Emergency Department Operations I: Emergency Medical Services and Patient Arrival.

The emergency department (ED) is by its nature inherently an environment with the potential for chaos because of the high volume and varied types of patients cared for in an ED setting. This article discusses potential system opportunities from the prehospital environment through arrival in the ED before provider evaluation. The Emergency Medical Treatment and Active Labor Act is reviewed in detail. Management and the reduction of risk to waiting room patients and patients who leave without being seen is explored. Description of the risks and mitigation strategies are discussed to decrease risk to patients, providers, and hospitals.

Measuring Agreement Among Prehospital Providers and Physicians in Patient Capacity Determination.

OBJECTIVES: If a patient wishes to refuse treatment in the prehospital setting, prehospital providers and consulting emergency physicians must establish that the patient possesses the capacity to do so. The objective of this study is to assess agreement among prehospital providers and emergency physicians in performing patient capacity assessments. METHODS: This study involved 139 prehospital providers and 28 emergency medicine physicians. Study participants listened to 30 medical control calls pertaining to patient capacity and were asked to interpret whether the patients in the scenarios had the capacity to refuse treatment. Participants also reported their comfort level using modified Likert scales. Inter-rater reliability was calculated utilizing Fleiss' and Model B kappa statistics. Fisher's exact tests were used to calculate p-values comparing the proportion in each cohort that responded "no capacity." Primary outcomes included inter-rater reliability in the physician and prehospital provider cohorts. RESULTS: The inter-rater agreement between the physicians was low (Fleiss' kappa = 0.31, standard error [SE] =0.06; model-based kappa = 0.18, SE = 0.04). Agreement was similarly low for the 135 prehospital providers (Fleiss' kappa = 0.30, SE = 0.06; model-based kappa = 0.28, SE = 0.04). The difference between the proportion of physicians and prehospital providers who responded "no capacity" was statistically significant in five of 30 scenarios. Median prehospital provider and physician confidence, on a 1 to 4 scale, was 2.00 (Q1-Q3 = 1.00-3.00 for prehospital providers and Q1-Q3 =1.0-2.0 for physicians). CONCLUSIONS: There was poor inter-rater reliability in capacity determination between and among the prehospital provider and physician cohorts. This suggests that there is need for additional study and standardization of this task.

An in vitro assessment of the sealing ability of resilon/epiphany using fluid filtration.

The aim of this in vitro study was to compare the sealing ability of Resilon/Epiphany to gutta-percha and Roth or AH Plus sealers. Leakage of the obturated roots was measured using the fluid filtration technique. There were eight groups of 12 teeth each. Group 1: obturated with Resilon/Epiphany; group 2: obturated with gutta-percha/Roth, allowed to set for 3 wk; group 3: obturated with gutta-percha/Roth; group 4: obturated with Resilon/Epiphany using a single cone; group 5: obturated with Resilon cones without using primer/sealer (positive control); group 6: obturated with gutta-percha/AH Plus; group 7: same as group 6, but allowed to set for 8 h; and group 8: sealed on the outside with three layers of nail varnish (negative control). The results showed that only the positive control (group 5) leaked significantly more (p < 0.05) than the other groups. There was no effect of time on leakage. Resilon/Epiphany was no better than gutta-percha/Roth or gutta-percha/AH Plus at sealing root canals.

Incidence of instrument separation using LightSpeed rotary instruments.

The use of nickel-titanium rotary instrument systems has gained popularity over the past 10 years. One of these instrument systems is the LightSpeed (LightSpeed Technology, Inc, San Antonio, TX). One drawback for all nickel-titanium rotary instruments is the incidence of instrument separation. The purpose of this study was to evaluate the incidence of nonretrievable instrument separation using the LightSpeed system in a clinical setting. A total of 3543 canals were treated over a 24 month period and during that time, 46 LightSpeed instruments were separated and found to be nonretrievable, resulting in a separation rate of 1.30%. This rate was lower than previous reported studies.

Paresthesia associated with endodontic treatment of mandibular premolars.

The objective of this retrospective study was to determine how often paresthesia occurs and to examine the role of the anatomy of the inferior alveolar nerve (IAN). The study took the form of a review of the records of the endodontic department at the Creighton University School of Dentistry, a literature review, and cadaver dissections. The result showed that of 6313 teeth treated during a 7-yr period, 832 were mandibular premolar teeth. The eight reported cases of paresthesia in that group reflected an incidence of 0.96%. Observations of dissected human-cadaver mandibles indicated that the paresthesias of the mandible could be related to the confinement of the IAN within the limits of the mandible. It was concluded that these paresthesias were related to the intrabony course of the IAN through the mandible, which contributed to the paresthesia symptoms.