Aerosolized metaproterenol in the treatment of asthmatics with severe airflow obstruction. Comparison of two delivery methods.

The bronchodilator response to metaproterenol delivered by metered-dose inhaler (MDI) with a spacer device (Aerochamber [A]) and by jet nebulizer was studied in 44 asthmatic patients who presented to the emergency department with acute severe (FEV1 less than 50 percent predicted) airflow obstruction. The delivery method was randomized, double-blinded and placebo controlled. The A group received one puff of metaproterenol every five minutes for a total of three puffs (1.95 mg). The jet nebulizer group received 15 mg of metaproterenol by continuous nebulization over ten minutes. Only about 2.75 mg of the original 15 mg delivered by jet nebulizer was calculated to be available for inhalation due to the inefficiencies of the delivery system. The mean percentage of improvement in FVC and FEV1 in the A group was 33.5 and 49.0 percent, respectively. The mean percentage of improvement in FVC and FEV1 in the jet nebulizer group was 22.8 and 33.0 percent, respectively. There was no significant difference in the mean percentage of improvement values between the two groups. We were unable to demonstrate a difference in bronchodilator response to metaproterenol delivered by MDI-A and jet nebulizer in emergency department asthmatics with acute severe airflow obstruction.

Morningness-eveningness preferences of emergency medicine residents are skewed toward eveningness.

OBJECTIVE: To determine the morningness-eveningness (ME) distribution of emergency medicine (EM) residents. METHOD: A voluntary, modified ME questionnaire was administered to all EM residents in the United States at the time of the 1995 American Board of Emergency Medicine's annual In-Training Examination. RESULTS: Seventy-eight percent (2,047/2,614) of the surveys were returned. ME scores ranged from 24 to 76, with a median score of 49 (interquartile range 44, 56). The scores were distributed differently from those of the normal population (p < 0.001), being skewed toward eveningness. There was a correlation (r = 0.13, p < 0.0001) between resident age and ME score, with older residents being more morning-oriented. Males were more morning-oriented than females (p = 0.005), and respondents with children living at home also were significantly more morning-oriented (p < 0.001). Stepwise logistic regression showed that the influence of age, gender, and children was cumulative (r = 0.19) but accounted for only 4% of the observed variability. CONCLUSION: EM residents are distributed differently from the normal population in terms of their ME preferences, tending slightly toward eveningness. The importance of this distribution in EM residents in unknown. A longitudinal follow-up of this cohort may help to determine the association of ME preference with overall practice satisfaction, tolerance of shift work, and career longevity.

The occupational risk of motor vehicle collisions for emergency medicine residents.

OBJECTIVE: To determine the prevalence and risk factors associated with motor vehicle collisions (MVCs) and near-crashes as reported by emergency medicine (EM) residents following various ED shifts. METHODS: A survey was sent to all allopathic EM-2-EM-4 residents in May 1996 asking whether they had ever been involved in an MVC or near-crash while driving home after an ED shift. The residents' night shift schedules, self-reported tolerance of night work, ability to overcome drowsiness, sleep flexibility, and morningness/eveningness tendencies also were collected. RESULTS: Seventy-eight programs participated and 62% of 1,554 eligible residents returned usable surveys. Seventy-six (8%, 95% CI = 6% to 10%) residents reported having 96 crashes and 553 (58%, 95% CI = 55% to 61%) residents reported being involved in 1,446 near-crashes. Nearly three fourths of the MVCs and 80% of the near-crashes followed the night shift. Stepwise logistic regression of all variables demonstrated a cumulative association (R = 0.19, p = 0.0004) that accounted for 4% of the observed variability in MVCs and near-crashes. Univariate analysis showed that MVCs and near-crashes were inversely related to residents' shiftwork tolerance (p = 0.019) and positively related to the number of night shifts worked per month (p = 0.035). CONCLUSIONS: Residents reported being involved in a higher number of MVCs and near-crashes while driving home after a night shift compared with other shifts. Driving home after a night shift appears to be a significant occupational risk for EM residents.

Emergency medicine residents' shiftwork tolerance and preference.

OBJECTIVES: To determine the shift lengths currently worked by emergency medicine (EM) residents and their shift length preferences, and to determine factors associated with EM residents' subjective tolerance of shiftwork. METHODS: A survey was sent to EM-2 through EM-4 allopathic EM residents in May 1996. This questionnaire assessed the residents' shift length worked, shift length preferences, night shift schedules, and self-reported ability to overcome drowsiness, sleep flexibility, and morningness-eveningness tendencies. When providing shift length preferences, the residents were asked to assume a constant total number of hours scheduled per month. RESULTS: Seventy-eight programs participated, and 62% of 1,554 eligible residents returned usable surveys. Current shift lengths worked were 8 hours (12%), 10 hours (13%), 12 hours (37%), combinations of 8-hour, 10-hour, or 12-hour (34%) shifts, and other combinations (4%). Seventy-three percent of the respondents indicated that they preferred to work 8-hour or 10-hour shifts, and only 21% preferred a 12-hour shift. Shiftwork tolerance was recorded as: not well at all (2%), not very well (14%), fairly well (70%), and very well (14%). The EM residents' eveningness preference, ability to overcome drowsiness, sleep flexibility, younger age, and having no children at home were all associated with greater shiftwork tolerance. CONCLUSIONS: Emergency medicine residents generally tolerate shiftwork well and prefer 8-hour or 10-hour shift lengths compared with 12-hour shift lengths. Emergency medicine residencies with 12-hour shifts should consider changing residents' shifts to shorter shifts.

Acute poisoning from gamma hydroxybutyrate (GHB).

Gamma hydroxybutyrate (GHB) is an illicitly marketed substance promoted by body builders as a growth hormone releaser. Poisoning can produce seizures and coma. Acute poisonings from GHB have primarily been reported on the West coast and the Southeast. We report two cases from Kansas City where the patients presented in, or developed profound coma. Physicians should suspect GHB poisoning in patients who present with unexplained seizures and/or coma, particularly if they are body builders, health food fanatics or dieters.

Thrombolytic therapy in Missouri hospital emergency departments: compliance with the National Heart Attack Alert Program guidelines.

A self-administered questionnaire concerning the current practice of thrombolytic administration, and the use of National Heart Attack Alert Program (NHAAP) guidelines was mailed to the medical directors of Missouri acute care emergency departments (EDs). Responses from 75% of the EDs surveyed were received. There were standing orders to perform an electrocardiogram at 92% of the EDs surveyed. Thrombolytics were stocked in 80% of EDs and thrombolytics were administered in the ED rather than the ICU or CCU at 98%. The emergency physician (EP) was authorized to make thrombolytic treatment decisions at 87% of the institutions; however, in 24% of the hospitals EPs were required to contact another physician prior to giving thrombolytics. An Acute Myocardial Infarction (AMI) Continuous Quality Improvement (CQI) program was in place at 67%, and 44% of the institutions had an interdepartmental AMI protocol. Less than half of the EDs reported a door-to-drug time of less than 30 minutes. The primary delay in starting thrombolytic therapy was identified as decision-making on the part of the emergency physician and/or consultants. Missouri EDs report that they generally follow the NHAAP guidelines for rapid identification and treatment of AMI, but, there were still significant delays reported in the administration of thrombolytics.

Emergency medicine residency faculty scheduling: current practice and recent changes.

STUDY OBJECTIVE: To assess current emergency medicine faculty scheduling practices, preferences, and recent changes. DESIGN: Mail survey. PARTICIPANTS: All emergency medicine residency program directors and full-time faculty. INTERVENTIONS: Questions were asked about current faculty scheduling practices, preferences, and recent changes. RESULTS: Eighty-five percent (79 of 93) of the programs and 63% (606 of 961) of the full-time faculty responded. Faculty most commonly worked a combination of 8- and 12-hour shifts. Seventy-five percent of full-time faculty stated that they would prefer to work 8-hour shifts. Eighty-three percent of those who work some or all 8-hour shifts preferred 8-hour shifts; 21% of those working 12-hour shifts preferred the same (P < .0005; test of proportions difference, 62%; 95% confidence interval, 55% to 69%). Over the past 5 years, 40% of programs had shortened shift lengths, and the number of night shifts worked per month and/or the number of nights in a row worked per faculty decreased for 34%. CONCLUSION: Residency faculty prefer and have moved toward working shorter shifts. They are also working fewer night shifts per month and fewer night shifts in a row.

An unusual presentation of bilateral facet dislocation of the cervical spine.

We report the case of a patient who presented complaining of neck pain after a fall. Initial physical examination was remarkable for an occipital scalp contusion and tenderness to palpation in the mid-cervical spine. Neurological examination demonstrated an absence of response to pinprick below approximately the T4 level. Upper extremities had equal withdrawal to pain and lower extremities were without movement. Initial cervical, thoracic, and lumbar spine films were normal. An emergency myelogram demonstrated a complete extradural block at the C6 level. Cross-table lateral cervical spine films revealed a C5-C6 bilateral facet dislocation. The patient subsequently underwent closed reduction with in-line-traction. He had a prolonged hospital course and was eventually transferred for rehabilitation, with some improvement in neurologic status.

Percentage of emergency medicine residency graduates who got their first choice of jobs did not change between 1995 and 1997.

The objective of this study was to compare the number of emergency medicine (EM) graduates unable to find a job in the city/area of their first choice in 1995 and 1997. Self-administered questionnaires were distributed to EM residents who graduated in both 1995 and 1997. The survey ascertained resident's practice city and state, whether their job was in the city/area of first choice and how satisfied they were with their practice selection. Eighty (83%) programs and 507 (70%) of eligible residents participated. Thirty-eight percent of graduates chose to practice in the city or metropolitan area where they trained and 75% of respondents were very satisfied with their practice selection. Nineteen percent stated they would not be practicing in the city/area of their first choice; one-third indicated there were no jobs available and two-thirds stated that jobs were available but not desirable. These numbers were similar to the 1995 data (P = .79). Job selection was more important than liking (P < .001) or having lived in (P < .001) a desired city/area of practice location. In conclusion, 1997 EM residency graduates were as successful as 1995 graduates in obtaining their first choice of jobs.

Foreign body retention in glass-caused wounds.

STUDY OBJECTIVE: To describe patient and wound characteristics that are clinically useful in identifying wounds that were caused by glass and retained a foreign body. DESIGN: Retrospective consecutive case review. SETTING: Urban, university-affiliated teaching hospital. TYPE OF PARTICIPANTS: Four hundred thirty consecutive patients with a total of 578 evaluable wounds caused by glass during a 12-month period. MEASUREMENTS AND RESULTS: Medical records were reviewed to determine patient demographics, primary wound data (eg, location, type, description), mechanism of injury, type of glass involved, and presence of foreign body sensation. Glass was found by examination in 7% of wounds. Eight percent of 137 radiographs were positive. Wounds with the highest prevalence of retained glass were puncture wounds (P < .0005), those caused by stepping on glass or by a motor vehicle accident (P < .005), and those of the head or foot (P < .003). CONCLUSION: Characteristics of wounds most likely to retain glass were identified in this retrospective study. The presence of these factors should increase the clinician's suspicion of a retained glass foreign body. The indications for radiography for the detection of retained glass in wounds should be clarified with prospective studies.

Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration.

A convenience sample of 164 adult patients with 185 glass-caused wounds who presented to an emergency department (ED) and consented to a radiograph was prospectively studied. The purpose was to determine the characteristics of wounds at high risk for foreign body (FB) and the predictive value of patient FB sensation and probing wound exploration for FB retention. Retained glass was located in 28 (15%) wounds. Motor vehicle as a mechanism of injury (P=.003), head as a location (P=.035), and puncture as wound type (P=.002) were more likely to be associated with retained FBs (chi2 analysis). Patients with wounds with glass were more likely to have a positive perception of a foreign body (41%) than those with no glass (17%) (P=.005). The positive predictive value of patient perception was 31%; negative predictive value was 89%. In five cases, wound exploration was negative and subsequent radiograph was positive for FB. In one of these cases, a 4-mm glass FB was removed; in the other four, no FB was found. In conclusion, head wounds resulting from motor vehicle accidents or puncture wounds are more likely to harbor retained glass FBs. Patients with glass FB in wounds are more likely to have a positive perception of FB; however, a positive perception has a low predictive value of glass FB. In this series, a negative wound exploration made the presence of retained FB greater than 2 mm less likely but did not rule out the presence of retained glass.

Emergency medicine resident choice of practice location.

STUDY OBJECTIVE: To describe the geographic distribution of practice locations for 1995 emergency medicine residency graduates and factors that are important to residents in their choice of practice location. METHODS: Self-administered questionnaires were distributed to Emergency medicine residents who graduated in 1995. The survey ascertained practice city and state, resident employment characteristics, and the importance of factors that influenced the residents' selection of employment. RESULTS: Eighty-six of 87 programs and 441 (69.4%) of 635 eligible residents participated. Forty-three percent of graduates chose to practice in the city or metropolitan area in which they trained; 46% of these had no personal tie to the area before their residency training. Liking the city was cited as being more important (P<.001) than other factors in picking practice location. Group personality and coworkers' credentials were more important (P< or =.01) than contract and salary arrangement. Twenty percent of respondents were not practicing in the city or area of their first choice. CONCLUSION: Residency training location, regardless of prior ties to the geographical area, appears to be a major factor in the choice of practice location of emergency medicine residency graduates. Coworkers' personalities and credentials are more important factors in job selection than salary and employment arrangements.

Opioid toxicity recurrence after an initial response to naloxone.

OBJECTIVE: To determine the frequency and potential predictors of opioid toxicity recurrence after a response to naloxone in adult Emergency Department patients. METHODS: A retrospective case-control study of naloxone-treated patients with opioid toxicity over an 8-year period. Both the patient response to naloxone and recurrence of opioid toxicity was determined by an expert Delphi Panel. The frequency of opioid toxicity recurrence was compared by the duration of opioid effect, the route of opioid exposure, and the presence of other CNS depressant drugs. RESULTS: Ninety of 221 (41%) cases with a discharge diagnosis of opioid toxicity were treated with naloxone; six patients were excluded because of a lack of toxicity. There was a response to naloxone in 50% of the 84 cases, and recurrence of toxicity in 31% (95% CI 17-45%) of naloxone responders. The most common opioids were codeine, heroin, propoxyphene, and oxycodone/hydrocodone. Recurrence of toxicity was more common with long-acting opioids (p = 0.04), and was not associated with the route of opioid exposure (p = 0.42), or presence of ethanol and other CNS depressants (p > or = 0.87). CONCLUSION: Opioid toxicity recurrence after a response to naloxone occurred in approximately 1/3 of adult Emergency Department opioid overdose cases. Recurrence was more common with long-acting opioids and was not associated with the route of opioid exposure. Other clinically useful predictors of toxicity recurrence were not identified.