[Show abstract][Hide abstract] ABSTRACT: To describe the epidemiology of emergency department mammalian animal exposures and to compare adult and pediatric exposure characteristics.
This was a prospective case series of patients presenting with animal exposure-related complaints from July 1996 to July 1998. Eleven university-affiliated, geographically diverse, urban emergency departments (EMERGEncy ID NET) participated.
A total of 1,631 exposures (80.5%) were from dogs, 267 (13.2%) from cats, 88 (4.3%) from rodents or rabbits, 18 (0.9%) from raccoons and wild carnivores, eight (0.4%) from livestock, nine (0.4%) from monkeys, and five (0.2%) from bats. Compared with adults, children were more likely to be bitten by dogs (odds ratio [OR], 2.9; 95% confidence interval [CI] = 2.2 to 3.8) or hamsters, gerbils, and rabbits (OR, 2.6; 95% CI = 0.79 to 9.2); to be bitten on the head, neck, or face (OR, 6.7; 95% CI = 5.2 to 8.6); and to be petting or playing with the animal at the time of exposure (OR, 2.6; 95% CI = 2.1 to 3.3).
Animal exposures are a common source of injury seen in the emergency department. These findings have potentially important public health implications in terms of emphasizing the need to effectively implement education programs for parents and children.
Academic Emergency Medicine 06/2007; 14(5):398-403. DOI:10.1197/j.aem.2006.12.012 · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to examine the effect of ultrasound experience level on emergency physicians' Focused Assessment with Sonography for Trauma (FAST) exam accuracy and emergency physicians' confidence in using FAST findings to assist in managing patients with blunt trauma.
This prospective, consecutive enrolment study evaluated adult trauma team activation blunt trauma patients. Based on the number of post-training FAST exams carried out, 11 attending emergency physicians were grouped into A (<25 exams, n = 4), B (26-50 exams, n = 4) or C (>50 exams, n = 3). The FAST exam was carried out prior to other diagnostic studies. The emergency physicians were asked to prospectively judge their perception of the need for surgery, abdominal CT or no further tests. All study patients ultimately underwent CT, diagnostic peritoneal lavage or laparotomy. Among each physician group, the number of subsequent CT scans deemed necessary by the emergency physician after a 'normal' FAST was calculated and compared.
Accuracy was greatest in group C. Sixty-nine of 80 patients in group A had a normal FAST exam; emergency physicians deemed CT necessary in 68/69 cases (99%; confidence interval [CI] 92-100%). Eighty-two of 98 patients in group C had a normal FAST exam; emergency physicians deemed CT necessary in 19/82 cases (23%; CI 15-34%). Physicians in groups B and C were less likely to order CT after a normal FAST than group A (P < 0.001).
FAST accuracy was greatest among more experienced emergency physicians. A normal FAST exam assisted more experienced emergency physicians with the perceived need to order significantly fewer CT scans than less experienced emergency physicians.
Emergency medicine Australasia: EMA 03/2005; 17(1):24-30. DOI:10.1111/j.1742-6723.2005.00681.x · 1.30 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Most resident physicians accrue significant financial debt throughout their medical and graduate medical education. The objective of this study was to analyze emergency medicine resident debt status, financial planning actions, and educational experiences for financial planning and debt management.
A 22-item questionnaire was sent to all 123 Accreditation Council on Graduate Medical Education-accredited emergency medicine residency programs in July 2001. Two follow-up mailings were made to increase the response rate. The survey addressed four areas of resident debt and financial planning: 1) accrued debt, 2) moonlighting activity, 3) financial planning/debt management education, and 4) financial planning actions. Descriptive statistics were used to analyze the data.
Survey responses were obtained from 67.4% (1,707/2,532) of emergency medicine residents in 89 of 123 (72.4%) residency programs. Nearly one half (768/1,707) of respondents have accrued more than 100,000 dollars of debt. Fifty-eight percent (990/1,707) of all residents reported that moonlighting would be necessary to meet their financial needs, and more than 33% (640/1,707) presently moonlight to supplement their income. Nearly one half (832/1,707) of residents actively invested money, of which online trading was the most common method (23.3%). Most residents reported that they received no debt management education during residency (82.1%) or medical school (63.7%). Furthermore, 79.1% (1,351/1,707) of residents reported that they received no financial planning lectures during residency, although 84.2% (1,438/1,707) reported that debt management and financial planning education should be available during residency.
Most emergency medicine residency programs do not provide their residents with financial planning education. Most residents have accrued significant debt and believe that more financial planning and debt management education is needed during residency.
Academic Emergency Medicine 02/2005; 12(1):52-6. DOI:10.1197/j.aem.2004.02.532 · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We determine tetanus seroprotection rates and physician compliance with tetanus prophylaxis recommendations among patients presenting with wounds.
A prospective observational study of patients aged 18 years or older who presented to 5 university-affiliated emergency departments (EDs) because of wounds was conducted between March 1999 and August 2000. Serum antitoxin levels were measured by enzyme immunoassay with seroprotection defined as more than 0.15 IU/mL. Seroprotection rates, risk factors for lack of seroprotection, and rates of physician compliance with tetanus prophylaxis recommendations by the Advisory Committee on Immunization Practices were determined.
The seroprotection rate among 1,988 patients was 90.2% (95% confidence interval 88.8% to 91.5%). Groups with significantly lower seroprotection rates were persons aged 70 years or older, 59.5% (risk ratio [RR] 5.2); immigrants from outside North America or Western Europe, 75.3% (RR 3.7); persons with a history of inadequate immunization, 86.3% (RR 2.9); and persons without education beyond grade school, 76.5% (RR 2.5). Despite a history of adequate immunization, 18% of immigrants lacked seroprotection. Overall, 60.9% of patients required tetanus immunization, of whom 57.6% did not receive indicated immunization. Among patients with tetanus-prone wounds, appropriate prophylaxis (ie, tetanus immunoglobulin and toxoid) was provided to none of 504 patients who gave a history of inadequate primary immunization (of whom 15.1% had nonprotective antibody titers) and to 218 (79%) of 276 patients who required only a toxoid booster.
Although seroprotection rates are generally high in the United States, the risk of tetanus persists in the elderly, immigrants, and persons without education beyond grade school. There is substantial underimmunization in the ED (particularly with regard to use of tetanus immunoglobulin), leaving many patients, especially those from high-risk groups, unprotected. Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.
Annals of emergency medicine 04/2004; 43(3):305-14. DOI:10.1016/S0196064403010515 · 4.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to compare the number of emergency medicine (EM) graduates unable to find a job in the city/area of their first choice in 1995 and 1997. Self-administered questionnaires were distributed to EM residents who graduated in both 1995 and 1997. The survey ascertained resident's practice city and state, whether their job was in the city/area of first choice and how satisfied they were with their practice selection. Eighty (83%) programs and 507 (70%) of eligible residents participated. Thirty-eight percent of graduates chose to practice in the city or metropolitan area where they trained and 75% of respondents were very satisfied with their practice selection. Nineteen percent stated they would not be practicing in the city/area of their first choice; one-third indicated there were no jobs available and two-thirds stated that jobs were available but not desirable. These numbers were similar to the 1995 data (P = .79). Job selection was more important than liking (P < .001) or having lived in (P < .001) a desired city/area of practice location. In conclusion, 1997 EM residency graduates were as successful as 1995 graduates in obtaining their first choice of jobs.
American Journal of Emergency Medicine 03/2000; 18(2):152-5. DOI:10.1016/S0735-6757(00)90007-X · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The objective of this study was to determine the prevalence of positive plasma drug screening for cocaine or amphetamine in adult emergency department seizure patients.
This prospective study evaluated consecutive eligible seizure patients who had a plasma sample collected as part of their clinical evaluation. Plasma was tested for amphetamine and the cocaine metabolite benzoylecgonine using enzyme-mediated immunoassay methodology. Plasma samples with benzoylecgonine greater than 150 ng/mL or an amphetamine greater than 500 ng/mL were defined as positive. Patient demographics, history of underlying drug or alcohol-related seizure disorder, estimated time from seizure to sample collection, history or suspicion of cocaine or amphetamine abuse, results of clinical urine testing for drugs of abuse, and assay results were recorded without patient identifiers.
Fourteen of 248 (5.6%, 95% CI 2.7%-8.5%) plasma samples were positive by immunoassay testing for benzoylecgonine and no samples (0%, 95% CI 0-1.2%) were positive for amphetamine. Positive test results were more common in patient visits where there was a history or suspicion of cocaine or amphetamine abuse (p < 0.0005).
During this study period, routine plasma screening for cocaine and amphetamines in adult seizure patients had a low yield. As a result, routine plasma screening would yield few cases of stimulant drug in which there was neither a history nor suspicion of drug abuse in this population.
Journal of toxicology. Clinical toxicology 01/2000; 38(6):609-13. DOI:10.1081/CLT-100102009
[Show abstract][Hide abstract] ABSTRACT: To determine the prevalence and risk factors associated with motor vehicle collisions (MVCs) and near-crashes as reported by emergency medicine (EM) residents following various ED shifts.
A survey was sent to all allopathic EM-2-EM-4 residents in May 1996 asking whether they had ever been involved in an MVC or near-crash while driving home after an ED shift. The residents' night shift schedules, self-reported tolerance of night work, ability to overcome drowsiness, sleep flexibility, and morningness/eveningness tendencies also were collected.
Seventy-eight programs participated and 62% of 1,554 eligible residents returned usable surveys. Seventy-six (8%, 95% CI = 6% to 10%) residents reported having 96 crashes and 553 (58%, 95% CI = 55% to 61%) residents reported being involved in 1,446 near-crashes. Nearly three fourths of the MVCs and 80% of the near-crashes followed the night shift. Stepwise logistic regression of all variables demonstrated a cumulative association (R = 0.19, p = 0.0004) that accounted for 4% of the observed variability in MVCs and near-crashes. Univariate analysis showed that MVCs and near-crashes were inversely related to residents' shiftwork tolerance (p = 0.019) and positively related to the number of night shifts worked per month (p = 0.035).
Residents reported being involved in a higher number of MVCs and near-crashes while driving home after a night shift compared with other shifts. Driving home after a night shift appears to be a significant occupational risk for EM residents.
Academic Emergency Medicine 11/1999; 6(10):1050-3. DOI:10.1111/j.1553-2712.1999.tb01191.x · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A convenience sample of 164 adult patients with 185 glass-caused wounds who presented to an emergency department (ED) and consented to a radiograph was prospectively studied. The purpose was to determine the characteristics of wounds at high risk for foreign body (FB) and the predictive value of patient FB sensation and probing wound exploration for FB retention. Retained glass was located in 28 (15%) wounds. Motor vehicle as a mechanism of injury (P=.003), head as a location (P=.035), and puncture as wound type (P=.002) were more likely to be associated with retained FBs (chi2 analysis). Patients with wounds with glass were more likely to have a positive perception of a foreign body (41%) than those with no glass (17%) (P=.005). The positive predictive value of patient perception was 31%; negative predictive value was 89%. In five cases, wound exploration was negative and subsequent radiograph was positive for FB. In one of these cases, a 4-mm glass FB was removed; in the other four, no FB was found. In conclusion, head wounds resulting from motor vehicle accidents or puncture wounds are more likely to harbor retained glass FBs. Patients with glass FB in wounds are more likely to have a positive perception of FB; however, a positive perception has a low predictive value of glass FB. In this series, a negative wound exploration made the presence of retained FB greater than 2 mm less likely but did not rule out the presence of retained glass.
American Journal of Emergency Medicine 12/1998; 16(7):627-30. DOI:10.1016/S0735-6757(98)90161-9 · 1.27 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe the geographic distribution of practice locations for 1995 emergency medicine residency graduates and factors that are important to residents in their choice of practice location.
Self-administered questionnaires were distributed to Emergency medicine residents who graduated in 1995. The survey ascertained practice city and state, resident employment characteristics, and the importance of factors that influenced the residents' selection of employment.
Eighty-six of 87 programs and 441 (69.4%) of 635 eligible residents participated. Forty-three percent of graduates chose to practice in the city or metropolitan area in which they trained; 46% of these had no personal tie to the area before their residency training. Liking the city was cited as being more important (P<.001) than other factors in picking practice location. Group personality and coworkers' credentials were more important (P< or =.01) than contract and salary arrangement. Twenty percent of respondents were not practicing in the city or area of their first choice.
Residency training location, regardless of prior ties to the geographical area, appears to be a major factor in the choice of practice location of emergency medicine residency graduates. Coworkers' personalities and credentials are more important factors in job selection than salary and employment arrangements.
Annals of Emergency Medicine 03/1998; 31(3):351-7. DOI:10.1016/S0196-0644(98)70346-4 · 4.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the frequency and potential predictors of opioid toxicity recurrence after a response to naloxone in adult Emergency Department patients.
A retrospective case-control study of naloxone-treated patients with opioid toxicity over an 8-year period. Both the patient response to naloxone and recurrence of opioid toxicity was determined by an expert Delphi Panel. The frequency of opioid toxicity recurrence was compared by the duration of opioid effect, the route of opioid exposure, and the presence of other CNS depressant drugs.
Ninety of 221 (41%) cases with a discharge diagnosis of opioid toxicity were treated with naloxone; six patients were excluded because of a lack of toxicity. There was a response to naloxone in 50% of the 84 cases, and recurrence of toxicity in 31% (95% CI 17-45%) of naloxone responders. The most common opioids were codeine, heroin, propoxyphene, and oxycodone/hydrocodone. Recurrence of toxicity was more common with long-acting opioids (p = 0.04), and was not associated with the route of opioid exposure (p = 0.42), or presence of ethanol and other CNS depressants (p > or = 0.87).
Opioid toxicity recurrence after a response to naloxone occurred in approximately 1/3 of adult Emergency Department opioid overdose cases. Recurrence was more common with long-acting opioids and was not associated with the route of opioid exposure. Other clinically useful predictors of toxicity recurrence were not identified.
Journal of toxicology. Clinical toxicology 02/1998; 36(1-2):11-7. DOI:10.3109/15563659809162577
[Show abstract][Hide abstract] ABSTRACT: Suicide is a major source of morbidity and mortality in patients with mental illness. The selective serotonin reuptake inhibitors (SSRIs) and other newer nontricyclic antidepressants appear to have less clinically significant toxicity in overdose, resulting in lower costs of treatment when compared with tricyclic antidepressant (TCA) overdoses. The resource utilization and cost of treatment for SSRI overdoses may not be less if (1) these agents are commonly ingested with other potentially toxic substances, or (2) health care practices have not changed in response to the apparent greater safety of SSRIs. This study evaluates demographic variables of antidepressant overdoses to determine whether differences exist in treatments and monitoring. Additionally, this study evaluates costs associated with care and the impact of co-ingestants on those same factors.