Annals of Emergency Medicine RSS feed: Current Issue. Scope and Stature of the Journal Annals of Emergency Medicine , the official journal of the American College of Emergency Physicians, is an international, peer-reviewed journal dedicated to improving the quality of care by publishing the highest quality science for emergency medicine and related medical specialties. Annals publishes original research, clinical reports, opinion, and educational information related to the practice, teaching, and research of emergency medicine. In addition to general emergency medicine topics, Annals regularly publishes articles on out-of-hospital emergency medical services, pediatric emergency medicine, injury and disease prevention, health policy and ethics, disaster management, toxicology, and related topics. The journal welcomes submissions from international contributors and researchers of all specialties. Although Annals of Emergency Medicine is the official journal of the American College of Emergency Physicians (ACEP) the journal maintains editorial independence from ACEP. Its content is selected by the editorial board and does not necessarily reflect the policies and beliefs of ACEP. Annals continues to be the largest circulation peer review journal in emergency medicine (over 31,000 subscribers, several times its nearest competitor). It is also one of the most accessible to non-subscribing readers, since more than 8,000 institutions include Annals in their online licenses for ScienceDirect (the world's largest electronic collection of science, technology and medicine full text and bibliographic information). ScienceDirect was utilized for access to Annals articles approximately 575,000 times in 2012. Annals is also available on the Web (with full text of all articles dating back to its inception), where it received more than 1,377,000 page views in 2012. Annals is the emergency medicine journal most frequently cited by authors and has the highest impact factor over the years of all 24 journals in the emergency medicine category of the SCI (Science Citation Index). The impact factor (the average number of citations per published article) is the commonest measure of journal influence; the 2011 impact factor for Annals was 4.133. Not only is Annals most frequently cited, but it is cited more promptly and longer than any other emergency medicine journal (9 years, versus only 5.1 years for its nearest competitor). Annals ' articles generate considerable interest in the lay media. During the calendar year 2012, there were 4,503 hits in various media outlets, including print, television, radio blogs and social media. Major outlets included New York Times, Washington Post, USA Today, Reuters (26 hits), Los Angeles Times, TIME, Chacago Triubne (10 hits), Boston Globe, Wall Street Journal, CBS, Market Watch, National Public Radio, ABC, CBS, CNN and NBC. Annals is an international journal; more than half of the full text articles accessed via ScienceDirect were downloaded by readers in countries outside the U.S. Our contributors are also international in scope; in 2012 submissions came to us from 46 different countries, with 41% of submissions originating outside the United States, and 26% originating outside North America and Western Europe. The largest volume other than the U.S. was submitted from Taiwan, France, Canada, China, United Kingdom, Italy, and Korea, in descending order. But the list also includes Indonesia, Pakistan, Qatar, Tunisia, and Serbia. We strongly believe we have an obligation to make our journal available to international audiences regardless of their financial resources, and therefore have participated for many years in the HINARI initiative sponsored by large journal publishers ( http://www.healthinternetwork.org/src/eligibility.php ), which makes Annals available free or at greatly reduced cost in low-income countries. http://www.annemergmed.com/?rss=yesElsevier Inc.en © 2012 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. Annals of Emergency Medicine0196-0644616June 2013 © 2012 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.annemergmed.com/article/PIIS019606441201699X/abstract?rss=yes Study objective: Emergency department (ED) crowding is a prevalent health delivery problem and may adversely affect the outcomes of patients requiring admission. We assess the association of ED crowding with subsequent outcomes in a general population of hospitalized patients. Methods: We performed a retrospective cohort analysis of patients admitted in 2007 through the EDs of nonfederal, acute care hospitals in California. The primary outcome was inpatient mortality. Secondary outcomes included hospital length of stay and costs. ED crowding was established by the proxy measure of ambulance diversion hours on the day of admission. To control for hospital-level confounders of ambulance diversion, we defined periods of high ED crowding as those days within the top quartile of diversion hours for a specific facility. Hierarchic regression models controlled for demographics, time variables, patient comorbidities, primary diagnosis, and hospital fixed effects. We used bootstrap sampling to estimate excess outcomes attributable to ED crowding. Results: We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs. Conclusion: Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients. Effect of Emergency Department Crowding on Outcomes of Admitted PatientsBenjamin C. Sun, Renee Y. Hsia, Robert E. Weiss, David Zingmond, Li-Jung Liang, Weijuan Han, Heather McCreath, Steven M. Asch10.1016/j.annemergmed.2012.10.026Annals of Emergency Medicine 61, 6 (2013)2012-12-10Annals of Emergency Medicine2012-12-10616S0196-0644(13)X0005-8Health Policy605611.e6http://www.annemergmed.com/article/PIIS0196064412018483/abstract?rss=yesSEE RELATED ARTICLE, P. 605. [Ann Emerg Med. 2013;61:612-614.] In this issue of Annals, Sun et al report on the association between emergency department (ED) crowding and 3 important outcomes—mortality, hospital length of stay, and costs—in a broad cohort of admissions in 187 California hospitals in 2007. Patients admitted on days with high crowding, measured as the top quartile of ambulance diversion, had a 5% higher chance of death, an almost 1% longer hospital stay, and 1% higher costs per admission, after adjusting for other factors. The estimate of the human and financial costs attributable to ED crowding was 300 additional inpatient deaths, 6,200 excess hospital days, and $17 million extra.Emergency Department Crowding in California: A Silent Killer?Jesse M. Pines10.1016/j.annemergmed.2012.12.016Annals of Emergency Medicine 61, 6 (2013)2013-02-01Annals of Emergency Medicine2013-02-01616S0196-0644(13)X0005-8Health Policy612614http://www.annemergmed.com/article/PIIS0196064413003466/abstract?rss=yesIn the April 2013 issue, in the letter to the editor by Cooper et al (“The Threshold for CT Scanning Anticoagulated Head Injury Patients Is Still Not Yet Clear,” pages 500-501), Jamie G. Cooper, MBChB, was listed twice as an author. We regret this error.Correction10.1016/j.annemergmed.2013.04.008Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Health Policy614614http://www.annemergmed.com/article/PIIS0196064412016101/abstract?rss=yesAn 8-year-old boy presented to the emergency department after a classroom stapler was thrown at him from close range. There was no loss of consciousness or vomiting. The patient had a Glasgow Coma Scale score of 15, a normal neurologic examination, and a 2-cm semilunar laceration over the left side of the parietal scalp, without significant underlying hematoma (). A period of observation was initially elected over computed tomography (CT). However, on irrigation of the wound, an elevated bone fragment was identified () and CT was performed ().A Child With Blunt Head InjuryKristin Berona, Eva Delgado, Christine Cho10.1016/j.annemergmed.2012.10.005Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Images in Emergency Medicine615615http://www.annemergmed.com/article/PIIS0196064413000139/abstract?rss=yes Study objective: Medicare's new, mandatory Hospital Inpatient Value-Based Purchasing Program introduces financial rewards or penalties to hospitals according to achievement or improvement on several publicly reported quality measures. Our objective was to describe hospital reporting on the 4 emergency department (ED)–related program measures, variation in performance on the ED measures across hospital characteristics, and the characteristics of hospitals that were more likely to receive performance scores based on improvement versus achievement. Methods: This was an exploratory, descriptive analysis. We merged 2008 to 2010 performance data from Hospital Compare with the 2009 American Hospital Association Annual Survey. We calculated a composite score for the 4 ED measures and used Kruskal-Wallis tests to examine differences in performance across hospital characteristics. We also examined differences in the percentage of scores that were awarded according to improvement versus achievement. Results: There were 2,927 hospitals that qualified for the value-based purchasing program and were included in the analysis. For-profit hospitals received the highest scores; public hospitals and hospitals lacking The Joint Commission (TJC) accreditation received the lowest scores. Public hospitals had the largest share of scores awarded according to improvement (39.8%); for-profit hospitals had the lowest (27.8%). Conclusion: We found variation in performance by hospital characteristics on the ED-related program measures. Although public and non–TJC-accredited hospitals trailed in performance, they showed strong signs of improvement, signaling that performance gaps by ownership and accreditation may decrease. Considering the increasing scope of the value-based purchasing program, ED leaders should monitor both achievement and improvement on the 4 ED-related program measures. An Early Look at Performance on the Emergency Care Measures Included in Medicare's Hospital Inpatient Value-Based Purchasing ProgramMegan McHugh, Jennifer Neimeyer, Emilie Powell, Rahul K. Khare, James G. Adams10.1016/j.annemergmed.2013.01.012Annals of Emergency Medicine 61, 6 (2013)2013-03-13Annals of Emergency Medicine2013-03-13616S0196-0644(13)X0005-8Health Policy616623.e2http://www.annemergmed.com/article/PIIS0196064412017350/abstract?rss=yesIn 2009, representatives from many of the major stakeholder organizations in emergency medicine convened in Dallas, TX, to discuss the future of emergency medicine, with a focus on workforce. The consensus article was subsequently published and remains a vital resource for projecting emergency medicine workforce needs. In reaction to the enactment of the Patient Protection and Affordable Care Act, representatives from the same major organizations in emergency medicine convened in Dallas in January 2011. There was consensus that health care reform had the potential to increase the percentage of physicians, not just emergency physicians, employed by large groups or hospitals. Concerns were also raised about the need for physicians to gather non–value-added data that do not benefit the patient. The following additional areas emerged as topics of concern: the projected physician workforce requirements in emergency medicine, the provision of quality care in rural areas, effect of health care reform on the practice of emergency medicine, particularly the threat of increased employment of physicians, the role of nonphysicians in providing emergency care within the ED and in the out-of-hospital setting, and the use of telemedicine to expand the reach of the emergency physician workforce.The Future of Emergency Medicine: Update 2011Angela Gardner, Sandra M. Schneider, The Future of Emergency Medicine Summit II Participants10.1016/j.annemergmed.2012.11.004Annals of Emergency Medicine 61, 6 (2013)2013-02-07Annals of Emergency Medicine2013-02-07616S0196-0644(13)X0005-8Health Policy624630http://www.annemergmed.com/article/PIIS0196064412018367/abstract?rss=yes Study objective: Enhancing emergency department (ED) patient satisfaction has wide-ranging benefits. We seek to determine how postvisit patient-physician contact by e-mail or telephone affects patients' satisfaction with their emergency physician. Methods: We undertook this crossover study from May 1, 2010, to June 30, 2010, at 2 community EDs. Forty-two physicians either e-mailed or telephoned their patients within 72 hours of the ED visit for 1 month; in the alternate month, they provided no contact, serving as their own controls. Patients received satisfaction surveys after their ED visit. Patient satisfaction is reported as a percentage of those responding very good or excellent on a 5-point Likert scale for 3 questions about their emergency physician's skills, care, and communication. We calculated differences between patient groups (noncontact versus contact) using an intention-to-treat analysis. Results: The mean patient satisfaction score was 79.4% for the 1,002 patients in the noncontact group and 87.7% for the 348 patients in the contact group (difference 8.3%; 95% confidence interval 4.0% to 12.6%). Patient satisfaction scores were similar for e-mail and telephone contact: 89.3% for the e-mail group and 85.2% for the telephone group (difference 4.1%; 95% confidence interval −2.3% to 10.5%). Conclusion: Patient satisfaction was higher when emergency physicians contacted patients briefly after their visit, either by e-mail or by telephone. Higher patient satisfaction was observed equally among patients contacted by e-mail and those contacted by telephone. Postvisit patient-physician contact could be a valuable practice to improve ED patient satisfaction. Physician E-mail and Telephone Contact After Emergency Department Visit Improves Patient Satisfaction: A Crossover TrialPankaj B. Patel, David R. Vinson10.1016/j.annemergmed.2012.12.005Annals of Emergency Medicine 61, 6 (2013)2013-02-27Annals of Emergency Medicine2013-02-27616S0196-0644(13)X0005-8The Practice of Emergency Medicine631637http://www.annemergmed.com/article/PIIS0196064413000383/abstract?rss=yes Study objective: We explore the variation in physician- and hospital-level admission rates in a group of emergency physicians in a single health system. Methods: This was a cross-sectional study that used retrospective data during various periods (2005 to 2010) to determine the variation in admission rates among emergency physicians from 3 emergency departments (EDs) within the same health system. Patients who left without being seen or left against medical advice, patients treated in fast-track departments, patients with primary psychiatric complaints, and those younger than 18 years were excluded, as were physicians with fewer than 500 ED encounters during the study period. Emergency physician–level and hospital-level admission rates were estimated with hierarchic logistic regression, which adjusted for patient age, sex, race, chief complaint, arrival mode, and arrival day and time. Results: A total of 389,120 ED visits were included in the analysis, and patients were treated by 89 attending emergency physicians. After adjusting for patient and clinical characteristics, the hospital-level admission rate varied from 27% to 41%. At the physician level, admission rates varied from 21% to 49%. Conclusion: There was 2.3-fold variation in emergency physician adjusted admission rates and 1.7-fold variation at the hospital level. In the new era of cost containment, wide variation in this common, costly decision requires further exploration. Emergency Department Physician-Level and Hospital-Level Variation in Admission RatesJameel Abualenain, William J. Frohna, Robert Shesser, Ru Ding, Mark Smith, Jesse M. Pines10.1016/j.annemergmed.2013.01.016Annals of Emergency Medicine 61, 6 (2013)2013-02-18Annals of Emergency Medicine2013-02-18616S0196-0644(13)X0005-8The Practice of Emergency Medicine638643http://www.annemergmed.com/article/PIIS0196064413001005/abstract?rss=yes Study objective: We undertake a systematic review of the quantitative literature related to the effect of computerized provider order entry systems in the emergency department (ED). Methods: We searched MEDLINE, EMBASE, Inspec, CINAHL, and CPOE.org for English-language studies published between January 1990 and May 2011. Results: We identified 1,063 articles, of which 22 met our inclusion criteria. Sixteen used a pre/post design; 2 were randomized controlled trials. Twelve studies reported outcomes related to patient flow/clinical work, 7 examined decision support systems, and 6 reported effects on patient safety. There were no studies that measured decision support systems and its effect on patient flow/clinical work. Computerized provider order entry was associated with an increase in time spent on computers (up to 16.2% for nurses and 11.3% for physicians), with no significant change in time spent on patient care. Computerized provider order entry with decision support systems was related to significant decreases in prescribing errors (ranging from 17 to 201 errors per 100 orders), potential adverse drug events (0.9 per 100 orders), and prescribing of excessive dosages (31% decrease for a targeted set of renal disease medications). Conclusion: There are tangible benefits associated with computerized provider order entry/decision support systems in the ED environment. Nevertheless, when considered as part of a framework of technical, clinical, and organizational components of the ED, the evidence base is neither consistent nor comprehensive. Multimethod research approaches (including qualitative research) can contribute to understanding of the multiple dimensions of ED care delivery, not as separate entities but as essential components of a highly integrated system of care. The Effect of Computerized Provider Order Entry Systems on Clinical Care and Work Processes in Emergency Departments: A Systematic Review of the Quantitative LiteratureAndrew Georgiou, Mirela Prgomet, Richard Paoloni, Nerida Creswick, Antonia Hordern, Scott Walter, Johanna Westbrook10.1016/j.annemergmed.2013.01.028Annals of Emergency Medicine 61, 6 (2013)2013-04-01Annals of Emergency Medicine2013-04-01616S0196-0644(13)X0005-8The Practice of Emergency Medicine644653.e16http://www.annemergmed.com/article/PIIS0196064412006099/abstract?rss=yes Study objective: We identify hospital-level factors from the administrative perspective that affect the availability and delivery of palliative care services in the emergency department (ED). Methods: Semistructured interviews were conducted with 14 key informants, including hospital executives, ED directors, and palliative care directors at a tertiary care center, a public hospital, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews. Results: Barriers to integrating palliative care and emergency medicine from the administrative perspective include the ED culture of aggressive care, limited knowledge, palliative care staffing, and medicolegal concerns. Incentives to the delivery of palliative care in the ED from these key informants' perspective include improved patient and family satisfaction, opportunities to provide meaningful care to patients, decreased costs of care for admitted patients, and avoidance of unnecessary admissions to more intensive hospital settings, such as the ICU, for patients who have little likelihood of benefit. Conclusion: Though hospital administration at 3 urban hospitals on the East coast has great interest in integrating palliative care and emergency medicine to improve quality of care, patient and family satisfaction, and decrease length of stay for admitted patients, palliative care staffing, medicolegal concerns, and logistic issues need to be addressed. Hospital Administrators' Views on Barriers and Opportunities to Delivering Palliative Care in the Emergency DepartmentCorita R. Grudzen, Lynne D. Richardson, Hannah Major-Monfried, Brandon Kandarian, Joanna M. Ortiz, R. Sean Morrison10.1016/j.annemergmed.2012.06.008Annals of Emergency Medicine 61, 6 (2013)2012-07-09Annals of Emergency Medicine2012-07-09616S0196-0644(13)X0005-8Palliative Care654660http://www.annemergmed.com/article/PIIS0196064413000425/abstract?rss=yes Study objective: We describe 11 clinical demonstrations of emergency department (ED) and palliative care integration to include traditional consultation services with hospital-based palliative care consultants through advanced integration demonstrations in which the ED provides subspecialty palliative care practice. Methods: An interview guide was developed by the Improving Palliative Care in Emergency Medicine board that consists of emergency clinicians and palliative care practitioners. Structured interviews of 11 program leaders were conducted to describe the following key elements of the ED–palliative care integration, to include structure, function, and process of the programs, as well as strengths, areas of improvement, and any tools or outcome measures developed. Results: In this limited number of programs, a variety of strategies are used to integrate palliative care in the ED, from traditional consultation to well-defined partnerships that include board-certified emergency clinicians in hospice and palliative medicine. Conclusion: A variety of methods to integrate palliative care in the emergency setting have emerged. Few programs collect outcomes-based metrics, and there is a lack of standardization about what metrics are tracked when tracking occurs. Demonstrations of Clinical Initiatives to Improve Palliative Care in the Emergency Department: A Report From the IPAL-EM InitiativeTammie Quest, Sherol Herr, Sangeeta Lamba, David Weissman10.1016/j.annemergmed.2013.01.019Annals of Emergency Medicine 61, 6 (2013)2013-04-01Annals of Emergency Medicine2013-04-01616S0196-0644(13)X0005-8Palliative Care661667http://www.annemergmed.com/article/PIIS0196064412019129/abstract?rss=yes Study objective: A variety of methods have been proposed and used in disaster triage situations, but there is little more than expert opinion to support most of them. Anecdotal disaster experiences often report mediocre real-world triage accuracy. The study objective was to determine the accuracy of several disaster triage methods when predicting clinically important outcomes in a large cohort of trauma victims. Methods: Pediatric, adult, and geriatric trauma victims from the National Trauma Data Bank were assigned triage levels, using each of 6 disaster triage methods: simple triage and rapid treatment (START), Fire Department of New York (FDNY), CareFlight, Glasgow Coma Scale (GCS), Sacco Score, and Unadjusted Sacco Score. Methods for approximating triage systems were vetted by subject matter experts. Triage assignments were compared against patient mortality at hospital discharge with area under the receiver operator curve. Secondary outcomes included death in the emergency department, use of a ventilator, and lengths of stay. Subgroup analysis assessed triage accuracy in patients by age, trauma type, and sex. Results: In this study, 530,695 records were included. The Sacco Score predicted mortality most accurately, with area under the receiver operator curve of 0.883 (95% confidence interval 0.880 to 0.885), and performed well in most subgroups. FDNY was more accurate than START for adults but less accurate for children. CareFlight was best for burn victims, with area under the receiver operator curve of 0.87 (95% confidence interval 0.85 to 0.89) but mistriaged more salvageable trauma patients to “dead/black” (41% survived) than did other disaster triage methods (≈10% survived). Conclusion: Among 6 disaster triage methods compared against actual outcomes in trauma registry patients, the Sacco Score predicted mortality most accurately. This analysis highlighted comparative strengths and weakness of START, FDNY, CareFlight, and Sacco, suggesting areas in which each might be improved. The GCS predicted outcomes similarly to dedicated disaster triage strategies. Head-to-Head Comparison of Disaster Triage Methods in Pediatric, Adult, and Geriatric PatientsKeith P. Cross, Mark X. Cicero10.1016/j.annemergmed.2012.12.023Annals of Emergency Medicine 61, 6 (2013)2013-02-27Annals of Emergency Medicine2013-02-27616S0196-0644(13)X0005-8Disaster Medicine668676.e7http://www.annemergmed.com/article/PIIS0196064413001091/abstract?rss=yes Study objective: Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs. Methods: Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies. Results: From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings. Conclusion: The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies. Systematic Review of Strategies to Manage and Allocate Scarce Resources During Mass Casualty EventsJustin W. Timbie, Jeanne S. Ringel, D. Steven Fox, Francesca Pillemer, Daniel A. Waxman, Melinda Moore, Cynthia K. Hansen, Ann R. Knebel, Richard Ricciardi, Arthur L. Kellermann10.1016/j.annemergmed.2013.02.005Annals of Emergency Medicine 61, 6 (2013)2013-03-25Annals of Emergency Medicine2013-03-25616S0196-0644(13)X0005-8Disaster Medicine677689.e101http://www.annemergmed.com/article/PIIS0196064412003563/abstract?rss=yesAcute pain management for patients sustaining injuries in natural disasters and complex emergencies should be a priority for medical providers. Although there are minimal data examining the modalities and effectiveness of pain control in disaster settings, what data exist reveal practices that would be considered grossly inadequate in a typical emergency department (ED) setting.Pain Control in Disaster Settings: A Role for Ultrasound-Guided Nerve BlocksSuzanne C. Lippert, Arun Nagdev, Michael B. Stone, Andrew Herring, Robert Norris10.1016/j.annemergmed.2012.03.028Annals of Emergency Medicine 61, 6 (2013)2012-05-14Annals of Emergency Medicine2012-05-14616S0196-0644(13)X0005-8Disaster Medicine690696http://www.annemergmed.com/article/PIIS0196064412018082/abstract?rss=yes Opposing authors provide succinct, authoritative discussions of controversial issues in emergency medicine. Authors are provided the opportunity to review and comment on opposing presentations. Each topic is accompanied by an Editor's Note that summarizes important concepts. Participation as at authoritative discussant is by invitation only, but suggestions for topics and potential authors can be submitted to the section editors.Continuous Capnography Should Be Used for Every Emergency Department Procedural SedationNicholas M. Mohr, Brian Wessman10.1016/j.annemergmed.2012.11.018Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Clinical Controversies697698http://www.annemergmed.com/article/PIIS0196064412017155/abstract?rss=yesAnd get the machine that goes “ping.” And get most the expensive machine, in case the administrator comes. —Monty Python's The Meaning of Life, 1983Routine Capnographic Monitoring is Not Indicated for All Patients Undergoing Emergency Department Procedural SedationSophie Terp, David L. Schriger10.1016/j.annemergmed.2012.10.041Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Clinical Controversies698699http://www.annemergmed.com/article/PIIS0196064413001376/abstract?rss=yes[Ann Emerg Med. 2013;61:700-702.] At the time of this writing, it has been 2 months since Newtown. We have each mourned from a distance, imagining the heartbreak. We have asked ourselves what we would have done were this our community, our school, our child. We have formed opinions about what may or may not have stopped this tragedy. And we have each quietly recalled other tragedies that we have witnessed.A Call to Action: Firearms, Public Health, and Emergency MedicineMegan L. Ranney, Jeffrey Sankoff, David H. Newman, Andrew Fenton, Leslie Mukau, William E. Durston, Dustin W. Ballard, Garen Wintemute10.1016/j.annemergmed.2013.02.015Annals of Emergency Medicine 61, 6 (2013)2013-03-13Annals of Emergency Medicine2013-03-13616S0196-0644(13)X0005-8Injury Prevention700702http://www.annemergmed.com/article/PIIS0196064413002199/abstract?rss=yes[National Highway Traffic Safety Administration. Not-in-Traffic Surveillance—non-crash injuries. Ann Emerg Med. 2013;61:703-704.] The Not-in-Traffic Surveillance (NiTS) system provides information about fatalities and injuries in nontraffic crashes and in noncrash incidents that has not routinely been collected by the National Highway Traffic Safety Administration (NHTSA) in the past. Additionally, NHTSA has created a Web site, Parents Central, to provide parents and caregivers with information about the potential dangers to children in and around motor vehicles, which may be accessed at http://www.safercar.gov/parents.Not-in-Traffic Surveillance—Non-Crash Injuries1National Highway Traffic Safety Administration10.1016/j.annemergmed.2013.03.008Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Injury Prevention703704http://www.annemergmed.com/article/PIIS0196064413002205/abstract?rss=yes[Patek G, Thoma T. Commentary: vehicular hyperthermia: the reason to look before you lock. Ann Emerg Med. 2013;61:704-706.] Emergency physicians understand that disaster often lurks just around the corner. Even the most peaceful shifts can be suddenly disrupted by tragedy. These tragedies are frequently life altering for the victim and their families, but for us, it is part of our job. Although most of us are compassionate, professional, and empathetic, we try not to allow these situations to become a component of our personal lives. Sometimes this becomes unavoidable. Last summer, a young professional in our community had altered his daily routine. While distracted on his way to work, he forgot to drop his 6-month-old daughter off at daycare. This omission was not discovered until late afternoon. The child was found unresponsive in the backseat, still restrained in her car seat, and rushed to our ED with heatstroke. Despite resuscitative measures, she did not survive. All of the employees on duty that day were devastated. Grief counseling was provided to our staff during the next several days. To our knowledge, this is only the second time in the last 20 years that such counseling was deemed necessary for our staff.Commentary: Vehicular Hyperthermia: The Reason to Look Before You LockGregory C. Patek, Todd G. Thoma10.1016/j.annemergmed.2013.03.009Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Injury Prevention704706http://www.annemergmed.com/article/PIIS0196064413001364/abstract?rss=yes [Ann Emerg Med. 2013;61:707.] Sitting in the backyard on a summer evening with friends and a beer, people trade anecdotes and talk about life and work. I want to share but feel left out. After hearing about the overly picky client for whom a friend is working on a new iPhone app and new issues with the landfill described by another who works for the city recycling program, I naturally want to contribute.Lost in TranslationNoah K. Rosenberg10.1016/j.annemergmed.2013.02.014Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Change of Shift707707http://www.annemergmed.com/article/PIIS0196064413002552/abstract?rss=yes This study used a waiver of informed consent because study patients were acutely agitated at enrollment and therefore unable to provide informed consent. Are 2 Drugs Better Than 1 for Acute Agitation? A Discussion on Black Box Warnings, Waiver of Informed Consent, and the Ethics of Enrolling Impaired Subjects in Clinical Trials: Answers to the January 2013 Journal Club QuestionsStephanie A. Eucker, Tyler W. Barrett, David L. Schriger10.1016/j.annemergmed.2013.03.020Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Annals of Emergency Medicine Journal Club708716http://www.annemergmed.com/article/PIIS0196064412016095/abstract?rss=yesA 16-year-old previously healthy black adolescent male presented to the emergency department (ED) with a rapidly enlarging mass on his hard palate for 2 months. During the previous 3 weeks, he had begun to experience mild dysphagia and intermittent bleeding when ingesting solid foods. The bleeding had become more severe during the past day, causing him to visit the ED. The patient denied any history of oral trauma, drooling, odynophagia, fever, or weight loss. His physical examination was unremarkable except for a complex, well-circumscribed, 4×4-cm, friable mass on the hard palate (). No cervical lymphadenopathy was noted.An Adolescent Male With a Large Palatal MassLauren E. Staple, Mohsen Saidinejad10.1016/j.annemergmed.2012.10.004Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Images in Emergency Medicine717717http://www.annemergmed.com/article/PIIS0196064412018173/abstract?rss=yes1,3-Dimethylamylamine (DMAA) is a central nervous system stimulant that can be synthesized and has been detected in small quantities in Pelargonium graveolens. Case studies of recreational DMAA use reported previously in Annals indicate acute vascular toxicity. DMAA-containing dietary supplement products, by virtue of their formulations and label instructions, may result in an order of magnitude lower DMAA consumption than DMAA “party pills,” which may contain 300 mg DMAA per pill. Authors of numerous clinical studies of DMAA in healthy adults (ingesting 30 to 60 mg DMAA/day) report transient increases in blood pressure but no toxic effects. Case studies may suggest that the implicit risk of adverse effects from DMAA consumption is defined by high-exposure hazards associated with recreational-abusive usage, rather than the dose-response relationship over the continuum of uses. For many dietary supplements, the available dose-response information is data poor. However, for DMAA, preliminary results of human pharmacokinetic trials, which we discuss presently, make possible quantitative comparisons between internal body burden and clinical effects of low-dose dietary supplement use and high-dose recreational abuse.Pharmacokinetic Data Distinguish Abusive Versus Dietary Supplement Uses of 1,3-DimethylamylamineJoseph V. Rodricks, Michael H. Lumpkin, Brian K. Schilling10.1016/j.annemergmed.2012.11.022Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Correspondence718719http://www.annemergmed.com/article/PIIS0196064412018161/abstract?rss=yesOur case reports had the obvious limitation that doses received by patients were self-reported and subject to recall bias. Rodricks et al have provided some data on the pharmacokinetics of Dimethylamylamine (DMAA) received at known doses. Given the limited number of persons studied so far, we cannot rule out individual differences in absorption, metabolism, or elimination as causes for the variation in blood levels. It is, however, useful to have further data to make comparisons and more useful if they are reported fully with peer review.In replyPaul Gee10.1016/j.annemergmed.2012.12.004Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Correspondence719720http://www.annemergmed.com/article/PIIS0196064412018513/abstract?rss=yesThe Centers for Medicare & Medicaid Services (CMS) adopted 7 imaging efficiency measures for the Hospital Outpatient Quality Reporting Program. Currently, CMS reports 4 measures on Hospital Compare and will expand to 6 measures in July 2012. We developed these measures with a transparent and rigorous development and testing process. The Technical Expert Panel convened for these measures included emergency physicians, radiologists, and other physicians. We also sought the opinions of hospital stakeholders, specialty societies, and patient advocates during 2 public comment periods and a listening session.Assessment of Medicare's Imaging Efficiency Measure for Emergency Department Patients With Atraumatic HeadacheSusan L. Arday, Shaheen Halim, Karen T. Nakano10.1016/j.annemergmed.2012.11.023Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Correspondence720721http://www.annemergmed.com/article/PIIS0196064412018525/abstract?rss=yesThe Outpatient Measure 15 (OP-15) measure developers question our methods, calculations of reliability and validity, and generalizability. First, they cite “information bias,” which we assume refers to our measure of reliability, for which we compared OP-15, which used administrative claims, to chart review data. This is the correct method for measuring the reliability of an administrative claims measure, as noted by the American Medical Association (AMA). Information bias refers to “a flaw in measuring exposure, covariate, or outcome variables that result in different quality (accuracy) of information between comparison groups,” which is not applicable here.In replyJeremiah D. Schuur, Ali S. Raja, Ali S. Raja10.1016/j.annemergmed.2012.12.019Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Correspondence721722http://www.annemergmed.com/article/PIIS0196064413000097/abstract?rss=yesWhen I first started reading When Doctors Don't Listen: How to Avoid Misdiagnoses and Unnecessary Tests, I must admit I was inherently skeptical. I was preparing myself for another “doctor bashing” book detailing how far we've gone astray from the path of the good old days when physicians made house calls, spent all night at a patient's bedside, and used seemingly magical powers of diagnosis to do what modern science still cannot. As a practicing emergency physician having worked in both the community and academic setting, I approached the author's primary premise, that modern “cookbook medicine” does less to aid in diagnosis discovery than the old standbys of combining a good history with a thorough physical examination, with a sense of ambivalence. To be clear, I fully agree with this premise and even teach it to my medical students and residents, but the reality is that the emergency department (ED) makes this kind of detective work challenging. In fact, the early case examples the authors chose seemed to only solidify my bias and confirmed that the ED is not the place to implement this open-ended approach to diagnosis; maybe the medicine wards or a specialty clinic, but not the ED, where we are charged with ruling out the most life-threatening diseases in multiple patients simultaneously. After all, it's not our job to figure out what's going on with the patient the ED, only what isn't, right?Dan S. Mosely10.1016/j.annemergmed.2013.01.008Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Book and Media Review723723http://www.annemergmed.com/article/PIIS019606441300317X/abstract?rss=yes[Ann Emerg Med. 2013;61:724-725.] The American College of Emergency Physicians (ACEP) believes that the quality of patient care is enhanced when emergency physicians interpret and record the results of the diagnostic studies they order at the time of service. Although the interpretation of diagnostic studies by other specialists may be important to patient care, the treating emergency physician is in the best position to fully integrate in a timely and effective manner all relevant clinical and other available information to optimize the quality of patient care in the emergency department (ED). Therefore, ACEP endorses the following principles. Policy Statements10.1016/j.annemergmed.2013.03.033Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Policy Statements724725http://www.annemergmed.com/article/PIIS0196064413003168/abstract?rss=yes [Ann Emerg Med. 2013;61:725.] The American College of Emergency Physicians (ACEP) supports the development and use of systems that provide appropriate patient information to a patient's health care providers. Such systems include but are not limited to medical alert badges, bracelets, wallet cards, portable electronic devices, and electronic medical records. ACEP recognizes the patient's right to confidential treatment of such information, including adherence to Health Insurance Portability and Accountability Act (HIPAA) requirements.Policy Statements10.1016/j.annemergmed.2013.03.032Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Policy Statements725725http://www.annemergmed.com/article/PIIS0196064413003181/abstract?rss=yes [Ann Emerg Med. 2013;61:725.] Emergency departments (EDs) often receive telephone calls from the public seeking medical advice. Each ED should have a procedure to identify the nature of all incoming calls. Callers who express a mental health or life- or limb-threatening medical emergency or concern should be instructed to access the emergency medical services system. Calls from patients recently discharged from the ED should be managed according to prearranged protocols that include the circumstances in which the patient should return to the ED.Policy Statements10.1016/j.annemergmed.2013.03.034Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Policy Statements725725http://www.annemergmed.com/article/PIIS0196064413003193/abstract?rss=yes[Ann Emerg Med. 2013;61:725-726.] The American College of Emergency Physicians (ACEP) supports the development and implementation of programs, policies, legislation, and regulations that will increase the safety of individuals using motorized recreational vehicles* and watercraft. These measures should emphasize the shared responsibility of owners, operators, passengers, and manufacturers to ensure the safety of riders and bystanders and must include the prohibition of child operators, the mandatory use of safety equipment, and mandatory safety training and testing of all operators.Policy Statements10.1016/j.annemergmed.2013.03.035Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Policy Statements725726http://www.annemergmed.com/article/PIIS019606441300320X/abstract?rss=yes[Ann Emerg Med. 2013;61:726.] The American College of Emergency Physicians (ACEP) supports efforts involving public education and legislation to ensure safe and responsible operation of motorized recreational vehicles* and watercraft. Operators and passengers should be educated about the dangers of intoxication with drugs or alcohol while engaged in motor vehicle or watercraft operation. Legislation should be enacted enabling the use of reasonable actions, including impoundment of property to ensure safe operation of motorized vehicles and watercraft.Policy Statements10.1016/j.annemergmed.2013.03.036Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Policy Statements726726http://www.annemergmed.com/article/PIIS0196064413003211/abstract?rss=yes[Ann Emerg Med. 2013;61:726-727.] Crowding occurs when the identified need for emergency services exceeds available resources for patient care in the emergency department (ED), hospital, or both.Policy Statements10.1016/j.annemergmed.2013.03.037Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8Policy Statements726727http://www.annemergmed.com/article/PIIS0196064413004095/abstract?rss=yesSubject and Author Indexes for Volume 6110.1016/S0196-0644(13)00409-5Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8728749http://www.annemergmed.com/article/PIIS0196064413003594/abstract?rss=yesTable of Contents10.1016/S0196-0644(13)00359-4Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA1A1http://www.annemergmed.com/article/PIIS0196064413003612/abstract?rss=yesEditors10.1016/S0196-0644(13)00361-2Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA9A11http://www.annemergmed.com/article/PIIS0196064413003636/abstract?rss=yesWhat's Coming in Annals ● July 201310.1016/S0196-0644(13)00363-6Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA12A12http://www.annemergmed.com/article/PIIS0196064413003296/abstract?rss=yesSome bite their cheek and spit blood into the urine cup to feign a kidney stone. Some use fake names or fake diseases, even cancer, to foster their addictions, and their presentations are often honed to textbook precision.Controlling Opioid Abuse in the Emergency Department: Legitimate Public Policy or “Legislative Medicine”?Alan Huffman10.1016/j.annemergmed.2013.04.007Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8News and PerspectiveA13A15http://www.annemergmed.com/article/PIIS0196064413003478/abstract?rss=yesThe inside of the fire station was a maelstrom of teachers, parents, children, and first responders. And it was amid this chaos that Robert Bazuro, DO, realized the true horror of what had occurred just a quarter of a mile down the street at Sandy Hook Elementary School, where his children attended.No Easy Answers: Emergency Physicians Engage in Gun Control DebateEric Berger10.1016/j.annemergmed.2013.04.009Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8News and PerspectiveA16A18http://www.annemergmed.com/article/PIIS0196064413003661/abstract?rss=yesInformation for Readers10.1016/S0196-0644(13)00366-1Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA19A19http://www.annemergmed.com/article/PIIS0196064413004290/abstract?rss=yesOhio ACEP Emergency Medicine Assembly. June 3-4, 2013. Columbus, OH. Sponsor: Ohio Chapter ACEP. Fee: $30.00 – $95.00. Contact: Steph Posey, 3510 Snouffer Rd, Ste 100, Columbus, OH, 43235. Email: admin@ohacep.org. 614-792-6506. (3.5)Calendar10.1016/S0196-0644(13)00429-0Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA23A36http://www.annemergmed.com/article/PIIS0196064413004319/abstract?rss=yesAds and complete payments must be received in writing by the issue's deadline date. These deadlines apply to insertions, cancellations, and changes. Classified 2013 Advertising Rates & Information: New Value-Added Feature—Your Ad Online at no Additional Cost!10.1016/S0196-0644(13)00431-9Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA38A38http://www.annemergmed.com/article/PIIS0196064413004320/abstract?rss=yes FLORIDA: Emergency Medicine Medical Director – EmCare is now accepting medical director candidates at Regional Medical Center Bayonet Point, a 290-bed acute care facility and home to a nationally acclaimed Heart Institute. In February 2013, the facility was awarded full Level II Trauma designation, marking the end of a year-long provisional period and commitment to trauma care that began in 2009. Bordered by the state's enchanting Gulf Coast, the city of Hudson sits at the top of the Tampa Bay metropolis, an area known for its beautiful coasts and world-class beaches. Position offers competitive pay with exceptional benefits. Candidates must be board certified in EM, have strong leadership skills and proven administrative experience. Contact Frances Miller at 727-507-2509 or email: Frances.Miller@EmCare.com.Classified10.1016/S0196-0644(13)00432-0Annals of Emergency Medicine 61, 6 (2013)2013-06-01Annals of Emergency Medicine2013-06-01616S0196-0644(13)X0005-8FrontmatterA39A49