inpatient admission for 57/86 (66%) of these patients. Other factors associated with higher agreement scores were years in emergency medicine practice by the EMP and suicidal ideation by the patient. CONCLUSION EMPs did not reliably predict psychiatric disposition decisions based on clinical 'gestalt'. Future research will focus on clinical guidelines to help EMPs better independently assess need for emergency psychiatric services.

As the number of patients at home with indwelling central venous catheters increases, more complications from their use will present to the emergency department. We report a case of pulmonary venous air embolism after a patient inadvertently severed the distal few centimeters of an indwelling central venous catheter.

[Drescher MJ. The conservation of matter. Ann Emerg Med . January 2002;39:91-93.]

Background.— Religious fasting is associated with headache. This has been documented as “Yom Kippur headache” and “first of Ramadan headache.” Etoricoxib, a Cox-2 inhibitor with a 22-hour half-life, has been shown effective in preventing fasting headache when taken just prior to the 25-hour Yom Kippur fast. We hypothesized that etoricoxib would also be effective in preventing headache during Ramadan, despite the different characteristics of the fast. Methods.— We performed a double-blind randomized prospective crossover trial of etoricoxib 90 mg vs placebo, taken just prior to the onset of fasting, during the first 2 weeks of Ramadan 2010. Healthy adults aged 18-65 years were enrolled. Demographics, headache history and a daily post-fast survey were collected. We compared incidence, time of onset, and intensity of headache on each day and side effects in control and treatment groups. Results.— We enrolled 222 patients and 189 completed the post-fast questionnaire (87%). Etoricoxib reduced the incidence of “first of Ramadan” headache by 54% (46% in placebo group [n = 92] vs 21% [n = 96] in etoricoxib group) (P

(Headache 2010;50:1328-1334) Background.— Religious fasting is associated with headache. This has been documented as “Yom Kippur Headache” and “First-of-Ramadan Headache.” Rofecoxib (Vioxx®), a cyclooxygenase-2 (Cox-2) inhibitor with a 17-hour half-life, has been shown to be effective in preventing fasting headache when taken just prior to the 25-hour Yom Kippur fast. Unfortunately for fasters rofecoxib is no longer available. We hypothesized that etoricoxib, another Cox-2 inhibitor with a longer half-life, would also be effective in preventing fasting headache. Methods.— We performed a double-blind randomized prospective trial of etoricoxib 120 mg vs placebo, taken just prior to the onset of fasting, Yom Kippur 2008. Healthy adults aged 18-65 years were enrolled from the community. Subjects completed a demographic data form and questions regarding headache history and a post-fast survey on headache during the fast. We compared incidence, time of onset and intensity of headache, general ease of fasting, and side effects in control and treatment groups. Results.— We enrolled 211 patients and 195 completed the post-fast questionnaire (92%). Of those subjects receiving etoricoxib (n = 99), 36 or 36.4% vs 65 or 67.7% of the placebo group (n = 96) developed any headache during the fast (P

Introduction.—Religious fasting is associated with headache. This has been documented as “Yom Kippur Headache” and “First of Ramadan Headache.” The Cox2 inhibitor, rofecoxib, has been reported effective in preventing perimenstrual migraine and in preventing recurrence of migraine. Given its 17 hour half-life, we undertook this study to see whether 50 mg rofecoxib taken just prior to the 25 hour Yom Kippur fast would be effective in preventing headache. Methods.—We performed a double-blind randomized prospective trial of rofecoxib 50 mg versus placebo, taken just prior to the onset of fasting, Yom Kippur 2004. Healthy adults aged 18 to 65 were enrolled from the community and from hospital staff. Subjects completed a demographic data form and questions regarding headache history and a post-fast survey on headache during the fast, headache intensity, general ease of fasting, and side effects. Results.—We sent out 170 forms of which 105 were completed and returned. Of those subjects receiving rofecoxib (n = 53), 10 or 18.9% versus 34 or 65.4% of the placebo group (n = 52) had headache at some point during the fast (P < .0001). Severity of headache in the treatment group was significantly less for the treatment group (3.45 vs 6.29 on a visual analog scale of 10 (P= .009)). None of those receiving rofecoxib reported a “more difficult than usual fast” whereas the distribution of difficult to easy fast among the placebo group was more even. Conclusion.—Rofecoxib 50 mg taken prior to a 25-hour ritual fast prevents and attenuates fasting headache.

Emergency Medicine (EM) was officially recognized as a specialty in Israel in 1999. In 2003 the first nine Israeli trained emergency physicians (EPs) were certified. This survey was undertaken to assess current staffing of Emergency Departments (ED) in Israel and to attempt to estimate future staffing needs for EPs. A survey was sent to all ED directors at general hospitals in Israel. We asked questions relating to staffing by number of physicians, type and level of training, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Twenty-four of 25 (96%) EDs responded. There were 59 EM specialists registered in Israel; there were 37 EM residents. EDs reported a total of 1,872,500 visits annually. Emergency care is otherwise given by specialists and residents in other fields, and non-specialist physicians. At large hospitals there is an average of 2.5 EM specialists during daytime hours, and another four specialists of other types on duty. During the night in large hospitals, there is an average of

Emergency physicians frequently encounter patients whose medical conditions represent a risk of loss of control while driving, e.g., epilepsy and diabetes. In certain states, physicians are under a legal obligation to report such drivers to the motor vehicular authorities. To determine the uniformity of legislated reporting requirements for physicians caring for patients whose medical conditions represent an automotive hazard, we conducted a survey of Department of Motor Vehicles (DMV) legal departments of all the states in the United States for the academic year 1999-2000 regarding physician reporting of patients with medical conditions that might predispose them to a motor vehicle crash (MVC) and compared the results to a similar study done in 1986. Six (12%) of the states had mandatory reporting laws, 25 (49%) had permissive reporting laws, and 20 (39%) had no laws regarding physician reporting. There was a significant difference between the distribution of laws by year. There was no uniformity on a national level concerning such legislation.

Study objective: Carbon monoxide (CO) is the leading cause of poisoning fatalities in the United States. We conducted a survey to sample the quality of the information available to the public from Connecticut heating oil distributors regarding these risks. Methods: An observational, cross-sectional telephone survey of oil distributors in Connecticut was conducted, using a scripted set of questions regarding CO poisoning risk from oil-burning furnaces. We first asked whether such a risk existed and then elicited explanations for confirmation or denial of that risk. We then inquired as to the proper response to a home CO detector alarm. Of 282 calls made, responses were obtained from 91 distributors. Reasons for lack of response included incorrect phone listings, duplicate listings, and unwillingness of the person answering to respond to the questions asked. Results: Nearly one fourth of distributors responding (23%) denied any risk of CO poisoning from oil burners, 43% of these claiming that the odor would provide protective warning before toxic exposure; another 33% stated that CO is a risk only with gas heaters. Of the 77% who confirmed the possibility of CO toxicity, half (49%) minimized the risk, also invoking a "warning odor." In case of CO alarm, only 14% of responders recommended turning off the furnace until the source is found. Five percent did not recommend having ambient CO levels checked at the time of the alarm. Conclusion: Heating oil companies in Connecticut do not uniformly provide correct information regarding CO risks. In our survey a majority of distributors responding offered misplaced "reassurance." As such, they are a potential area for public health intervention and an untapped resource for educating the public on these risks. [Drescher MJ, Bayer MJ, Barko I, Caros L, McCormick MA: Heating oil company responses to inquiries concerning carbon monoxide toxicity. Ann Emerg Med April 1999;33:406-408.]

Study objectives: Emergency medicine was officially recognized as a specialty in Israel in 1999. In November 2003, the first class of 9 Israeli trained and examined emergency physicians were certified as specialists. We undertake this survey to assess current staffing of emergency departments (EDs) in Israel and attempt to estimate the need for emergency physicians in the future. Methods: A survey instrument was sent to all ED directors in general hospitals having EDs in Israel. The ED directors were informed that the information would be kept anonymous and only used in the aggregate. We asked questions relating to ED staffing by number of physicians, type of specialty, resident or specialist, and differential staffing by time of the day and week. In addition, we inquired as to the census, structure, hospital resources available, and size of the ED. Results: We had a response rate of 96% (23 of 24 hospitals). There are 59 certified emergency medicine specialists working in EDs in Israel, caring for a total of 1,872,500 visitors annually. A minority are residency trained. There are currently 37 emergency medicine residents enrolled in 19 programs in Israel. Emergency care is otherwise given by specialists and residents in other fields and by nonspecialist physicians. Presence of emergency medicine specialists is not evenly distributed by hospital type or time of day. During the day shift at large hospitals, there is an average of 2.25 emergency medicine specialists and another 4 specialists of other types on duty. From midnight to 8 am in large hospitals, there is an average of less than 1 specialist of any kind (typically not emergency medicine) on duty in the ED. Evenings and nights in most EDs, care is given by nonspecialists (residents in various specialties and others nonspecialists) working 16-hour shifts. The shortage of emergency physicians is greatest in medium-sized hospitals (average ED census 88,000 visits per year) where there is an average of only 5.3 full-time physicians (of all types) employed, which is in contrast to large hospitals (average ED census 104,000) where there is an average of 9.3 full-time ED physicians (of all specialties). Nineteen of 23 responding hospitals have been recognized as potential training sites for emergency medicine residents. Conclusion: The recognition of the need for emergency medicine as a specialty in Israel by the medicopolitical establishment has not as yet translated into care of emergencies by emergency physicians for most patients. It is apparent that to adequately staff the existing EDs in Israel around the clock full time, there is a need for a large increase in the number of emergency specialists. This increase will require a policy emphasis on funding positions for emergency medicine staff and a concentrated effort directed at emergency medicine resident education.