Annals of Emergency Medicine

Improved Glottic Exposure With the Video Macintosh Laryngoscope in Adult Emergency Department Tracheal Intubations

2010-03-04

Study objective: Glottic visualization with video is superior to direct laryngoscopy in controlled operating room studies. However, glottic exposure with video laryngoscopy has not been evaluated in the emergency department (ED) setting, where blood, secretions, poor patient positioning, and physiologic derangement can complicate laryngoscopy. We measure the difference in glottic visualization with video versus direct laryngoscopy.Methods: We prospectively studied a convenience sample of tracheal intubations at 2 academic EDs. We performed laryngoscopy with the Karl Storz Video Macintosh Laryngoscope, which can be used for conventional direct laryngoscopy, as well as video laryngoscopy. We rated glottic visualization with the Cormack-Lehane (C-L) Scale, defining “good” visualization as C-L I or II and “poor” visualization as C-L III or IV. We compared glottic exposure between direct and video laryngoscopy, determining the proportion of poor direct visualizations improved to good visualization with video laryngoscopy. We also determined the proportion of good direct visualizations worsened to poor visualization by video laryngoscopy.Results: We report data on 198 patients, including 146 (74%) medical, 51 (26%) trauma, and 1 (0.51%) unknown indications. All were tracheally intubated by emergency physicians. Postgraduate year 3 or 4 residents performed 102 (52.3%) of the laryngoscopies, postgraduate year 2 residents performed 60 (30.8%), interns performed 20 (10.3%), attending physicians performed 9 (4.6%), and operator experience and specialty were not reported in 4. Overall, good visualization (C-L grade I or II) was attained in 158 direct (80%) versus 185 video laryngoscopies (93%; McNemar's P<.0001). Of the 40 patients with poor glottic exposure on direct laryngoscopy, video laryngoscopy improved the view in 31 (78%; 95% confidence interval 62% to 89%). Of the 158 patients with good glottic view on direct laryngoscopy, video laryngoscopy worsened the view in 4 (3%; 95% confidence interval 0.7% to 6%).Conclusion: Video laryngoscopy affords more grade I and II views than direct laryngoscopy and improves glottic exposure in most patients with poor direct glottic visualization. In a small proportion of cases, glottic exposure is worse with video than direct laryngoscopy.

Endotracheal Tube Intracuff Pressure During Helicopter Transport

Marco Bassi, Mathias Zuercher, Jean-Jacques Erne, Wolfgang Ummenhofer — 2010-02-26

Study objective: We evaluate changes in endotracheal tube intracuff pressures among intubated patients during aeromedical transport. We determine whether intracuff pressures exceed 30 cm H2O during aeromedical transport.Methods: During a 12-month period, a helicopter-based rescue team prospectively recorded intracuff pressures of mechanically ventilated patients before takeoff and as soon as the maximum flight level was reached. With a commercially available pressure manometer, intracuff pressure was adjusted to ≤25 cm H2O before loading of the patient. The endpoint of our investigation was the increase of endotracheal tube cuff pressure during helicopter transport.Results: Among 114 intubated patients, mean altitude increase was 2,260 feet (95% confidence interval [CI] 2,040 to 2,481 feet; median 2,085 feet; interquartile range [IQR] 1,477.5 to 2,900 feet). Mean flight time was 14.8 minutes (95% CI 13.1 to 16.4 minutes; median 13.5 minutes; IQR 10 to 16.1 minutes). Intracuff pressure increased from 28.7 cm H2O (95% CI 27.0 to 30.4 cm H2O [median 25 cm H2O; IQR 25 to 30 cm H2O]) to 62.6 cm H2O (95% CI 58.8 to 66.5 cm H2O; median 58; IQR 48 to 72 cm H2O). At cruising altitude, 98% of patients had intracuff pressures ≥30 cm H2O, 72% had intracuff pressures ≥50 cm H2O, and 20% even had intracuff pressures ≥80 cm H2O.Conclusion: Endotracheal cuff pressure during transport frequently exceeded 30 cm H2O during aeromedical transport. Hospital and out-of-hospital practitioners should measure and adjust endotracheal cuff pressures before and during flight.

A Woman With Ankle Pain

Anna L. Waterbrook — 2010-08-01

[Ann Emerg Med. 2010;56:94.] A 40-year-old woman presented to the emergency department (ED), complaining of severe left ankle pain. She stated that just before arrival, she twisted her ankle and then fell to the ground. She had no medical history and had no previous injuries to the affected ankle. On physical examination, she had a significant amount of swelling around her ankle. She had tenderness to palpation over her medial malleolus (), as well as her proximal fibula (). Radiographs were performed in the ED. ().

Emergency Department Management of the Airway in Obese Adults

James Dargin, Ron Medzon — 2010-04-05

Airway management in obese adults can be challenging, and much of the literature on this subject focuses on elective surgical cases, rather than acutely ill patients. In this article, we review the emergency department evaluation of the airway in obesity, discussing anatomy, physiology, and pharmacology. In addition, we describe techniques and devices used to improve intubating conditions in the obese patient. After our review of the relevant literature, we conclude that research in this particular area of acute care remains in its infancy.

The Effect of a Bolus Dose of Etomidate on Cortisol Levels, Mortality, and Health Services Utilization: A Systematic Review

2010-03-26

Study objective: To synthesize the evidence on the effect of a bolus dose of etomidate on adrenal function, mortality, and health services utilization compared with other induction agents used for rapid sequence intubation.Methods: We developed a systematic search strategy and applied it to 10 electronic bibliographic databases. We hand searched journals; reviewed conference proceedings, gray literature, and bibliographies of relevant literature; and contacted content experts for studies comparing a bolus dose of etomidate with other induction agents. Retrieved articles were reviewed and data were abstracted with standardized forms. Data were pooled with the random-effects model if at least 4 clinically homogenous studies of the same design reported the same outcome measure. All other data were reported qualitatively.Results: From 3,083 titles reviewed, 20 met our inclusion criteria. Pooled mean cortisol levels were lower in elective surgical patients induced with etomidate compared with those induced with other agents between 1 and 4 hours postinduction. The differences varied from 6.1 μg/dL (95% confidence interval [CI] 2.4 to 9.9 μg/dL; P=.001) to 16.4 μg/dL (95% CI 9.7 to 23.1 μg/dL; P<.001). Two studies in critically ill patients reported significantly different cortisol levels up to 7 hours postinduction. None of the studies reviewed, nor our pooled estimate (odds ratio 1.14; 95% CI 0.81 to 1.60), showed a statistically significant effect on mortality. Only one study reported longer ventilator, ICU, and hospital lengths of stay in patients intubated with etomidate.Conclusion: The available evidence suggests that etomidate suppresses adrenal function transiently without demonstrating a significant effect on mortality. However, no studies to date have been powered to detect a difference in hospital, ventilator, or ICU length of stay or in mortality.

A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis

2010-02-08

Study objective: We assess the diagnostic accuracy of emergency physician–performed bedside ultrasonography and radiology ultrasonography for the detection of cholecystitis, as determined by surgical pathology.Methods: We conducted a prospective, observational study on a convenience sample of emergency department (ED) patients presenting with suspected cholecystitis from May 2006 to February 2008. Bedside gallbladder ultrasonography was performed by emergency medicine residents and attending physicians at an academic institution. Emergency physicians assessed for gallstones, a sonographic Murphy's sign, gallbladder wall thickness, and pericholecystic fluid, and the findings were recorded before formal imaging. The test characteristics of bedside and radiology ultrasonography were determined by comparing their respective results to pathology reports and clinical follow-up at 2 weeks.Results: Of the 193 patients enrolled, 189 were evaluated by bedside ultrasonography. Forty-three emergency physicians conducted the ultrasonography, and each physician performed a median of 2 tests. After the bedside ultrasonography, 125 patients received additional radiology ultrasonography. Twenty-six patients underwent cholecystectomy, 23 had pathology-confirmed cholecystitis, and 163 were discharged home to follow-up. Twenty-five were excluded (23 lost to follow-up and 2 unavailable pathology). The test characteristics of bedside ultrasonography were sensitivity 87% (95% confidence interval [CI] 66% to 97%), specificity 82% (95% CI 74% to 88%), positive likelihood ratio 4.7 (95% CI 3.2 to 6.9), negative likelihood ratio 0.16 (95% CI 0.06 to 0.46), positive predictive value 44% (95% CI 29% to 59%), and negative predictive value 97% (95% CI 93% to 99%). The test characteristics of radiology ultrasonography were sensitivity 83% (95% CI 61% to 95%), specificity 86% (95% CI 77% to 92%), positive likelihood ratio 5.7 (95% CI 3.3 to 9.8), negative likelihood ratio 0.20 (95% CI 0.08 to 0.50), positive predictive value 59% (95% CI 41% to 76%), and negative predictive value 95% (95% CI 88% to 99%).Conclusion: The test characteristics of emergency physician–performed bedside ultrasonography for the detection of acute cholecystitis are similar to the test characteristics of radiology ultrasonography. Patients with a negative ED bedside ultrasonography result are unlikely to require cholecystectomy or admission for cholecystitis within 2 weeks of their initial presentation.

Bedside Biliary Sonography: Advancement and Future Horizons

Timothy B. Jang — 2010-04-19

SEE RELATED ARTICLE, P.114. [Ann Emerg Med. 2010;56:123-125.]

Prospective Double-Blinded Study of Abdominal-Pelvic Computed Tomography Guided by the Region of Tenderness: Estimation of Detection of Acute Pathology and Radiation Exposure Reduction

2010-01-14

Study objective: Computed tomography (CT) is increasingly used for emergency department (ED) patients with abdominal tenderness. CT-related radiation contributes to 2% of US cancers. We hypothesized that in the ED patient with nontraumatic abdominal tenderness, the tender region accurately delineates acute pathology. z axis–restricted CT guided by this region could detect pathology while reducing radiation dose.Methods: This was a prospective double-blinded observational trial with informed consent and was institutional review board–approved and registered with ClinicalTrials.gov. A convenience sample of ED patients undergoing abdominal CT was recruited, excluding pregnant women, patients with altered mental status or abdominal sensation, preverbal children, and patients with abdominal trauma or surgery in the previous month. Before standard CT, physicians demarcated the tender region with labels invisible to radiologists on abdominal windows. Radiologists blinded to the tender region recorded cephalad-caudad limits of pathology on CT. Personnel blinded to pathology location recorded label positions on lung windows. Two hypothetical CT strategies were then explored: CT restricted to the tender region and CT from the cephalad skin marker to the lower caudad limit of the usual CT. The percentage of the pathologic region contained within the extent of the 2 hypothetical z axis restricted CTs was calculated. z axis reduction, which is linearly related to radiation reduction, from the restricted CTs was determined.Results: One hundred two subjects were enrolled, 93 with complete data for analysis. Fifty-one subjects had acute pathology on CT. CT limited to the tender region would reduce z axis (radiation exposure) by 69% (95% confidence interval [CI] 60% to 78%). All acute pathology was included within these boundaries in 17 of the 51 abnormal cases (33%; 95% CI 22% to 47%). CT from the cephalad marker through the caudad abdomen and pelvis would reduce z axis (radiation exposure) by 38% (95% CI 29% to 48%). All acute pathology was included within these boundaries in 36 of 51 abnormal cases (71%; 95% CI 57% to 81%). With both strategies 1 and 2, the pathologic region was at least partially included within the CT region in the majority of cases (84% and 92%, respectively).Conclusion: CT with z axis restriction based on abdominal tenderness could reduce radiation exposure but with a potentially unacceptably high rate of misdiagnosis, using our current methods. Further prospective study may be warranted to determine the diagnostic utility of partially visualized pathology.

The Effect of Removal of Point-of-Care Fecal Occult Blood Testing on Performance of Digital Rectal Examinations in the Emergency Department

Nathan J. Cleveland, Michael Yaron, Adit A. Ginde — 2010-01-11

Study objective: We determine whether removing point-of-care fecal occult blood testing from the emergency department (ED) is associated with a decrease in documented digital rectal examinations.Methods: We performed a retrospective observational chart review study examining documented digital rectal examinations, before and after removal of a point-of-care fecal occult blood test, on all adult patients who presented to our ED with chief complaints that were likely to warrant a fecal occult blood test (intervention-sensitive). We studied the 6 months immediately before and after switching from bedside fecal occult blood testing to immunohistochemical laboratory fecal occult blood testing. We compared the results with those from a similar cohort of patients who presented during the same period, with chief complaints that would warrant a digital rectal examination for reasons other than fecal occult blood test (intervention-insensitive).Results: A total of 4,981 and 5,557 patients met our inclusion criteria during the before and after intervention periods, respectively. We observed an overall reduction of 10% (95% confidence interval [CI] 8% to 12%) in digital rectal examinations in patients with intervention-sensitive chief complaints. The largest relative decreases in digital rectal examinations were observed in patients with chief complaints of abdominal pain, nausea/vomiting, and diarrhea. Smaller decreases were observed in gastrointestinal bleeding, constipation, and rectal problem. There was an overall reduction of 3% (95% CI 0% to 5%) in documented digital rectal examinations in intervention-insensitive chief complaints. After controlling for all covariates, digital rectal examinations decreased in the postintervention period for intervention-sensitive (odds ratio 0.44 [95% CI 0.39 to 0.50]) and, to a lesser extent, for intervention-insensitive (odds ratio 0.67 [95% CI 0.52 to 0.86]) conditions.Conclusion: Removal of point-of-care fecal occult blood test from our ED was associated with a reduction in digital rectal examinations, particularly among chief complaints that may require fecal occult blood testing.

Placing Emergency Care on the Global Agenda

Renee Hsia, Junaid Razzak, Alexander C. Tsai, Jon Mark Hirshon — 2010-02-08

Emergency care serves a key function within health care systems by providing an entry point to health care and by decreasing morbidity and mortality. Although primarily focused on evaluation and treatment for acute conditions, emergency care also serves as an important locus of provision for preventive care with regard to injuries and disease progression. Despite its important and increasing role, however, emergency care has been frequently overlooked in the discussion of health systems and delivery platforms, particularly in developing countries. Little research has been done in lower- and middle-income countries on the burden of disease reduction attributable to emergency care, whether through injury treatment and prevention, urgent and emergency treatment of acute conditions, or emergency treatment of complications from chronic conditions. There is a critical need for research documenting the role of emergency care services in reducing the global burden of disease. In addition to applying existing methodologies toward this aim, new methodologies should be developed to determine the cost-effectiveness of these interventions and how to effectively cover the costs of and demands for emergency care needs. These analyses could be used to emphasize the public health and clinical importance of emergency care within health systems as policymakers determine health and budgeting priorities in resource-limited settings.

Emergency Department Care in the United States: A Profile of National Data Sources

2010-01-15

Study objective: Emergency departments (EDs) are an integral part of the US health care system, and yet national data sources on the care received in the ED are poorly understood, thereby limiting their usefulness for analyses. We provide a comparison of data sources that can be used to examine utilization and quality of care in the ED nationally.Data sources and comparisons: This article compares 7 data sources available in 2005 for conducting analyses of ED encounters: the American Hospital Association Annual Survey Database™, Hospital Market Profiling Solution©, National Emergency Department Inventory, Nationwide Emergency Department Sample, National Hospital Ambulatory Medical Care Survey, National Electronic Injury Surveillance System–All-Injury Program, and the National Health Interview Survey. In addition to describing the type and scope of data collection, available characteristics, and sponsor of the ED data sources, we compare (where possible) estimates of the total number of EDs, national and regional volume of ED visits, national and regional admission rates (percentage of ED visits resulting in hospital admission), patient characteristics, hospital characteristics, and reasons for visit generated by the various data sources.Major findings: The different data sources yielded estimates of the number of EDs that ranged from 4,609 to 4,884 and the number of ED encounters from more than 109 million to more than 116 million. Admission rates across data sources varied from 12.0% to 15.3%. Although comparisons of the 7 data sources were somewhat limited by differences in available information and operational definitions, variation in estimates of utilization and patterns of care existed by region, expected payer, and patient and hospital characteristics. The rankings and estimates of the top 5 first-listed conditions seen in the ED are relatively consistent between the 2 data sources with diagnoses, although the Nationwide Emergency Department Sample estimates 1.3 to 5.8 times more ED visits for each chronic and acute all-listed condition examined relative to the National Hospital Ambulatory Medical Care Survey.Conclusion: Each of the data sources described in this article has unique advantages and disadvantages when used to examine patterns of ED care, making the different data sources appropriate for different applications. Analysts should select a data source according to its construction and should bear in mind its strengths and weaknesses in drawing conclusions based on the estimates it yields.

Attrition From Emergency Medicine Clinical Practice in the United States

Adit A. Ginde, Ashley F. Sullivan, Carlos A. Camargo — 2009-12-25

Study objective: We estimate the annual attrition from emergency medicine clinical practice.Methods: We performed a cross-sectional analysis of the American Medical Association's 2008 Physician Masterfile, which includes data on all physicians who have ever obtained a medical license in at least 1 US state. We restricted the analysis to physicians who completed emergency medicine residency training or who obtained emergency medicine board certification. We defined attrition as not being active in emergency medicine clinical practice. Attrition was reported as cumulative and annualized rates, with stratification by years since training graduation. Death rates were estimated from life tables for the US population.Results: Of the 30,864 emergency medicine–trained or emergency medicine board-certified physicians, 26,826 (87%) remain active in emergency medicine clinical practice. Overall, type of attrition was 45% to non–emergency medicine clinical practice, 22% retired, 14% administration, and 10% research/teaching. Immediate attrition (<2 years since training graduation) was 6.5%. The cumulative attrition rates from 2 to 15 years postgraduation were stable (5% to 9%) and thereafter were progressively higher, with 18% having left emergency medicine clinical practice at 20 years postgraduation and 25% at 30 years postgraduation. Annualized attrition rates were highest for the first 5 years postgraduation and after 40 years postgraduation; between 5 and 40 years, the rates remained low (<1%). The overall annual attrition rate from emergency medicine clinical practice, including estimated death rate, was approximately 1.7%.Conclusion: Despite the high stress and demands of emergency medicine, overall attrition remains low and compares favorably with that of other medical specialties. These data have positive implications for the emergency physician workforce and are important for accurate estimation of and planning for emergency physician workforce needs.

The Development of Civilian Emergency Medical Care During an Insurgency: Current Status and Future Outlook in Iraq

Ross I. Donaldson, Tariq Hasson, Sharaf Aziz, Waleed Ansari, Gerald Evans — 2010-01-25

We review the development of civilian out-of-hospital and hospital-based emergency medical care in Iraq, focusing on the non-Kurdish regions. Emergency medicine in the country has made encouraging steps during the last several years, including the establishment of national emergency medicine policy, the training of out-of-hospital caregivers, the education of physicians currently working in Iraqi emergency departments, and the development of emergency medicine residency programs, among others. The utilization of a national Emergency Medicine Working Group has been a key resource in the development of emergency medicine in the country, a strategy we recommend to others aiding low- and middle-income nations.

The Future of Emergency Medicine

2010-06-28

[Ann Emerg Med. 2010;56:178-183.] Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem.

Fatal Crashes Involving Young Drivers1

National Highway Traffic Safety Administration — 2010-08-01

[National Highway Traffic Safety Administration. Fatal crashes involving young drivers. Ann Emerg Med. 2010;56:184-185.] Fatalities from crashes involving young drivers have accounted for just under one fifth of all fatalities on the nation's roads. This population of young drivers has specific characteristics that set them apart from older drivers, as well as a specific set of laws pertaining to their ability to drive. Previous research has shown that young drivers lack the experience behind the wheel that most older drivers have, do not have the same maturity level as older drivers, and are more prone to risk-taking behavior. These characteristics influenced the development of graduated driver licensing programs in different areas of the country to provide opportunities for experience, lessen the opportunity for risk-taking behavior, and educate young drivers about hazards on roadways. Although these programs are greatly beneficial, young-driver-related crashes remain a prevalent issue in our nation. The National Highway Traffic Safety Administration (NHTSA) undertook this analysis to describe characteristics and trends in fatal crashes involving young drivers.

Commentary: Youth Risk for Deadly Driving

Chris Kahn — 2010-08-01

[Khan CA. Commentary: youth risk for deadly driving. Ann Emerg Med. 2010;56:186-187.] It should come as no surprise that teenagers don't always make the best decisions. We, having survived our adolescence, can comfortably look back and laugh at how we managed to scrape by with (hopefully) no more than a few cuts and bruises, or perhaps a good story about a particularly interesting fracture. Unfortunately, this issue's NHTSA report reminds us that living past childhood is not guaranteed.

All Quiet on Cambridge Street

Leana S. Wen — 2010-08-01

[Ann Emerg Med. 2010;56:188.] It's not yet 10 pm and Cambridge Street is uncharacteristically—and eerily—quiet. Cambridge is a 4-lane major thoroughfare that cuts through downtown Boston. Most days, its traffic lanes are crammed with cars heading in and around Boston and ambulances heading to and from the General. Its narrow sidewalks overflow with pedestrians window-shopping in the area's vintage stores and going between its many pubs and restaurants. Even in the wee hours of the morning, when I often finish my shifts, I could always count on a couple dozen drunk partiers staggering home to shield me from being alone with the amorphous shapes of the homeless who sleep huddled in Cambridge Street's dark corners.

Is the Golden Hour Tarnished? Registries and Multivariable Regression: Answers to the March 2010 Journal Club Questions

Tyler W. Barrett, Jeremy J. Brywczynski, David L. Schriger — 2010-08-01

Missing data can bias a study's conclusions. Large multicenter observational studies are likely to encounter more missing data than a small, prospective, single-center trial.

Woman With Unresponsiveness

David H. Jang, Lewis S. Nelson — 2010-08-01

[Ann Emerg Med. 2010;56:201.] A 43-year-old woman presented to an emergency department (ED) with unresponsiveness. According to emergency medical services, the patient admitted to taking a handful of a “pesticide” in a suicide attempt. At that time, the patient's vital signs and physical examination results were unremarkable. By her arrival to the ED, she had become confused and agitated and subsequently became unresponsive. The patient's vital signs were as follows on arrival: blood pressure 110/65 mm Hg, pulse rate 75 beats/min, respiratory rate 11 breaths/min, rectal temperature 37°C (99°F) room air oxygen saturation 99%, and finger stick glucose level 132 mg/dL. The patient was immediately intubated for airway protection, at which time her airway was observed to be clear. She subsequently developed bradycardia (pulse rate of 46 beats/min), diaphoresis, miosis, and several episodes of diarrhea. The New York City Poison Control Center was contacted.

Emergency Department Admissions and Inpatient Discharges: A Complex Relationship

Joseph R. Shiber — 2010-08-01

I would like to comment on the important article by Vermeulen et al in the December 2009 issue of Annals of Emergency Medicine. The authors make many valid points in their well-done study, and I commend them on attempting to deal with this difficult problem. While prolonged emergency department (ED) length of stay may decrease the quality of care for certain time-sensitive disorders, attempting to balance the disequilibrium between admitted and discharged patients by only addressing discharges from the inpatient units may also affect the quality of care delivered. Instead of seeing the process as linear, with our patients presenting to the ED and then making a disposition (for home or admission), the relationship is actually more circular. When hospital beds are full and there is pressure to make room for new admissions, inpatients may be discharged home or transferred from the ICU to a lower-acuity bed earlier than if there were not such pressure. ED patients awaiting admission may also get discharged home directly after evaluation by hospitalist or other consulting physicians when there are limited beds. These same patients may return to the ED with incomplete resolution of their same disease process, only to be (re)admitted. What appears to be a solution to the ED crowding problem may only shift the problem forward.

In reply

Marian J. Vermeulen, Joel G. Ray, Michael J. Schull — 2010-08-01

We thank Dr. Shiber for his comments and for the opportunity to clarify several points. First of all, we do not advocate discharging patients home before they are ready and agree that this would be counterproductive insofar as it may lead to bounce-backs to the emergency department (ED). However, recently discharged patients represent a small proportion of ED visits, and it has not been established that early discharge from the hospital is associated with return ED visits. On the other hand, it has been shown that shorter inhospital lengths of stay are safe for a number of types of patients. Delays in transferring ED patients to inpatient care appear to pose more of a threat not only with respect to the initiation of time-sensitive treatments but also, in some cases, with respect to increasing the risk of mortality.

“I Think” Is Cheap; “I Am Sure” May Cost You

Boris D. Veysman — 2010-08-01

With great interest I read Dr. Coulehan's original essay in Health Affairs (where I too publish narratives) and the News and Perspective piece by Eric Berger reporting it in February 2010. Dr. Coulehan recounts visiting the emergency department (ED), complaining of isolated severe unilateral facial pain. Although he reports diagnosing shingles “over a hundred times” in his long and accomplished career, Dr. Coulehan himself was unconvinced this diagnosis explained his pain. Yet after his ED workup turned out negative and the classic rash appeared over time, Dr. Coulehan blamed the emergency physician for inexperience and an unnecessarily complex workup costing $9,000. I wish to ask Dr. Coulehan if his life and vision are worth the money.

Improving Handoffs in the Emergency Department

Douglas A. Propp — 2010-08-01

I read with some enthusiasm the article by Cheung et al and the accompanying editorial in the February issue of Annals, focusing on handoffs that regularly occur between emergency physicians. At our Level I suburban teaching emergency department (ED) with 58,000 annual visits, we have made significant improvements in our handoffs, utilizing several other tactics that were not mentioned in the original article.

In reply

Dickson S. Cheung, Scott C. Gibson — 2010-08-01

Thank you for sharing your experience in combating faulty handoffs. Kudos to you and your group for successfully improving this vital process. As mentioned in the “Improving Handoffs in the Emergency Department” article, your practice of having the arriving physician critique cases may allow for potential rescue of patients headed down a perilous path. The Quality Improvement and Patient Safety Handoff Grant Team spent a considerable amount of time debating how best to provide this “opportunity to ask and respond to questions.” In the end, we decided—because published evidence is sorely lacking—that the handoff should be synchronous but not necessarily face to face. Your custom of having the departing physician call back an hour after departing his shift for any lingering questions certainly fits within this framework. This may be particularly effective for “closing the loop” as questions about patients sometimes do not become evident until the departing physician has left the building. How about a suggestion to improve on your already excellent practice? The only thing better than providing the option to ask and respond to questions is to allow for multiple opportunities. A contact number for the departing physician would allow addressing concerns at any time without delay.

Matthew R. Lewin — 2010-08-01

It is usually a pleasure to be invited to review a book, receive it, and review it. Unfortunately, this was not the case with Natural Disasters and Public Health: Hurricanes Katrina, Rita and Wilma as the book's introduction and chapters 2 through 25 (of 27) are a verbatim reproduction of a special issue of the Journal of Healthcare for the Poor and Underserved. The jacket, editor's acknowledgement, and introduction lead the reader to believe that this is an original publication rather than a collection of articles already published in the order they appear in the original journal issue. For the reader interested in the subjective experience of what it was like to work in Louisiana and Houston, the book provides some interesting reading. For academics interested in quantitative analyses, most articles will be available through their university libraries. At $30.00, it is less expensive to buy the book than to order the individual articles from the Journal of Healthcare for the Poor and Underserved. In that respect, the book is reasonably priced.

Robert I. Golomb — 2010-08-01

A memory from 25 years ago still haunts me. Code 3 ring down, a GSW to the head. The paramedics bring in yet another young African-American man. The bullet has removed most of his forehead, some of the frontal lobes. Blood and brain are spattered about. His eyes move about, but I cannot tell if it is purposeful. He offers no resistance as I intubate his trachea. I do not remember his name, I do not know why he was shot, and I do not know if he survived his injury.

Manuscript Submission Agreement

2010-08-01

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2010-08-01

Editors

2010-08-01

What's Coming in Annals ● September 2010

2010-08-01

Beyond Regionalization: Experts Grapple With Research Agenda in Response to IOM Report

Maryn McKenna — 2010-08-01

Phoenix—If emergency medicine is to respond to the Institute of Medicine's (IOM's) 2006 call for a “coordinated, regionalized and accountable” emergency care system—emphasis on the “regional”—then it will have to tackle significant problems of culture, competition, and distrust that have gone unsolved for decades. At the moment, no one seems sure how to do that. But judging by the frank discussions held in June at the Society for Academic Emergency Medicine's (SAEM's) 11th annual Consensus Conference, “Beyond Regionalization: Integrated Networks of Emergency Care,” the specialty is beginning to feel confident at least of the right questions to ask.

Electronic Health Records: Promises and Realities: A 3-Part Series Part I: The Digital Sea Change, Ready or Not

William B. Millard — 2010-08-01

Most American hospitals have been slow to adopt electronic health records (EHRs), despite widespread anticipation that these systems would improve both clinical performance and economic efficiency.

Information for Readers

2010-08-01

Annals of Emergency Medicine is the official publication of the American College of Emergency Physicians (www.acep.org). The journal is provided to all ACEP members as a membership benefit. For information about becoming an ACEP member, contact ACEP's member services department at the address below. For your convenience, a postage-paid card for obtaining membership information is included in every issue of the journal.

Calendar

2010-08-01

Practical Emergency Airway Management Course. August 5–6, 2010. Baltimore, MD. Sponsor: Thomas Jefferson University. Fee: $1,545.00. Contact: Jefferson Medical College, Office of CME, 1020 Locust St JAH M5, Philadelphia, PA 19107. Email: jeffersoncme@jefferson.edu. 888-533-3263. (16)

Classified 2010 Advertising Rates & Information: New Value-Added Feature—Your Ad Online at no Additional Cost!

2010-08-01

Ads and complete payments must be received in writing by the issue's deadline date. These deadlines apply to insertions, cancellations, and changes.

Classified

2010-08-01

OHIO: The Ohio State University: Academic Position. Residency Program. Level 1 trauma center. Nationally recognized research program. Clinical opportunities at OSU Medical Center and affiliated hospitals. Responsibilities include medical student and resident education; research in laboratory, translation and/or clinical settings. Contact Douglas A. Rund, MD, Professor and Chairman, Department of Emergency Medicine, The Ohio State University or sharon.pfeil@osumc.edu (614-293-8176). AAEOE

Annals of Emergency Medicine

Improved Glottic Exposure With the Video Macintosh Laryngoscope in Adult Emergency Department Tracheal Intubations

Endotracheal Tube Intracuff Pressure During Helicopter Transport

A Woman With Ankle Pain

Emergency Department Management of the Airway in Obese Adults

The Effect of a Bolus Dose of Etomidate on Cortisol Levels, Mortality, and Health Services Utilization: A Systematic Review

A Prospective Evaluation of Emergency Department Bedside Ultrasonography for the Detection of Acute Cholecystitis

Bedside Biliary Sonography: Advancement and Future Horizons

Prospective Double-Blinded Study of Abdominal-Pelvic Computed Tomography Guided by the Region of Tenderness: Estimation of Detection of Acute Pathology and Radiation Exposure Reduction

The Effect of Removal of Point-of-Care Fecal Occult Blood Testing on Performance of Digital Rectal Examinations in the Emergency Department

Placing Emergency Care on the Global Agenda

Emergency Department Care in the United States: A Profile of National Data Sources

Attrition From Emergency Medicine Clinical Practice in the United States

The Development of Civilian Emergency Medical Care During an Insurgency: Current Status and Future Outlook in Iraq

The Future of Emergency Medicine

Fatal Crashes Involving Young Drivers1

Commentary: Youth Risk for Deadly Driving

All Quiet on Cambridge Street

Is the Golden Hour Tarnished? Registries and Multivariable Regression: Answers to the March 2010 Journal Club Questions

Woman With Unresponsiveness

Emergency Department Admissions and Inpatient Discharges: A Complex Relationship

In reply

“I Think” Is Cheap; “I Am Sure” May Cost You

Improving Handoffs in the Emergency Department

In reply

Manuscript Submission Agreement

Table of Contents

Editors

What's Coming in Annals ● September 2010

Beyond Regionalization: Experts Grapple With Research Agenda in Response to IOM Report

Electronic Health Records: Promises and Realities: A 3-Part Series Part I: The Digital Sea Change, Ready or Not

Information for Readers

Calendar

Classified 2010 Advertising Rates & Information: New Value-Added Feature—Your Ad Online at no Additional Cost!

Classified