Setting the educational agenda and curriculum for error prevention in emergency medicine.

Graduate and postgraduate medical education currently teaches safety in patient care by instilling a deep sense of personal responsibility in student practitioners. To increase safety, medical education will have to begin to introduce new concepts from the "safety sciences," without losing the advantages that the values of commitment and responsibility have gained. There are two related educational goals. First, we in emergency medicine (EM) must develop a group of safety-educated practitioners who can understand and implement safe practice innovations in their clinical settings, and will be instrumental in changing our professional culture. Second, EM must develop a group of teachers and researchers who can begin to deeply understand how safety is maintained in emergency care, develop solutions that will work in emergency department settings, and pass on those insights and innovations. The specifics of what should be taught are outlined briefly. Work is currently ongoing to identify more specifically the core content that should be included in educational programs on patient safety in emergency care. Finally, careful attention will have to be paid to the way in which these principles are taught. It seems unlikely that a series of readings and didactic lectures alone will be effective. The analysis of meaningful cases, perhaps supplemented by high-fidelity simulation, seems to hold promise for more successful education in patient safety.

Development of a unique decentralized rapid-response capability and contingency mass-casualty field hospital for the 1996 Democratic National Convention.

This article describes the planning, development, and execution of a unique, decentralized, and flexible medical response capability that was developed for the 1996 Democratic National Convention in Chicago. Concerns for coordinated acts of violence, terrorism, toxicologic exposures, and logistic problems posed by the United Center prompted the development of a decentralized and flexible rapid-response plan. Contingency planning for the remote possibility of a full-scale disaster led to the additional development of a contingency mass-casualty field hospital on site. The plans for this mass-gathering response are described in considerable detail. Forty-four patient encounters across the four days of the convention were recorded, with a combination of minor injuries and potentially serious medical presentations. The 1.46 EMS encounters per 1,000 attendees at the Democratic National Convention is comparable to other utilization rates for mass gatherings in the literature. Proactive attention to comprehensive contingency planning for equipment, supplies, personnel, and organizational needs, especially when multiagency response and cooperation are required, is essential.

Qualitative research methodologies in emergency medicine.

Qualitative research methodologies, though often used in other fields and in medical educational investigations. have not been used to study problems in emergency medicine (EM). These methodologies address qualitative data and provide a process of describing, interpreting, and explaining the dynamics of a population or phenomenon. The stages of a qualitative investigation include initial narrative description, interpretation, theory development, assessment of generalization, and evaluation. Important differences between this framework and those of quantitative research methods are described. These methods may be applied to systematic investigation of virtually any observable phenomenon or process in EM in which a better understanding of process would be valuable, such as patient flow, patient satisfaction issues, patient turnover and sign-out processes, bedside teaching, EM teamwork dynamics, and development of the career interests of students and residents. As with quantitative research, EM academicians should seek collaboration and appropriate training with guidance by established qualitative investigators when applying these methods.

Hypokalemic paralyses: a review of the etiologies, pathophysiology, presentation, and therapy.

Acute hypokalemic paralysis is an uncommon cause of acute weakness. Morbidity and mortality associated with unrecognized disease include respiratory failure and death. Hence, it is imperative for physicians to be knowledgeable about the causes of hypokalemic paralysis, and consider them diagnostically. The hypokalemic paralyses represent a heterogeneous group of disorders with a final common pathway presenting as acute weakness and hypokalemia. Most cases are due to familial hypokalemic paralysis; however, sporadic cases are associated with diverse underlying etiologies including thyrotoxic periodic paralysis, barium poisoning, renal tubular acidosis, primary hyperaldosteronism, licorice ingestion, and gastrointestinal potassium losses. The approach to the patient with hypokalemic paralysis includes a vigorous search for the underlying etiology and potassium replacement therapy. Further therapy depends on the etiology of the hypokalemia. Disposition depends on severity of symptoms, degree of hypokalemia, and chronicity of disease.

Chloral hydrate for emergent pediatric procedural sedation: a new look at an old drug.

Chloral hydrate has been time honored for pediatric procedural sedation, but its efficacy in sedation for emergency department (ED) procedures is unreported. It is hypothesized that chloral hydrate is safe and effective for ED pediatric sedation. Ninety-five consecutive children ranging from 1-10 years and requiring procedural intervention in a municipal teaching hospital ED were included in a nonrandomized controlled trial. Patients with respiratory depression, somnolence, allergy, multisystem trauma, head injury, or abdominal pain were excluded. Forty-two subjects received chloral hydrate 25 to 50 mg/kg orally at physician discretion, and 53 subjects served as controls. Cooperation with procedural completion was rated by the treating physician using the four-point sedation scoring system modified from Moody et al (1 = poor, 4 = excellent). The two groups' sedation scores were compared by the Mann Whitney U test with significance at P less than .05. Age-related subgroups of children were similarly compared. The treatment group achieved sedation score of 2.86, whereas controls had sedation score of 2.75 (P = 0.63, beta error 20% at 0.37 score difference). Subgroup analysis of children less than 6 years old (2.95 experimental versus 2.57 control) and less than 4 years old (3.00 experimental versus 2.32 control) reveals statistically significant differences (P less than .0001 and P = .01, respectively) in favor of higher sedation scores in the chloral hydrate group. Time to sedation was 42.7 minutes, time to recovery was 42.0 minutes, and no adverse drug effects were noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Zidovudine for prophylaxis of human immunodeficiency virus infection after accidental exposure.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in emergency medicine. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items of progress in emergency medicine that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Emergency Medicine of the California Medical Association, and the summaries were prepared under its direction.

Evaluation and management of supraventricular tachycardia in children.

Emergency physicians may be called on to resuscitate acute complications in pediatric patients with congenital heart disease. Supraventricular tachycardia, with or without hemodynamic decompensation, is one of the most serious complications. We present the case of a 22-month-old boy with a history of single ventricle who presented to our institution with a history of syncope and hemodynamically stable supraventricular tachycardia. Initial attempts at pharmacologic conversion with propranolol and verapamil failed. The arrhythmia was terminated in response to an IV fluid bolus and dopamine infusion and probably resulted from a combination of anemia, hypovolemia, and impaired contractility. Appropriate evaluation and management relating to the cre of acute supraventricular tachycardia in children are discussed.