Proposed fellowship training program in international emergency medicine.

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.

Planning recommendations for international emergency medicine and out-of-hospital care system development.

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 familiar with EM. METHODS: The techniques and programs used by the authors and others in assisting in EM development in other countries to date are described. CONCLUSIONS: Some aspects of EM system development 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 efficacy of these efforts. Further studies are needed on the relative effectiveness and cost-benefit of different EM development efforts.

Hypoglycemia.

Hypoglycemia is a common and easily treatable condition in the pre-hospital and Emergency Department settings. Recognition of the varied faces of clinical hypoglycemia, coupled with determination of blood glucose levels and expeditious glucose replacement, can prevent serious morbidity. A directed history, careful physical examination, and appropriate laboratory studies during the Emergency Department visit can uncover the etiology of hypoglycemia in most cases, and in the rest will contribute to any further diagnostic evaluation that may prove necessary.

Metabolic acidosis.

This article reviews acid-base homeostasis and discusses the approach to the acidotic patient, with special reference to problems commonly encountered in emergency practice. General principles of therapy are presented, and their application to specific types of life-threatening metabolic acidosis addressed. By extension, recommendations are made concerning the treatment of the acidosis associated with cardiac arrest. Finally, preliminary information is presented on promising new approaches to the treatment of metabolic acidosis that are currently under investigation.

Respiratory physiology.

A basic review is presented of the anatomy and physiology of the airways and the alveolar - capillary interface. Lung volumes are defined, as are terms used in pulmonary function testing, and alveolar ventilation is discussed. Five common mechanisms of arterial hypoxemia are explored and some common examples are presented, and the value and limitations of arterial blood gas determinations and pulse oximetry in the Emergency Department setting are discussed.

Ethical issues in geriatric emergency medicine.

The emergence of ethics, geriatrics, and emergency medicine as areas of specialized interest has proceeded rapidly over the past two decades. Each of these fields continues to grow in response to patient needs, but it is clear that scientific knowledge alone cannot provide the physician with all the guidance necessary to ensure the provision of optimal care. Patient care cannot consist only of making diagnoses, prescribing medications, and performing technical procedures. Particularly in the care of the elderly, the emergency physician must be able to recognize ethical issues and to respond to them in the manner that will provide the greatest benefit to the patient. With the application of such skills, the emergency treatment of the elderly promises more benefit for elderly patients and their families and less doubt and anguish for emergency practitioners.

Pancreatitis.

Pancreatitis is a common but rather poorly understood entity most often associated with alcohol abuse or biliary tract disease. Despite the availability of a variety of diagnostic tests and imaging techniques, the diagnosis of pancreatitis continues to be primarily a clinical one. Of major concern to the emergency physician is distinguishing pancreatitis from other, potentially lethal, causes of abdominal pain, and identifying those patients with severe pancreatitis who are at risk for a complicated course secondary to the remote systemic effects of the disease.

Continuous ambulatory peritoneal dialysis.

Many patients with end-stage renal disease are maintained on continuous ambulatory peritoneal dialysis (CAPD). This technique offers a number of advantages over hemodialysis, but it is associated with certain potential complications. Peritonitis and other infectious complications are the most commonly seen in the emergency department. The evaluation and management of other emergency problems may also need to be modified in patients on CAPD.

Hemodialysis-related emergencies--Part 1.

Hemodialysis patients are seen in the emergency department much more frequently than their relatively small number would suggest. Many pitfalls attend the management of these patients, in whom there is a high potential for serious morbidity and mortality. This article outlines the principles of emergency department management of hemodialysis patients and describes the approach to the diagnosis and treatment of their most common presenting problems. Many of these are related to the hemodialysis procedure itself or to underlying chronic renal failure. Special attention is given to the problems of the vascular access, the hemodialysis patient's lifeline. The indications for emergent dialysis are discussed, as well as the temporizing measures available to the emergency physician while awaiting institution of dialysis.

Hemodialysis-related emergencies--Part II.

The management of medical emergencies in hemodialysis patients is not simple and is best carried out in consultation with experienced nephrologists. However, emergency staff who are likely to encounter such emergencies must be familiar with the principles of their diagnosis and treatment and have practical management strategies at their disposal.

Oral indomethacin for acute renal colic.

A number of studies have suggested that nonsteroidal antiinflammatory agents can relieve renal colic by a mechanism of action different from that of narcotics, offering the potential advantage of avoiding narcotic side-effects such as alteration of mental status. The authors prospectively administered oral indomethacin, 50 mg, to 25 nonvomiting patients with acute renal colic due to a documented stone. Eleven patients group (I) received the drug in an unblinded, nonrandomized fashion after failure of oral or parenteral narcotics to provide satisfactory pain relief, either at home or in the emergency department. In 14 additional patients group (II) indomethacin was given as the only initial treatment. Pain intensity before and after treatment was reported using a 1-to-10 scale. In group I, pain decreased from 5.8 +/- 2.7 to 3.6 +/- 3.8 (P less than .02). Six of the 11 patients reported a decrease in pain intensity of 50% or more, which occurred within 25 +/- 11 minutes, and in 5 of these 6, pain decreased to a 0 or 1 level. In group II, pain decreased from 7.6 +/- 1.5 to 4.6 +/- 4.0 (P less than .008). Eight of the 14 patients reported a decrease in pain intensity of 50% or more, which occurred within 40 +/- 14 minutes, and in 5 of these 8 pain decreased to a 0 or 1 level. Among all 25 patients who received indomethacin, pain relief was not significantly associated with the duration of pain before treatment or with patient age or sex. There was a trend for pretreatment pain intensity to be higher among nonresponders (P = .07).(ABSTRACT TRUNCATED AT 250 WORDS)

Routine admission electrocardiography in emergency department patients.

STUDY OBJECTIVES: To determine whether routine performance of an ECG could have been safely avoided in a subset of emergency department patients admitted to a university hospital. DESIGN: Retrospective consecutive case series. SETTING: University teaching hospital. TYPE OF PARTICIPANTS: All ED patients admitted to the medical service of the study hospital during a three-month period. METHODS AND INTERVENTIONS: Acceptable indications for an admission ECG were prospectively developed. Charts of all patients were reviewed to determine whether any of these indications were present, whether an admission ECG was performed, and whether an admission ECG resulted in a change in patient management or outcome. An ECG was classified as routine when performed in the absence of documentation of any of these indications. No interventions were performed. MEASUREMENTS AND MAIN RESULTS: There were 636 ED admissions to the medical service during the study period. Of the 631 patients whose chart could be located, 384 (61%) had at least one indication for an ECG and all but one had an ECG performed. No indications for an admission ECG were identified in the remaining 247 patients; of these, 202 (82%) had an ECG performed and 45 (18%) did not. Among the 202 who had a routine admission ECG, the test resulted in a change in management in only three (1.5%) (95% confidence interval [CI], 0.3% to 4.3%) and affected patient outcome in none (95% CI, 0% to 1.5%). Among the 45 without indications who did not have a routine admission ECG, none experienced an identifiable adverse consequence during hospitalization (95% CI, 0% to 6.7%). CONCLUSION: The admission ECG could have been avoided in an identifiable subset of ED patients admitted to the medical service of our hospital, with no adverse effect on patient outcome. This finding, if corroborated in other patient populations, suggests the potential for significant cost savings for the US health care system as a whole.

The myth of the fecalith.

A radiographically demonstrated fecalith is widely considered a virtually pathognomonic sign of acute appendicitis. This case report describes a patient with a clinical presentation suggestive of appendicitis and a well-defined right lower quadrant fecalith who was found to have a normal appendix at surgery. This case calls into question the venerable dogma surrounding the fecalith and highlights the necessity for the physician to continue to rely on clinical judgment in making the diagnosis of appendicitis.

ECG changes with perforated duodenal ulcer mimicking acute cardiac ischemia.

A 38-year-old man presented to the emergency department with severe epigastric pain. An electrocardiogram (ECG) showed T wave inversions in leads V2 through V4 consistent with myocardial ischemia. The patient had undergone stress thallium testing and cardiac angiography several months prior for recurrent chest pain, and results from both studies were normal. Pneumoperitoneum seen on a chest X-ray prompted emergency laparotomy. A perforated duodenal ulcer was found and repaired. The ECG changes reverted to normal after surgery.

Emphysematous cystitis: a complication of urinary tract infection occurring predominantly in diabetic women.

The case of a patient with emphysematous cystitis who presented with complaints of lower abdominal pain, dysuria, and pneumaturia is presented. The presenting symptoms, differential diagnosis, and radiographic and cystoscopic appearances of emphysematous cystitis, a rare complication of lower urinary tract infection occurring almost exclusively in diabetics, are reviewed. Treatment consists of urinary drainage, prompt initiation of antibiotic therapy, and strict glucose control. The prognosis usually is excellent.

Diagnosis of acute thoracic aortic dissection in the emergency department.

In this article we try to determine how frequently emergency physicians (EPs) suspected the diagnosis in acute aortic dissection (AD). In this retrospective descriptive study, we identified all patients with the final diagnosis of AD initially evaluated in 1 of 3 emergency departments (EDs) over a 5-year period. Patients were included if AD was not suspected before ED evaluation. Patients undergoing thoracic aorta imaging as the initial ED study were defined as suspected AD. Forty-three patients totaling 44 presentations were identified. EPs suspected AD in 19 of 44 presentations. EPs suspected AD in 12 of 14 (86%) cases of chest and back pain and in 5 of 11 (45%) of chest pain. Thirteen of 39 (33%) painful presentations involved abdominal pain; EPs suspected AD in 1 of 13 (8%). EPs suspected the diagnosis in 43% of acute AD; location of pain was most predictive of a suspected diagnosis.

Ethical conflicts in the prehospital setting.

STUDY OBJECTIVE: To assess the range of ethical conflicts that confront prehospital care providers. DESIGN: Convenience sample, from October 1989 to January 1990. SETTING: An urban advanced life support emergency medical service that transports approximately 3,000 patients per month. METHODS: Six hundred seven paramedic responses were analyzed by a single observer. An ethical conflict was identified when the paramedic faced a dilemma about what "ought to be done" and the paramedic's values conflicted or potentially conflicted with the patient's. Cases with potential ethical consequence were brought to experts in medical ethics and epidemiology for further analysis and classification. RESULTS: Ethical conflicts arose in 14.4% of paramedic responses (88 of 607 cases). Twenty-seven percent of the conflicts involved issues of informed consent, such as refusal of treatment or transport, conflicts of hospital destination, treatment of minors, and consent for research. Difficulties regarding the duty of the paramedics, usually under threatening circumstances, accounted for 19% of the dilemmas encountered. Requests for limitation of resuscitation accounted for 14%. Other circumstances that presented ethical conflicts involved questions of patient competence (17%), resource allocation (10%), confidentiality (8%), truth telling (3%), and training (1%). CONCLUSION: The data demonstrate a range of ethical conflicts in the prehospital setting and point to areas in which policy needs to be developed. The data also can be used in a prehospital ethics curriculum for paramedics and physicians. Because case sampling was not strictly random, absolute conclusions should not be drawn regarding the frequency of the dilemmas.

A survey of observation units in the United States.

Observation units have been proposed as a tool in lowering over-all health care costs and increasing the quality of care in outpatient facilities. Emergency department (ED) use of these units has been evaluated at single facilities but never at a national level. A survey of 250 facilities across the United States was performed to gather information about the observation unit phenomenon. Of the 250 hospitals in the survey group, 27% had operational observation or holding units and another 16% planned units within 1 year. A statistically significant increase in the use of these units was noted in nonteaching facilities when compared with their teaching counterparts. A trend toward higher use of observation units in suburban/urban settings was noted when compared with rural locations, although the difference was not statistically significant. Of the units in existence, 93% were located within the ED, staffed by emergency physicians, and administrated by the ED director. Most are staffed by ED nurses and ancillary help. No hospital had both an ED unit and a non-ED unit, and many units functioned as both holding and observation areas. The units are perceived to be beneficial in patient care and in lowering health care casts, although objective documentation to validate these beliefs is lacking. Further prospective research is needed to evaluate these units scientifically before broad recommendations can be made.

Gonococcal peritonitis in a patient treated with continuous ambulatory peritoneal dialysis (CAPD).

We report a case of gonococcal peritonitis in a sexually active female on continuous ambulatory peritoneal dialysis. The presumed route of entry into the peritoneal cavity was via the Fallopian tube. The episode responded rapidly to a standard antibiotic treatment protocol. Some episodes of culture-negative peritonitis may be caused by genital tract organisms which are not cultured by routine methods.