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Matching into emergency medicine (EM) is getting progressively more competitive. Applicants must therefore prepare for the possibility of not matching and, accordingly, be ready to participate in the Supplemental Offer and Acceptance Program (SOAP). In this article, we elaborate on the SOAP and the options for applicants who fail to match during Match Week. Alternative courses of action include applying for a preliminary year, matching into a categorical residency program, or aiming to secure EM spots outside the Match through the Council of Emergency Medicine Residency Directors, Society for Academic Emergency Medicine, and American Association of Medical Colleges.

BACKGROUND A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s. METHODS We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge. RESULTS Of 4, 895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04). CONCLUSIONS Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

Background Ultrasound has been suggested as a useful non-invasive tool for the detection of early blood loss. Two possible sonographic markers for hypovolemia are the diameter of the inferior vena cava (IVC) and the thickness of the left ventricle (LV). Study Objectives The goal of the study was to evaluate the utility of ultrasound to detect signs of early hemorrhagic shock in healthy volunteers, compared with changes in vital signs. Methods In the current study, healthy volunteers from blood donation drives were used as models for early hemorrhage. Changes in vital signs, IVC diameter, and LV wall thickness were recorded after approximately 500 cc of blood loss. Results Thirty-eight subjects were enrolled and completed the study. After blood donation, there was a 7-mm Hg (8%) decrease in mean arterial pressure without a significant change in heart rate. There was a decrease in maximum IVC diameter (IVCmax) (12% decrease [95% confidence interval (CI) −6 to −19] in short axis and 20% decrease [95% CI −12 to −27] in long axis), but no change was seen in the respiratory caval index ((IVCmax − IVCmin)/IVCmax) × 100). There was no change in LV wall thickness. Conclusion In this study, serial changes in vital signs, IVC diameter, and LV wall thickness were clinically insignificant after approximately 500 cc of blood loss in healthy volunteers.

Objective The purpose of this study is to determine whether emergency department (ED) visit volume is associated with ED quality of care in patients with acute exacerbations of chronic obstructive pulmonary disease (COPD). Methods We performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. Using a standard protocol, we interviewed consecutive ED patients with COPD exacerbation, reviewed their charts, and completed a 2-week telephone follow-up. The associations between ED visit volume and quality of care (process and outcome measures) were examined at both the ED and patient levels. Results After adjustment for patient mix in the multivariable analyses, chest radiography was less frequent among patients with COPD exacerbations in the low-volume (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.1-0.4) and high-volume EDs (OR, 0.1; 95% CI, 0.05-0.5), with medium-volume EDs as the reference. Arterial blood gas testing was less frequent in the low-volume EDs (OR, 0.1; 95% CI, 0.02-0.8). Medication use was similar across volume tertiles. With respect to outcome measures, patients in high-volume EDs were more likely to be discharged (OR, 4.2; 95% CI, 2.2-7.7) and to report ongoing exacerbation at a 2-week follow-up (OR, 1.9; 95% CI, 1.02-3.5). Conclusions Traditional positive volume-quality relationships did not apply to emergency care of COPD exacerbation. High-volume EDs used less guideline-recommended diagnostic procedures, had a higher admission threshold, and had a worse short-term patient-centered outcome.

Objectives: The primary objective of this study was to assess variables that residency applicants ranked as influential in making residency choices. The secondary objective was to determine if residents were satisfied with their residency choices. Methods: A secondary analysis was performed on a cohort database from a stratified, random sampling of 322 emergency medicine (EM) residents collected in 1996–1998 and 2001–2004 from the American Board of Emergency Medicine Longitudinal Study on Emergency Medicine Residents (ABEM LSEMR). Residents rated the importance of 18 items in response to the question, “How much did each of the following factors influence your choice of residency program location?” The degree to which residents’ programs met prior expectations and the levels of satisfaction with residency programs were also assessed. All analyses were conducted using descriptive statistics. Results: Three-hundred twenty-two residents participated in the survey. Residents considered the following to be the most important variables: institutional reputation, hospital facilities, program director reputation, and spousal influence. Several geographic and gender differences were noted. Ninety percent (95% confidence interval [CI] = 86% to 93%) of residents surveyed in their final year answered that the residency program met or exceeded expectations. Seventy-nine percent (95% CI = 76% to 82%) of residents identified themselves as “highly satisfied” with their residency choice. Conclusions: The most influential factors in residency choice are institutional and residency director reputation and hospital facilities. Personal issues, such as recreational opportunities and spousal opinion, are also important, but are less influential. Significant geographic differences affecting residency choices exist, as do minor gender differences. A majority of residents were highly satisfied overall with their residency choices.

Objective: To evaluate the achievement gof women in academic emergency medicine (EM) rel- ative to men. Methods: This study was a cross-sec- tional mail survey of all emergency physicians who were employed at three-fourths full-time equivalent or greater at the 105 EM residency programs in the United States from August 1997 to December 1997. The following information was obtained: demograph- ics, training and practice issues, roles and responsi- bilities in academic EM, percentage of time spent per week in clinical practice, teaching, administrative and research activities, academic productivity, and funding. Results: Of the 1,575 self-administered questionnaires distributed by the office of the chairs, 1,197 (76%) were returned. Two hundred seventy- four (23%) of the respondents were women, and 923 (77%) were men. There was a significant difference noted between men and women in all demographic categories. The numbers of respondents who were nonwhite were extremely small in the sample and, therefore, the authors are hesitant to draw any con- clusions based on race/ethnicity. There was no differ- ence in training in EM between men and women (82% vs 82%, p = 0.288), but a significantly higher propor- tion of male respondents were board-certified in EM (84% vs 76%, p < 0.002). Women in academic EM were less likely to hold major leadership positions, spent a greater percentage of time in clinical and teaching activities, published less in peer-reviewed journals, and were less likely to achieve senior aca- demic rank in their medical schools. Conclusions: These findings mirror those of most medical special- ties: academic achievement of women in academic EM lags behind that of men. The paucity of minority physicians in academic EM didn't permit analysis of their academic achievements. Key words: academic emergency medicine; women; gender. ACADEMIC EMERGENCY MEDICINE 2000; 7:999-1007

To assess the psychometric properties of the short-form chronic respiratory disease questionnaire (SF-CRQ) as a quality-of-life (QOL) instrument in chronic obstructive pulmonary disease (COPD) exacerbations.In a prospective multicenter cohort study, consecutive emergency department (ED) patients with COPD exacerbation were interviewed using the SF-CRQ and other instruments. Baseline information was collected in the ED and from follow-up data 2 weeks later. The results of the SF-CRQ were compared with the results of the other instruments and clinical variables by correlation and factor analyses.Of the 301 enrolled patients, 80% reported improvements across each of the domains of the SF-CRQ over the 2-week post-ED period. Overall median changes for the dyspnea, fatigue, emotional function, and mastery domains were 2, 1, 1, and 1.5, respectively (P0.001 for each domain). Correlation and factor analyses support their convergent/divergent validity and construct validity. The reliability for the change score of the SF-CRQ was high (Cronbach's alpha coefficient, 0.82). Overall minimal clinically important difference for improvement in the SF-CRQ was 1.01 (95% confidence interval, 0.72-1.31).SF-CRQ is a valid, reliable, and responsive instrument for the assessment of short-term QOL change in patients with COPD exacerbations.

Objectives To determine the patient factors associated with hospital admission among adults who present to the emergency department (ED) with acute exacerbations of chronic obstructive pulmonary disease (COPD) and to determine whether admissions were concordant with recommendations in the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Methods The authors performed a prospective multicenter cohort study involving 29 EDs in the United States and Canada. By using a standard protocol, consecutive ED patients with COPD exacerbation were interviewed, and their charts were reviewed. Predictors of admission were determined by multivariate logistic regression. Results Of 384 patients, 233 (61%; 95% confidence interval = 56% to 66%) were admitted. Multivariate analysis showed that a higher likelihood of admission was associated with older age, female gender, more pack-years of smoking, recent use of inhaled corticosteroid, self-reported activity limitation in the past 24 hours, higher respiratory rate at ED presentation, and a concomitant diagnosis of pneumonia. Patients who reported the ED as their usual site for problem COPD care, or who had mixed COPD and asthma, were less likely to be admitted. The authors confirmed five of the seven testable indications for hospital admission in the GOLD guidelines. Conclusions Several patient factors were independently associated with hospital admission among ED patients with COPD exacerbations. Overall, concordance with admission recommendations in the GOLD guidelines was high. The authors also identified a few novel predictors of admission (female gender, ED as the usual site for problem COPD care, mixed diagnosis of COPD and asthma, recent use of inhaled corticosteroid) that require replication in future studies.

Early American physician education lacked quality and consistency. Poorly funded institutions with weak curricula and little patient contact before graduation trained our earliest doctors. With the advent of the twentieth century, a reformation of medical education took place that created the foundation of our modern American medical education system. The importance of physician education increased, leading to the production of specialty boards and requirements for continuing medical education and culminating in a continuous certification process now required of all specialties including the American Board of Emergency Medicine. While the utility of continuing medical education has been questioned, technological advances, the Internet, and improved education techniques are helping physicians practice modern medicine in a time of rapidly expanding science.

IntroductionOptimal emergent management of traumatic hemorrhagic shock patients requires a better understanding of treatment provided in the prehospital/Emergency Medical Services (EMS) and emergency department (ED) settings.Hypothesis/ProblemDescribed in this research are the initial clinical status, airway management, fluid and blood infusions, and time course of severely-injured hemorrhagic shock patients in the EMS and ED settings from the diaspirin cross-linked hemoglobin (DCLHb) clinical trial.MethodsData were analyzed from 17 US trauma centers gathered during a randomized, controlled, single-blinded efficacy trial of a hemoglobin solution (DCLHb) as add-on therapy versus standard therapy.ResultsAmong the 98 randomized patients, the mean EMS Glasgow Coma Scale (GCS) was 10.6 (SD = 5.0), the mean EMS revised trauma score (RTS) was 6.3 (SD = 1.9), and the mean injury severity score (ISS) was 31 (SD = 17). Upon arrival to the ED, the GCS was 20% lower (7.8 (SD = 5.3) vs 9.7 (SD = 6.3)) and the RTS was 12% lower (5.3 (SD = 2.0) vs 6.0 (SD = 2.1)) than EMS values in blunt trauma patients (P< .001). By ED disposition, 80% of patients (78/98) were intubated. Rapid sequence intubation (RSI) was utilized in 77% (60/78), most often utilizing succinylcholine (65%) and midazolam (50%). The mean crystalloid volume infused was 4.2 L (SD = 3.4 L), 80% of which was infused within the ED. Emergency department blood transfusion occurred in 62% of patients, with an average transfused volume of 1.2 L (SD = 2.0 L). Blunt trauma patients received 2.1 times more total fluids (7.4 L vs 3.5 L, < .001) and 2.4 times more blood (2.4 L vs 1.0 L,P< .001). The mean time of patients taken from injury site to operating room (OR) was 113 minutes (SD = 87 minutes). Twenty-one (30%) of the 70 patients taken to the OR from the ED were sent within 60 minutes of the estimated injury time. Penetrating trauma patients were taken to the OR 52% sooner than blunt trauma patients (72 minutes vs 149 minutes,P< .001).ConclusionBoth GCS and RTS decreased prior to ED arrival in blunt trauma patients. Intubation was performed using RSI, and crystalloid infusion of three times the estimated blood loss volume (L) and blood transfusion of the estimated blood loss volume (L) were provided in the EMS and ED settings. Surgical intervention for these trauma patients most often occurred more than one hour from the time of injury. Penetrating trauma patients received surgical intervention more rapidly than those with a blunt trauma mechanism.SloanEP,KoenigsbergM,WeirWB,ClarkJM,O'ConnorR,OlingerM,CydulkaR.Emergency resuscitation of patients enrolled in the US diaspirin cross-linked hemoglobin (DCLHb) clinical efficacy trial.Prehosp Disaster Med.2015;30(1):1-8.

Objectives: Although more men are diagnosed as having chronic obstructive pulmonary disease (COPD), its prevalence is increasing among women. Little is known about gender differences in exacerbations of COPD. The objective of this study was to determine if acute presentation, management, and outcomes differ among men and women seeking care in the emergency department (ED) for exacerbation of COPD. Methods: This was a secondary analysis of a prospective cohort study of ED patients aged 55 years or older who presented with an exacerbation of COPD. Subjects underwent structured interviews in the ED and two weeks later. Results: The cohort consisted of 397 subjects with COPD, of whom 52% were women. Self-report of COPD only tended to be more common among men (61% of men vs. 52% of women), while mixed COPD/asthma tended to be more common among women (39% vs. 48%; p = 0.10). Despite reporting similar chronic symptom severity, women were less likely than men to use anticholinergic agents before their ED visit (59% vs. 69%; p = 0.04). During the exacerbation, women initiated less home therapy and were less likely to seek emergency care within the first 24 hours of symptom onset (25% vs. 36%; p = 0.01). Although ED care and disposition were similar, post-ED outcomes differed. At two-week follow-up, men were more likely to report an ongoing exacerbation (42% vs. 31%; p = 0.03). Conclusions: Men and women who present to the ED for treatment of an exacerbation of COPD have substantial differences in long-term medication use, self-treatment during exacerbation, delay in emergency care, and post-ED outcomes. Further studies are warranted to confirm and explain these gender-related differences.

Acute exacerbations of chronic obstructive pulmonary disease are a common problem in the emergency department. Despite considerable research involving the management of this disease over the past decade, much remains unclear from an emergency medicine perspective. Increased research would better guide the management of these complex patients from the perspectives of the patient, the caregiver, and society. The major areas of research can be divided into diagnosis, therapy, and education. The reliability and validity of different definitions of acute exacerbations of chronic obstructive pulmonary disease need to be assessed. The utility and performance characteristics of diagnostic testing need to be determined for this difficult patient population. Specific diagnostic tests include measures of dyspnea, spirometry and exercise tolerance, measures of gas exchange, airway inflammation, and chest imaging. It remains unclear which patient-specific therapies (oxygen, bronchodilators, corticosteroids, antibiotics, noninvasive positive pressure ventilation, and methylxanthines) should be used and monitored. Finally, the utility of education of both health care providers and patients and how it may be applied to the acute setting need to be addressed.

The majority of studies published in the emergency medicine literature attempt to show a difference between two interventions, but often fail to do so. Failing to detect a difference, however, is not the same as demonstrating that one intervention is at least as effective as or better than the other intervention, or that the two interventions are equivalent--a fine point that is often overlooked. The purpose of this paper is to review classical hypothesis testing and then introduce the methodology to determine whether one intervention is at least as effective as another intervention, or whether two interventions are equivalent. Appreciating the conceptual differences between failing to find a difference, demonstrating that one intervention is at least as effective as another, and demonstrating equivalence may lead to a better understanding of the true significance or potential significance of study results.

Study objective The purpose of this study is to determine what factors influence emergency physicians' decisions to prescribe an opioid analgesic for 3 common, painful conditions. Methods We developed items thought to influence the decision to prescribe an opioid analgesic through a review of the literature, expert consultation, and interviews with practicing emergency physicians. We developed a baseline vignette and items expected to influence the decision for each of the 3 conditions: migraine, back pain, and ankle fracture. We surveyed 650 physicians randomly selected from the American College of Emergency Physicians. The influence of individual items was explored through a univariate analysis of the response distribution. Patterns were assessed by analytically creating scales. Results We received responses from 398 (63%) of the 634 eligible physicians. Physicians' likelihoods of prescribing an opioid showed marked variability, with at least 10% of physicians saying they were unlikely and 10% of physicians saying they were likely to prescribe for each condition. Physician responses to individual pieces of clinical information, such as the patient requesting "something strong" for the pain, were also highly variable, with at least 10% of physicians saying they would be negatively influenced by this request and at least 10% saying they would be positively influenced by it. Conclusion Even when faced with identical case scenarios, physicians' decisions to prescribe opioid analgesics are highly variable. Moreover, the same clinical information, such as a patient requesting a strong analgesic, changes the likelihood of prescribing opioids in opposite directions for different physicians.

Objective: Racial/ethnic disparities in physician treatment have been documented in multiple areas, including emergency department (ED) analgesia. The purpose of this study was to determine if physicians were predisposed to different treatment decisions based on patient race/ethnicity and if physicians’ treatment predispositions changed when socially desirable information about the patient (occupation, socioeconomic status, and relationship with a primary care physician) was made explicit. Methods: The authors developed three clinical vignettes designed to engage physicians’ decision-making processes. The patient’s race/ethnicity was included. Each vignette randomly included or omitted explicit socially desirable information. The authors mailed 5,750 practicing emergency physicians three clinical vignettes and a one-page questionnaire about demographic and practice characteristics. Chi-square tests of significance for bivariate analyses and multiple logistic regression were used for multivariate analyses. Results: A total of 2,872 (53%) of the 5,398 potential physician subjects participated. Patient race/ethnicity had no effect on physician prescription of opioids at discharge for African Americans, Hispanics, and whites: absolute differences in rates of prescribing opioids at discharge were less than 2% for all three conditions presented. Making socially desirable information explicit increased the prescribing rates by 4% (95% CI ¼ 0.1% to 8%) for the migraine vignette and 6% (95% CI ¼ 3% to 8%) for the back pain vignette. Conclusions: Patient race/ethnicity did not influence physicians’ predispositions to treatment plans in clinical vignettes. Even knowing that the patient had a high-prestige occupation and a primary care provider only minimally increased prescribing of opioid analgesics for conditions with few objective findings. Key words: emergency department; analgesia prescription; race/ethnicity; usual source of care; communication; access. ACADEMIC EMERGENCY MEDICINE 2003; 10:1239–1248.

Asthma is a chronic inflammatory illness with acute exacerbations, which often is encountered in the ED setting. Knowledge of the presentation and treatment of asthma is crucial for any physician treating patients with this disease. Beta-agonist, anticholinergic, and corticosteroid therapy continue to be the mainstay of emergency therapy despite advances in newer medications. Proper attention to long-term treatment of asthma and aggressive treatment of acute exacerbations should help reduce morbidity and mortality.

The American Board of Medical Specialties described six core competencies considered essential elements of medical practice: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. In response, the Accreditation Council for Graduate Medical Education (ACGME) mandated that all residency programs assess trainees for the newly defined core competencies. Despite the mandate for including these six competencies in residency training, neither a specific curriculum nor a method to assess the outlined objectives has been developed by the ACGME. Instead, it is up to individual residency programs to document how they plan to incorporate and assess the core competencies in their programs. This article describes the potential use of direct observation to assess resident performance in the interpersonal skills core competency.

Objective: To examine whether dissatisfaction with one's usual source of care (USC) and perceived access difficulties to one's USC were associated with nonurgent emergency department (ED) use. Methods: Variables that measured USC satisfaction and access were identified in the 1996 cohort of the Medical Expenditure Panel Survey (MEPS), a nationally representative sample administered by the Agency for Healthcare Research and Quality. The main outcome measured was nonurgent ED use at least once during 1996. Results: A total of 9,146 adults had a USC other than the ED, had at least one contact with the health care system or were unable to get needed care, and had complete data for all the variables in the final model. Dissatisfaction with the USC, dissatisfaction with the USC staff, lack of confidence in the USC's ability, difficulty scheduling an appointment, difficulty reaching the USC by phone, and long waiting times with an appointment were all associated with having a nonurgent ED visit in 1996 (all at p < 0.05). The positive associations between both dissatisfaction and perceived access barriers and nonurgent ED use persisted even in multiple logistic regression that adjusted for age, sex, race, education, health status, employment status, income, insurance, region of residence, and rural vs. urban residence. Conclusions: Patients who are dissatisfied with their USC or perceive access barriers to their USC are more likely to have a nonurgent ED visit.

A multicenter study in the late 1990s demonstrated suboptimal emergency asthma care for pregnant women in US EDs. After a decade, follow-up data are lacking. We aimed to examine changes in emergency asthma care of pregnant women since the 1990s.We combined data from four multicenter observational studies of ED patients with acute asthma performed in 1996 to 2001 (three studies) and 2011 to 2012 (one study). We restricted the data so that comparisons were based on the same 48 EDs in both time periods. We identified all pregnant patients aged 18 to 44 years with acute asthma. Primary outcomes were treatment with systemic corticosteroids in the ED and, among those sent home, at ED discharge.Of 4,895 ED patients with acute asthma, the analytic cohort comprised 125 pregnant women. Between the two time periods, there were no significant changes in patient demographics, chronic asthma severity, or initial peak expiratory flow. In contrast, ED systemic corticosteroid treatment increased significantly from 51% to 78% across the time periods (OR, 3.11; 95% CI, 1.27-7.60; P = .01); systemic corticosteroids at discharge increased from 42% to 63% (OR, 2.49; 95% CI, 0.97-6.37; P = .054). In the adjusted analyses, pregnant women in recent years were more likely to receive systemic corticosteroids, both in the ED (OR, 4.76; 95% CI, 1.63-13.9; P = .004) and at discharge (OR, 3.18; 95% CI, 1.05-9.61; P = .04).Between the two time periods, emergency asthma care in pregnant women significantly improved. However, with one in three pregnant women being discharged home without systemic corticosteroids, further improvement is warranted.

[Cydulka RK, Schneider S, on behalf of the Society for Academic Emergency Medicine: Commentary on "A Study of the Workforce in Emergency Medicine." Ann Emerg Med May 1999;33:558-561.]

Sore throat, earache, and sinusitis are common presenting complaints in the emergency department, and all fall within the top ten in the United States. These complaints usually have a benign course but rarely can be a symptom of a serious disease process. This article provides an evidence-based review of the literature regarding the diagnosis of pharyngitis, otitis media, and sinusitis.

Purpose The optimal dose of albuterol to use in the treatment of acute asthma has yet to be established. The National Asthma Education and Prevention Program (NAEPP) recommends a starting dose of 2.5 to 5 mg of aerosolized albuterol every 20 min, although European authorities recommend higher doses. The purpose of this study was to compare 2.5 vs 7.5 mg of nebulized albuterol for the treatment of acute asthma. Subjects We studied 160 patients presenting to the emergency department with acute asthma. Methods On enrollment, patients underwent baseline testing, including initial spirometry. All patients received prednisone, 60 mg, orally. Patients then received in a randomized, double-blinded fashion, nebulized albuterol either 2.5 or 7.5 mg every 20 min for a total of three doses. Spirometry was repeated after each of the first two treatments and again 40 min after completion of the three treatments. Results The pretreatment FEV1 was 36.9+/-16.6% of predicted normal in the low-dose group vs 41.5+/-15.4% of predicted normal in the high-dose group (not significant [NS]). The patients in the low-dose group had a 50.3+/-62.6% improvement in FEV1 pretreatment to post-treatment, whereas those in the high-dose group had a 44.6+/-48.2% improvement in FEV1 (NS). There was no difference in the admission rate in the low-dose group (43%) as compared with that of the high-dose group (39%; NS). Conclusion We conclude that there is no advantage to the routine administration of doses of albuterol higher than 2.5 mg every 20 min. It is possible that there may be an advantage in the most severely obstructed patients, although this study did not enroll enough patients with very severe asthma to evaluate this. As has been previously demonstrated, patients who subsequently require admission have a diminished response to albuterol. This decreased responsiveness is seen with the first aerosol administration and is unaffected by increasing the dose.

Study objectives: Several studies have suggested that legally intoxicated drivers who are injured when involved in a motor vehicle crash are unlikely to be cited or prosecuted for driving under the influence (DUI). The purpose of this study was to determine (1) the rates of citation and prosecution of legally intoxicated drivers who are injured in a motor vehicle crash and hospitalized in a Level I trauma center, (2) the rates of previous and subsequent alcohol-related citation in this population, and (3) the rate of referral for treatment of alcohol-related problems made during the hospital stay. Methods: In a retrospective review of trauma registry and Cleveland Municipal Court records from January 1993 through April 1995, we examined the records of all drivers injured in a motor vehicle crash who were transported to a Level I urban trauma center, admitted to the trauma service, and determined to have a blood alcohol content (BAC) of .10 gm% or higher at the time of admission to the emergency department. Results: Seventy drivers admitted after a motor vehicle crash had a BAC of .10 gm% or higher. This represented 33% of the drivers older than 16 years of age who were admitted to the trauma service. Twenty-three drivers (32.8%) were cited for DUI, and 15 (21%) of the 70 were successfully prosecuted and convicted. Four of 23 cited drivers had previous citations; another 5 incurred subsequent citations during the study period. Eight of the 70 drivers who were admitted with a high BAC were referred for outpatient alcohol counseling after discharge. None were offered counseling as inpatients. Conclusion: Citation and prosecution rates of legally intoxicated drivers injured in motor vehicle crashes and hospitalized in our trauma center were low. Recognition of alcoholism and inpatient counseling were rare. Multiple alcohol-related citations were common among drivers cited for DUI. [Cydulka RK, Harmody MR, Barnoski A, Fallon W, Emerman CL: Injured intoxicated drivers: Citation, conviction, referral, and recidivism rates. Ann Emerg Med September 1998;32:349-352.]

The purpose of this study was to describe the impact of asthma and chronic obstructive pulmonary disease (COPD) in the elderly on health care utilization. The Health Care Financing Administration (HCFA) file for the year 1984 through 1991 involving beneficiaries < or = 65 yr were searched for the diagnoses of asthma and COPD by ICD-9 codes. The study groups were created by determining the first admission for an exacerbation of either disease during each year from 1984 through 1991. Patients were identified by their social security number. The 1984 cohort consisted of 56,692 patients with asthma exacerbation and 162,899 with COPD exacerbation. The 1991 cohort consisted of 67,758 patients with asthma exacerbation and 131,974 patients with COPD exacerbation. In addition, the 1984 cohort was tracked by social security number for evidence of rehospitalization for either asthma or COPD through 1991. Length of hospitalization increased as patients grew older. The discharge rate to an independent living facility diminished as age increased. The use of convalescent and nursing homes or home health care after discharge more than doubled from 1984 through 1991. The utilization of health care resources by elderly patients with asthma and COPD is immense, both during hospitalization and after discharge.

This study examined how smoking-related causal attributions, perceived illness severity, and event-related emotions relate to both intentions to quit and subsequent smoking behavior after an acute medical problem (sentinel event).Three hundred and seventy-five patients were enrolled from 10 emergency departments (EDs) across the USA and followed for six months. Two saturated, manifest structural equation models were performed: one predicting quit attempts and the other predicting seven-day point prevalence abstinence at 14 days, three months, and six months after the index ED visit. Stage of change was regressed onto each of the other predictor variables (causal attribution, perceived illness severity, event-related emotions) and covariates, and tobacco cessation outcomes were regressed on all of the predictor variables and covariates.Non-White race, baseline stage of change, and an interaction between causal attribution and event-related fear were the strongest predictors of quit attempt. In contrast, abstinence at six months was most strongly predicted by baseline stage of change and nicotine dependence.Predictors of smoking behavior after an acute medical illness are complex and dynamic. The relations vary depending on the outcome examined (quit attempts vs. abstinence), differ based on the time that has progressed since the event, and include significant interactions.

Objectives The objective was to survey practicing emergency physicians (EPs) across the United States regarding the frequency of using ultrasound (US) guidance in central venous catheter (CVC) placement and, secondarily, to determine factors associated with the use or barriers to the use of US guidance. Methods This was a cross-sectional survey mailed to presumed practicing EPs as part of the American Board of Emergency Medicine (ABEM)'s longitudinal study of EPs. The selection process used stratified, random sampling of cohorts thought to represent four different stages within the development of the specialty of emergency medicine (EM). Multivariable logistic regression was used to identify independent factors associated with both high comfort using US guidance and high-percentage usage of US guidance. Results The survey was mailed to 1,165 subjects, and the response rate was 79%. The median number of years of practice was 20 (interquartile range [IQR] = 7 to 28 years). As their primary practice setting, 64% work in private or community hospitals, 60% received training in US-guided vascular access, and 44% never use US guidance in placing CVCs. Barriers differed in those who never use US and those who sometimes or always used US guidance. In those who never use US, top barriers were insufficient training (67%) and lack of equipment (25%). In those who use US, top barriers were the perceptions that US was too time-consuming (27%) and that the preferred site was not amenable to US (24%). Independent factors associated with high comfort and high-percentage use of US guidance were training in US-guided vascular access (adjusted odds ratio = 5.1 [high comfort]; 95% confidence interval [CI] = 2.6 to 10.1; adjusted odds ratio 11.1 = (high percentage); 95% CI = 5.0 to 24.8) and being a recent residency graduate. Conclusions Among EPs, the translation of evidence to clinical practice regarding the benefits of US guidance for CVC placement is poor and still faces many barriers. Training and education are potentially the best ways to overcome such barriers. Resumen Objetivos El objetivo fue encuestar a los urgenciologos de Estados Unidos sobre la frecuencia de uso de ecografia (Eco) para guiar la insercion de un cateter venoso central (CVC); y secundariamente determinar los factores asociados con el uso o con las barreras para usar la guia por Eco. Metodologia Encuesta transversal via correo electronico a los urgenciologos con supuesta actividad asistencial que forman parte del Estudio Longitudinal de Medicina de Urgencias y Emergencias de la American Board. El proceso de seleccion uso muestras de cohortes estratificadas y aleatorizadas pensadas para representar cuatros etapas diferentes en el desarrollo de la especialidad de urgencias y emergencias. Se utilizo una regresion logistica multivariable para identificar los factores independientes asociados tanto con el alto grado de satisfaccion como con el alto porcentaje de uso de la guia por Eco. Resultados La encuesta fue enviada por correo electronico a 1.165 sujetos, con un porcentaje de respuesta de un 79%. La mediana de numero de anos de practica fue de 20 (rango intercuartilico 7 a 28). Segun su escenario de practica habitual, un 64% trabaja en un hospital privado o de la comunidad, un 60% recibio formacion en acceso vascular guiado por Eco y un 44% nunca usa la Eco para guiar la insercion de una CVC. Las barreras difirieron en aquellos que nunca usan Eco y aquellos que a veces o siempre usan Eco. En los primeros, las principales barreras fueron la formacion insuficiente (67%) y la falta de equipo (25%). En los segundos, las principales barreras fueron las sensaciones que la Eco consumia demasiado tiempo (27%) y que el sitio preferido no era abordable para la Eco (24%). Los factores independientes asociados con un alto grado de satisfaccion y un alto porcentaje de uso de la guia por Eco fueron la formacion en acceso vascular guiado por Eco (razon de ventajas ajustada 5,1 [alta satisfaccion]; intervalo de confianza [IC] 95% = 2,6 a 10,1; razon de ventajas ajustada 11,1 [alto porcentaje]; IC 95% = 5,0 a 24,8) y ser un residente recientemente graduado. Conclusiones Entre los urgenciologos, la traslacion de la evidencia a la practica clinica sobre los beneficios de la Eco para la guia de la insercion de los CVC es pobre y todavia tiene muchas barreras. La formacion y docencia son potencialmente las mejores formas para superar dichas barreras.

Purpose The National Asthma Education and Prevention Program (NAEPP) published guidelines for asthma management in 1991. The purpose of this study is to assess the concordance between emergency physicians' practice and the guidelines. Design Survey mailed to emergency physicians. Nonrespondents were mailed a second copy of the survey. Participants Eight hundred randomly selected active members of the American College of Emergency Physicians. Interventions None. Measurements Participants were asked questions regarding training, current asthma practices, and sources of information on asthma management. Results Eight hundred questionnaires were mailed, of which 416 (52%) were returned. Sixty-four percent of respondents administer β-agonists consistent with the NAEPP guidelines. Seventy-five percent of respondents administer corticosteroids in similar accord, while 75% prescribed outpatient corticosteroids in concordance with those recommendations. Fortyseven percent report measuring pretreatment pulmonary function more than half the time and only 38% report checking pulmonary function prior to disposition more than half the time. Conclusions Most emergency physicians surveyed use β-agonists and steroids at least as often as recommended. A minority of emergency physicians reported utilizing pulmonary function testing in the manner recommended by the NAEPP.

Hypoxia has been observed when infants undergo lumbar puncture in a tight flexed lateral recumbent position. This study used sonographic measurements of lumbar interspinous spaces to investigate the anatomic necessity and advantage derived from this tight flexed positioning in infants.This was a brief, prospective, observational study of a convenience sample of patients. Twenty-one healthy infants under 1 month of age were scanned in two positions: prone in a spine-neutral position and lateral recumbent with their knees bent into their chest and their neck flexed. In each position, a 5- to 10-MHz linear array transducer was used to scan midline along the lumbar spinous processes in the sagittal plane. The distances between the spinous processes were measured near the ligamentum flavum using the ultrasound machine's calipers. Pulse oximetry was monitored on all infants during flexed positioning.In the spine-neutral position, all studied interspinous spaces were much wider than a 22-gauge spinal needle (diameter 0.072 cm). The mean (±SD) interspinous spaces for L3-4, L4-5, and L5-S1 in a spine-neutral position were 0.42 (±0.07), 0.37 (±0.06), and 0.36 (±0.11) cm, respectively. Flexing the infants increased the mean lumbar interspinous spaces at L3-4, L4-5, and L5-S1 by 31, 51, and 44%, respectively.This study verified that tight, lateral flexed positioning substantially enhances the space between the lumbar spinous processes and that a spine-neutral position also allows for a large enough anatomic interspinous space to perform lumbar puncture. However, further clinical research is required to establish the feasibility of lumbar puncture in a spine-neutral position.

ACADEMIC EMERGENCY MEDICINE 2011; 18:215–218 © 2011 by the Society for Academic Emergency Medicine Abstract Objectives: Hypoxia has been observed when infants undergo lumbar puncture in a tight flexed lateral recumbent position. This study used sonographic measurements of lumbar interspinous spaces to investigate the anatomic necessity and advantage derived from this tight flexed positioning in infants. Methods: This was a brief, prospective, observational study of a convenience sample of patients. Twenty-one healthy infants under 1 month of age were scanned in two positions: prone in a spine-neutral position and lateral recumbent with their knees bent into their chest and their neck flexed. In each position, a 5- to 10-MHz linear array transducer was used to scan midline along the lumbar spinous processes in the sagittal plane. The distances between the spinous processes were measured near the ligamentum flavum using the ultrasound machine’s calipers. Pulse oximetry was monitored on all infants during flexed positioning. Results: In the spine-neutral position, all studied interspinous spaces were much wider than a 22-gauge spinal needle (diameter 0.072 cm). The mean (±SD) interspinous spaces for L3–4, L4–5, and L5–S1 in a spine-neutral position were 0.42 (±0.07), 0.37 (±0.06), and 0.36 (±0.11) cm, respectively. Flexing the infants increased the mean lumbar interspinous spaces at L3–4, L4–5, and L5–S1 by 31, 51, and 44%, respectively. Conclusions: This study verified that tight, lateral flexed positioning substantially enhances the space between the lumbar spinous processes and that a spine-neutral position also allows for a large enough anatomic interspinous space to perform lumbar puncture. However, further clinical research is required to establish the feasibility of lumbar puncture in a spine-neutral position.

Study objectives: The objectives of this study were to assess the incidence of abnormal chest radiographs and to test the validity of previously developed high-yield criteria. There is disagreement about the need for chest radiography in acute exacerbation of chronic obstructive pulmonary disease, although high-yield criteria have been developed. Design: Retrospective chart review study. Setting: County-owned, university-affiliated, urban emergency department. Participants: ED patients seen between January 1988 and July 1991 with chronic obstructive pulmonary disease. Results: Eight hundred forty-seven ED visits were identified; medical records were available for 742. Radiographs were not taken in 8%, leaving 685 ED visits in the study. One hundred nine patients (16%) had significant abnormalities, including 88 new infiltrates, two new lung masses, one pneumothorax, and 20 episodes of pulmonary edema. A history of congestive heart failure and fever was associated with abnormalities, as were findings of rales, pedal edema, and jugular venous distension. There was no association with WBC count, temperature, coronary artery disease, chest pain, or sputum production. Previously published high-yield criteria had a sensitivity of .76; specificity, .41; positive predictive value, .20; negative predictive value, .90; and accuracy, .47. Conclusion: Radiographic abnormalities are common findings in acute exacerbation of chronic obstructive pulmonary disease. We found that almost one fourth of radiographic abnormalities are not predictable on the basis of previously developed high-yield criteria. Routine chest radiography should be considered in patients with acute exacerbation of chronic obstructive pulmonary disease to diagnose treatable, radiographically apparent abnormalities.

The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 guidelines advise the addition of ipratropium bromide to short-acting β-agonist therapy for the treatment of patients with severe acute asthma exacerbation.This was a prospective, double-blind, randomized, controlled study involving 141 adults, presenting to two EDs with acute severe asthma exacerbation. Patients were treated using a standardized pathway with levalbuterol plus ipratropium or levalbuterol alone. Primary outcomes were changes from baseline in the percentage of predicted forced expiratory volume in 1 second (FEV₁) at 30 minutes and 60 minutes after completion of treatment. Secondary outcomes included hospitalization and relapse rates. Occurrence of adverse events was recorded.Sixty-seven patients in the levalbuterol plus ipratropium group and 74 patients in the levalbuterol group completed the study. Overall, there was no significant difference in the improvement in percent predicted FEV₁ between the two groups at 30 minutes [difference in change between study groups at 30 minutes: 1% (95% CI: ?3 to 2%) or at 60 minutes: 3% (95% CI: 1-6%)] No difference was noted in hospitalization rates between the treatment groups [combination therapy group, 33%; single therapy group, 47%, difference: -14% (95% CI: -30 to 20%)]. Post-hoc analysis revealed that patients receiving ipratropium in addition to levalbuterol were 1.5 times more likely to experience side effects (palpitations) than patients treated with levalbuterol alone (RR 1.5; 95% CI: 1.2-1.9) No differences in relapse rates were noted between the groups. Post-hoc analysis revealed more side effects in patients receiving levalbuterol plus ipratropium.We were unable to demonstrate superiority of adding ipratropium to levalbuterol in alleviating obstruction as measured by FEV₁ or in decreasing the need for hospitalization among adult patients presenting to the ED with acute severe asthma exacerbation.

This study evaluated the ability of emergency medical technicians (EMT-As) and emergency medical technicians-paramedics (EMT-Ps) to use pulse oximetry measurements in determining patient oxygen requirements.Prospective case series.Cleveland emergency medical services (EMS) system.Five hundred thirty-two consecutive patients transported to Cleveland area hospitals by the Cleveland EMS system; no exclusions.EMT-Ps and EMT-As predicted patients' supplemental oxygen requirements based on clinical assessment. Pulse oximetry was performed while patients were breathing room air (RA SpO2). Treatment intervention, including oxygen supplementation and medication given, oxygen saturation after intervention, and oxygen saturation on arrival at the hospital, was also recorded. Therapy guided by the patient's initial RA SpO2 was reviewed to determine the appropriateness of oxygen therapy.Data were analyzed using the chi 2 test and correlation analysis. Eleven percent (59) of patients transported by Cleveland EMS had an initial RA SpO2 of less than 91%. Advanced life support units increased oxygen supplementation on all desaturated patients, whereas basic life support units failed to make appropriate increases in FIO2 in 20% (two) of desaturated patients (P less than .0001). Sixty percent (164) of patients transported by EMT-Ps and 62% (162) of patients transported by EMT-As had an initial RA SpO2 of 97% or greater. EMT-Ps gave supplemental oxygen therapy to all but 7% (11) of these already well-saturated patients, and EMT-As gave supplemental oxygen to all but 6% (nine) of these patients. EMT-Ps administered a higher FIO2 than they had predicted clinically necessary to 2% (four) of patients with an initial RA SpO2 of 97% of greater, whereas EMT-As gave a higher FIO2 than initially predicted to 16% (25) of such patients (P less than .0001).EMT-Ps were more likely to appropriately base oxygen therapy on oximetry measurements than were EMT-As. Both groups failed to decrease supplemental oxygen in patients with high explicit protocols for EMS systems contemplating the use of oximetry to guide oxygen therapy. Our results further suggest that pulse oximetry could be used to avoid unnecessary oxygen therapy on a significant number of patients transported by EMS systems because they are already well saturated on room air.

Objective The study objectives were to identify emergency department (ED) handoff practices and describe handoff communication errors among emergency physicians. Methods Two investigators observed patient handoffs among emergency physicians in a major metropolitan teaching hospital for 8 weeks. A data collection form was designed to assess handoff characteristics including duration, location, interruptions, and topics including examination, laboratory examinations, diagnosis, and disposition. Handoff errors were defined as clinically significant examination or laboratory findings in physician documentation that were reported significantly differently during or omitted from verbal handoff. Multivariate negative binomial regression models assessed variables associated with these errors. The study was approved by the institutional review board. Results One hundred ten handoff sessions encompassing 992 patients were observed. Examination handoff errors and omissions were noted in 130 (13.1%) and 447 (45.1%) handoffs, respectively. More examination errors were associated with longer handoff time per patient, whereas fewer examination omissions were associated with use of written or electronic support materials. Laboratory handoff errors and omissions were noted in 37 (3.7%) and 290 (29.2%) handoffs, respectively. Fewer laboratory errors were associated with use of electronic support tools, whereas more laboratory handoff omissions were associated with longer ED lengths of stay. Conclusions Clinically pertinent findings reported in ED physician handoff often differ from findings reported in physician documentation. These errors and omissions are associated with handoff time per patient, ED length of stay, and use of support materials. Future research should focus on ED handoff standardization protocols, handoff error reduction techniques, and the impact of handoff on patient outcomes.

In addition to preventing maternal and fetal hypoxia, the goals of treating acute asthma exacerbation during pregnancy mirror those in the nongravid patient: rapid reversal of airflow obstruction with aerosolized bronchodilators,reduction of likelihood of recurrence by the addition of corticosteroids, and ongoing assessment of mother and fetus. Disposition decisions are multifaceted and must take into account the health and well-being of the pregnant patient and that of her fetus. Discharge planning includes prescription of scheduled 3-2 agonist treatments until symptoms resolve, intensification of daily treatment as needed, prescriptions for systemic and ICSs, as well provision of patient education, a personalized action plan, and close follow-up.

To describe acute asthma in younger versus older adults presenting to the emergency department (ED).Prospective cohort study. Asthmatic adults were divided into three age groups: 18 to 34, 35 to 54, and 55 and older. The analysis was restricted to never smokers and smokers with fewer than 10 pack-years.ED.Two thousand sixty-four patients aged 18 and older with a physician diagnosis of asthma.Medications and peak expiratory flow.There were 1,158 (56%) subjects aged 18 to 34; 777 (37%) aged 35 to 54; and 129 (6%) aged 55 and older. Older patients were most likely to have a primary care provider (65%, 74%, and 91%, respectively; P.001); most were not taking inhaled corticosteroids (39%, 55%, and 48%, respectively; P.001). Older patients reported fewer ED visits for asthma (2, 2, and 1, respectively; P=.001) but were more likely to report asthma hospitalization (24%, 31%, and 37%, respectively; P.001). All groups had severe exacerbations (initial percentage predicted peak flow: 47, 47, and 47, respectively; P=.50), but older patients were least likely to report severe symptoms (72%, 79%, and 67%, respectively; P=.001). Older patients did not respond as well to bronchodilators, even after controlling for other demographic factors, markers of asthma severity, and ED management (change between initial and final peak expiratory flow, using subjects aged 18 to 34 as reference: aged 35-54, beta=-0.7 (95% CI=-9.4-8.0); agedor = 55, beta=-18.4 (-31.9 to -4.9)). The smaller change in peak expiratory flow contributed most to older patients' greater likelihood of hospitalization.Older asthma patients were less responsive to emergency bronchodilation. This may reflect chronic undertreatment with inhaled corticosteroids.