A study of the workforce in emergency medicine.

STUDY OBJECTIVE: Emergency medicine has progressed significantly since its initial recognition as a medical specialty. Relatively little factual information is known, however, regarding who or how many physicians practice emergency medicine. The purpose of this study is to determine the total number of physicians practicing clinical emergency medicine during a specified period, to describe certain characteristics of those individuals, and to estimate the total number of full-time equivalents (FTEs), as well as the total number of individuals needed to staff those FTEs. METHODS: Data were gathered from a survey of a random sample of 2,062 hospitals drawn from a population of 5,220 hospitals reported by the American Hospital Association as having, or potentially having, an emergency department. The survey instrument addressed items such as descriptive data on the institution, enumeration of physicians in the ED, as well as the total number working during the period June 1, 1997, through June 14, 1997. Demographic data on the individuals were also collected. RESULTS: A total of 942 hospitals responded (a 45.7% return rate). These hospitals reported a total of 5,872 physicians were working during the specified period, or an average of 7.48 persons scheduled per institution. The physicians were scheduled for a total of 297,062 hours. The average standard for FTE was 40 clinical hours per week. This equates to 3,713 FTEs or 4.96 FTEs per institution. The ratio of persons to FTEs was 1.51:1. With regard to demographics, 83% of the physicians were men and 81% were white. Their average age was 42 years. As to professional credentials, 58% were emergency medicine-residency trained and 53% were board certified in emergency medicine; 46% were certified by the American Board of Emergency Medicine. CONCLUSION: Given that there are 4,945 hospitals with EDs and given that the data indicate there are 4.96 FTEs per ED, the total number of FTEs is projected to be 24,548 (standard error = 437). Given further that the data indicate a physician/FTE ratio of 1.51:1, we conclude that there are 36,990 persons (standard error = 683) needed to staff those FTEs. When adjusted for persons working at more than one ED, that number is reduced to 32,026.

Attending coverage in academic emergency medicine: a national survey.

We surveyed the 66 accredited emergency medicine residency programs in the United States during 1986 on the issue of attending coverage. Responses were received from 411 residents and 288 faculty; this accounted for 42% of the residents and 56% of the faculty from the 56 responding programs. Seventy-three percent of emergency medicine residency programs had 24-hour attending coverage. According to residents, faculty from programs with 24-hour coverage spent a greater percentage of their shift doing primary patient care than faculty from programs without 24-hour coverage (35% vs 17%, respectively, P less than .0001), and a smaller percentage of their shift educating residents (21% vs 30%, respectively, P less than .0001). Ninety-five percent of faculty and 71% of residents thought that the quality of patient care was better when faculty were present in the ED (P less than .0001). Sixty-one percent of residents and 60% of faculty did not think that 24-hour attending coverage in academic emergency medicine should be mandated. The impact of night-time attending coverage in emergency medicine residency programs on patient care, resident education, and faculty development is unclear and minimally studied.

Assessment of suicide potential by nonpsychiatrists using the SAD PERSONS score.

We were unable to validate the predictive ability of a previously described mneumonic (SAD PERSONS score, SPS) for determining the need for hospitalization of patients who have expressed suicidal ideation or behavior. After reviewing published studies on the subject, we arrived at a modification of this scale (MSPS). The MSPS obtained by nonpsychiatric and psychiatric house staff was compared and correlated with patient disposition for 100 consecutive adult patients presenting to the Harbor-UCLA Medical Center emergency department for the assessment of suicidal behavior. We were unable to correlate the MSPS with patient disposition. However, four criteria were found to correlate with the need for hospitalization (P less than .001). After weighting the MSPS, giving two points for each of these four criteria, and one point for each of the other six, we found that a score of greater than or equal to 6 had a sensitivity of 94% and a specificity of 71% in identifying need for hospitalization. A score of less than or equal to 5 had a negative predictive value for hospitalization of 95%. When two nonsuicidal patients, admitted for situational reasons only, were eliminated, a score of greater than or equal to 6 had a 100% sensitivity and a score of less than or equal to 5 had a 100% negative predictive value in identifying patients requiring hospitalization. Subsequent use of the weighted MSPS for an additional 82 patients confirmed these results. Follow-up of 97.5% (116/119) of all patients discharged from the emergency department at 6 to 12 months found no mortalities. Using a weighted MSPS, nonpsychiatrists can quickly and easily obtain the objective information necessary to make an initial assessment of suicidality.(ABSTRACT TRUNCATED AT 250 WORDS)

Spinal epidural abscess: a rapidly progressive disease.

We report a case of spinal epidural abscess in a 42-year-old diabetic. The patient first presented with four days of low back pain with radicular symptoms following exertion. When he returned five days later with overt symptoms and signs of spinal cord compression, an epidural mass was diagnosed by myelogram and computed tomography scan. Following drainage of a large posterior epidural abscess, the patient was left with residual weakness requiring ongoing physical therapy.

Ectopic pregnancy.

Ectopic pregnancy is a potentially lethal disorder that is often difficult to diagnose clinically. More than 70,000 ectopic pregnancies are reported annually in the United States, and the incidence is rising. A thorough knowledge of predisposing factors, clinical presentation, common misdiagnoses, and recent advances in diagnostic modalities should help the Emergency Department physician avoid the pitfalls that lead to misdiagnosis with resulting morbidity and, occasionally, mortality.

Hematuria induced by urethral catheterization.

The amount of traumatic hematuria induced by urethral catheterization was studied by comparing the pre- and post-catheterization urinalyses of 93 patients presenting to the emergency department with abdominal complaints of an acute nature. Thirty-nine male patients ranging in age from 4 to 91 years and 51 female patients ranging in age from 1 to 70 years were studied. Catheterizations were performed by nurses (54%), resident house-staff (38%), and nurse practitioners (8%). Overall, hematuria was induced in 16 of 93 patients (17.2%) and, when present, never exceeded 3 RBC/hpf.

Varicella pneumonia in adults: a spectrum of disease.

Varicella (Chicken pox) is a contagious disease common in childhood but uncommon in adulthood. Pneumonia, however, is a relatively common complication of the disease in adults. Recognition of the potential for this complication in adult patients with varicella is essential for the emergency physician. Three cases of varicella pneumonia in adults are presented, representing the spectrum of disease. The first patient was a 58-year-old man without respiratory complaints who was managed successfully as an outpatient. The second patient was a 24-year-old woman who progressed from mild to marked respiratory distress over several hours, and was treated successfully with high-flow oxygen alone. The third patient was a pregnant 23-year-old woman who presented without respiratory symptoms but rapidly developed adult respiratory distress syndrome, resulting in death. Clinical assessment, patient management, and indications for hospitalization are discussed.

Myocardial contusion diagnosed by first-pass radionuclide angiography.

Myocardial contusion, (traumatic myocardial dysfunction) is a relatively common complication of blunt trauma. The diagnosis is often elusive. Studies using clinical and laboratory parameters often fail to detect patients with significant myocardial injury. No constellation of clinical signs, electrocardiographic findings, or cardiac enzymes has been sensitive or specific enough to evaluate such patients accurately. Recently, radionuclide angiography was found to be a sensitive indicator of myocardial dysfunction. The authors studied ten patients with blunt thoracic or multisystem trauma who had myocardial dysfunction documented by first-pass radionuclide angiography. Follow-up study within five weeks demonstrated normalization or improvement in ejection fraction and wall motion abnormalities in all patients. Radionuclide angiography is cost effective, can be performed in the emergency department, and can assist in the management of patients with blunt thoracic or multisystem trauma.

Pulmonary embolism.

Pulmonary embolism is one of the major diagnostic challenges facing the emergency physician, since the failure to rapidly diagnose and treat this condition can result in early mortality. Presently, as many as 100,000 preventable deaths a year may be caused by pulmonary embolism. A high index of suspicion and a well thought out approach to the diagnosis and treatment of this elusive condition should help emergency physicians to improve upon these statistics.