Management of casualties from the bombing at the centennial olympics.

BACKGROUND: The explosion of a bomb 75 to 100 yards away from attendees at a concert who were in the process of being evacuated from Centennial Olympic Park at approximately 1:25 AM on July 27, 1996, resulted in a multiple-casualty event involving primarily four hospitals in proximity to the blast. The purpose of this study was to review triage and care of the victims, emphasizing those with significant injuries. METHODS: Retrospective review of triage and care of injured patients. RESULTS: Ninety-six of the 111 victims of the blast were triaged in the first half hour to four hospitals within 3 miles of the bombing. Only four minor operations were performed in 61 patients evaluated at community hospitals. Ten of 35 patients evaluated at the regional trauma center underwent emergency or urgent operations, and all who were seriously injured did well. CONCLUSIONS: Although overtriage to the regional trauma center occurred, outcome was excellent in all seriously injured victims treated there.

Role of emergency medicine residency programs in determining emergency medicine career choice among medical students.

STUDY OBJECTIVE: To characterize the role of emergency medicine residency programs in determining emergency medicine career choice among medical students. DESIGN: Observational, cross-sectional, descriptive study. Information on student career choice was obtained through a targeted query of the National Resident Matching Program data base, simultaneously stratified by specialty and school, and adjusted for class size. PARTICIPANTS: All accredited emergency medicine residency programs and four-year allopathic medical schools. RESULTS: Fifty-two schools (42%) had a closely affiliated emergency medicine residency program, ie, one based primarily at the institution's main teaching hospital(s). This configuration was associated with a 70% increase in the median proportion of students choosing emergency medicine as a career when compared to the 73 schools with no closely affiliated emergency medicine residency (5.1% vs 3.0%, P < .0001). When institutions were stratified by overall commitment to emergency medicine, the median proportion of students choosing emergency medicine as a career was 2.9% for institutions with a minimal commitment to emergency medicine (neither an academic department of emergency medicine nor a closely affiliated emergency medicine residency), 4.1% for institutions with a moderate commitment to emergency medicine (either a department of emergency medicine or an emergency medicine residency, but not both), and 5.7% for institutions with a substantial commitment to emergency medicine (a department of emergency medicine and an emergency medicine residency) (P < .0001). When institutional commitment to emergency medicine was examined in a simple multivariate model, only the presence of an emergency medicine residency was associated independently with student career choice (P < .001). CONCLUSION: An emergency medicine residency program that is closely affiliated with a medical school is strongly and independently associated with a quantitatively and statistically significant increase in the proportion of students from that school who choose a career in emergency medicine. These data support the proposition that, if emergency medicine is to meet national manpower shortage needs by attracting students to the specialty, it must establish residency programs within the primary teaching hospital(s) of medical schools. Such a configuration does not currently exist in the majority of schools.

Current status of academic emergency medicine within academic medicine in the United States.

OBJECTIVE: To characterize the status of emergency medicine within U.S. academic medical centers. METHODS: All accredited emergency medicine residency programs and all four-year allopathic medical schools in the United States were identified. Institutions were defined as academic medical centers based upon NIH research grant funding. These institutions were ranked using five measures of academic stature: a survey of medical school deans, a survey of internal medicine residency directors, level of research funding, characteristics of the student body, and an unweighted composite variable reflecting overall academic stature. The relationship between institutional academic stature and an empiric scale of institutional affiliation with emergency medicine was assessed. RESULTS: Sixty-two institutions were designated academic medical centers. These medical schools captured 90% of all NIH grant monies awarded in fiscal year 1990. Twenty-six of 87 emergency medicine residency programs (30%) were closely affiliated with one of these medical schools. Within academic medical centers, the presence of a residency or an academic department of emergency medicine was inversely associated with the medical school deans' ranking (p < 0.005), research rank (p < 0.001), and composite academic rank (p < 0.001). CONCLUSION: The majority of emergency medicine residency programs (70%) are not closely affiliated with institutions receiving the bulk (90%) of NIH resources for research. Within the institutions receiving the majority of NIH funding, there is a quantitatively and statistically significant inverse association of institutional emergency medicine affiliation and institutional academic rank.

Heterotopic pregnancy.

A 35-year-old woman presented to the emergency department with abdominal pain 36 hours after a therapeutic abortion. A positive pregnancy test was thought to be related to the recently terminated intrauterine gestation. The patient was admitted for observation. When monitoring revealed intraabdominal hemorrhage, exploratory surgery was performed and a ruptured tubal pregnancy discovered. The patient recovered uneventfully. The incidence, predisposing factors, and diagnosis of simultaneous intrauterine and extrauterine pregnancy are discussed.

Where we've been, where we are, and where we're going: emergency medicine--past, present, and future.

The challenge to emergency medicine for the future is to maintain the intensity of attraction and appeal that the specialty currently enjoys through the next decade and beyond. This will only be accomplished by attracting some of this bright young talent into full-time academic emergency medicine for research and teaching activities. Currently there are unfilled academic positions in the department at LAC/USC Medical Center and across the country in emergency medicine. This is because the salaries are not competitive, and most physicians completing their residencies with indebtedness for their education have the need of high income for a period after residency training. However, few return to academic medicine after becoming accustomed to a higher standard of living. This trend must change if we are to maintain the cutting edge of clinical emergency medicine and become the academic equivalent of the other specialties. The 12 physicians who founded ABEM, and especially the remaining six founding members who will be leaving the Board in a few days, feel honored that you selected us to serve. I am deeply grateful that you selected me to give the Kennedy Lecture, though I must admit to moments of anxiety and panic these last few weeks and days. Also, I would like to thank all the candidates for Board certification whom it was my privilege to examine during a delicate and stressful moment of their professional lives. It is really they who make the job worthwhile. Hopefully, we have laid a good foundation so that we can legitimately say the "ball" is yours now, "run with it."

Pneumomediastinum as a complication of "crack" smoking.

Three cases of pneumomediastinum related to smoking cocaine in the form of "crack" are presented. The patients complained of chest or neck pain occurring 1 to 6 hours after smoking crack. All three did not immediately divulge a history of cocaine use. There was spontaneous resolution of pneumomediastinum in every case, and the creation of pneumomediastinum appeared to be directly related to the route of drug use. The abuse of crack and the mechanism of spontaneous pneumomediastinum are discussed.

Exsanguinating hemorrhage from peripheral varicosities.

A 48-year-old woman presented to the emergency department in cardiovascular collapse after the onset of spontaneous bleeding from a noninflamed, nontraumatized varicose vein of the lower extremity. Despite successful immediate resuscitation she later succumbed to the sequelae of hemorrhagic shock. There was no evidence of coagulopathy or coagulation defect. No cardiovascular disease was found on autopsy. Although not common, spontaneous rupture of peripheral varicosities occurs often enough to be of concern. The pathologic lesions have been classified as acute and chronic, with acute lesions occurring in otherwise normal skin. Exsanguination from this source is not mentioned in standard texts, and only 27 cases have been reported in the literature.

Simultaneous bilateral quadriceps tendon rupture: a case report and subject review.

Both unilateral and simultaneous bilateral rupture of the quadriceps tendon are frequently misdiagnosed. Patients typically present to the emergency department after a fall associated with sudden sharp pain and inability to extend the knee. Most frequently, the patient is elderly. Those under age 40 with bilateral quadriceps rupture usually have an associated metabolic disorder. The 22-year-old uremic patient we report is the youngest case with simultaneous bilateral rupture of the quadriceps tendon described in the English literature. Emphasis is placed on the initial clinical presentation and management. In addition, the pathophysiology and differential diagnosis are reviewed.

Research algorithms for emergency medicine.

The computer-instigated development of graphic depictions showing rationales and decisions required in the care of patients has allowed clinicians to standardize science in the art of clinical medicine. Such condensation of medical judgment and information into algorithms is particularly important for emergency medicine. This paper describes the background and development of such algorithms in a research setting, and suggests modes for adaptation to clinical settings.

Prospective vs retrospective data for evaluating emergency care: a research methodology.

Emergency department records and patient charts do not provide enough or sufficiently detailed data for audit of quality of care in a high volume emergency department. As a solution, at the Department of Emergency Medicine, University of Southern California School of Medicine, three emergency medical technicians--hospital-based paramedics--were trained as observers of patient process and treatment. In addition to basic identification information, the form completed by observers listed 21 procedural steps and process data such as sequence, time for completion, type of personnel performing, necessary equipment and supplies, and space for comments. Direct observation of patient process was carried out in 442 patients, a total of 3,882 procedures was observed and recorded. The direct observation is perhaps the most accurate method of data collection for auditing purposes because it reflects actual events. This data was used by the Research Peer Review Committee to help rate the quality of patient treatment process.

A unique approach to evaluation of emergency care.

A quality care evaluation system was designed to serve as a framework for on-going research in the area of quality assurance in emergency medicine. It included a set of basic evaluation tools, such as direct observation of patient care, record review and analysis, and patient follow-up interview for outcome. These tools are used in an attempt to quantify relationships between quality care and patient outcome.

Management and outcome of class A diabetes mellitus.

Patients who have a normal fasting serum glucose (FSG) and an abnormal glucose tolerance test, and who require little dietary regulation, have been designated as Class A diabetics by White. During the period 1970 through 1972, 261 Class A women were delivered at Los Angeles County (LAC) Women's Hospital. These patients were managed by a uniform protocol which included dietary supervision and continued surveillance for the onset of overt diabetes. Elective intervention prior to 40 weeks' gestation was to be avoided. Twenty-five per cent of the Class A patients--those who had had a previous stillbirth or who developed pre-clampsia--were considered at greater risk for perinatal death and were managed as if they had overt diabetes. The perinatal death rate for the entire Class A group was 19/1,000 as compared to 32/1,000 in the general population. Five perinatal deaths occurred, three associated with congenital malformations. There were no unexplained stillbirths or deaths due to trauma or iatrogenic prematurity. Our data thus indicate that as long as the FSG remains normal, an unexplained intrauterine death is a rare event. Twenty-five per cent of the infants did experience some morbidity.