A prospective study of in-line skating: observational series and survey of active in-line skaters--injuries, protective equipment, and training.

OBJECTIVES: 1) To assess the relationship between types of injuries incurred and training and protective equipment worn by adults injured while in-line skating; 2) to observe the type and amount of protective equipment worn by in-line skaters while skating; and 3) to survey active in-line skaters about formal training, protective equipment, and history of injuries incurred, and the effect of such injuries on the protective equipment subsequently worn. METHODS: A prospective study of consecutive adult patients presenting to the ED for evaluation of in-line skating injuries; a consecutive-series observational study of active in-line skaters to assess protective equipment worn; and a survey of selected active in-line skaters. Eighty-five adult patients were included who presented with a history of injury related to in-line skating to the EDs of an urban academic medical center, a suburban academic-affiliated hospital, and a community hospital. Four hundred eleven active in-line skaters on the Chicago lakefront were observed for protective equipment worn, 91 of whom participated in the survey. RESULTS: Of those presenting to the ED with injuries, only 15% indicated that they had received formal in-line skating instruction. Of the ED patients, 50% wore no protective equipment; overall, 6% wore a helmet; 44%, wrist protection; 23%, knee protection; and 19%, elbow protection. Only 2% wore all of the above equipment. The primary mechanism of injury reported was a loss of balance (58%); others included collision with objects (25%), collision with bicycles (11%), and collision with cars (5%). Fractures or dislocations occurred in 48% of the patients; 6% had head injuries necessitating CT scans. Those who wore no protective gear were more likely to require hospital admission (p < 0.05). Of the 411 in-line skaters observed, 157 (38%) wore no protective equipment. Compared with the injured group presenting to the ED, fewer observed participants were without protection (p < 0.05). Among those surveyed, prior injury was not associated with the subsequent use of protective gear. CONCLUSION: Patients who present to the ED for evaluation of in-line skating injuries have a high incidence of fractures/dislocations. Few injured or surveyed in-line skaters had formal training. Use of protective equipment by injured skaters was associated with a decreased likelihood of hospitalization. Observed in-line skaters more commonly wore protective gear than did those who presented to the ED with injuries.

Prospective evaluation of emergency medicine instruction for rotating first-postgraduate-year residents.

OBJECTIVE: To determine whether either bedside teaching alone (group A) or bedside teaching with written course materials (group B) improved written examination scores, satisfaction with the rotation, or clinical grades of rotating PGY1 residents. METHODS: A prospective, controlled educational trial was conducted. Sixty-five PGY1 residents from diverse specialties rotated in the ED for one month over a ten-month study period, and were included in the study. The PGY1 residents were assigned to group by month of rotation. All the PGY1 residents received unstructured bedside teaching by emergency medicine (EM) residents and faculty. In addition, group B received written course materials on day 1. RESULTS: Mean posttest scores were higher than mean pretest scores for the interns considered as a whole (p < 0.0001), but mean pretest, posttest, and clinical grades were comparable across instructional groups. Mean satisfaction ratings were higher for group A than for group B (p < 0.015). The interns specializing in EM achieved higher mean test scores (p < 0.013) and clinical grades (p < 0.003) than did the interns specializing in another medical specialty. CONCLUSION: Both instructional methods were associated with improved written test performance. Written course materials did not augment bedside teaching in terms of test scores, clinical grades, or satisfaction with the rotation. At a university-based, high-volume ED, bedside teaching offers educational benefit to rotating PGY1 residents that may not be augmented by written course materials.

Diagnostic modalities in the pregnant patient.

Pregnancy determination may be made within 3 to 4 weeks' gestational age using radioimmunoassay or two-site ELISA assay. Using serum progesterone concentrations, serial quantitative beta-hCG levels, culdocentesis, sonography, laparoscopy, and fetal heart rate determination, the clinician is able to determine fetal viability and implantation site often within 6 to 7 weeks' gestational age. Improved sensitivity in diagnostic modalities, as well as increased awareness of the often subtle clinical findings in ectopic pregnancy are probably both responsible for the decline in morbidity and mortality seen with ectopic pregnancy over the past 25 years. As the incidence has seen an even greater increase than this decline, however, ectopic pregnancy remains the leading cause of first-trimester maternal mortality in this country. With the use of imaging in pregnancy, the question of fetal safety must also arise. The modalities currently used in the first trimester of pregnancy appear to pose minimal risks to the developing fetus if used only when necessary, and then with caution.

Severe oral phenytoin overdose does not cause cardiovascular morbidity.

STUDY OBJECTIVE: To evaluate the potential for cardiovascular toxicity from severe oral phenytoin overdose. STUDY POPULATION: Fifty-seven patients admitted during a two-year period to an inner-city hospital for severe oral phenytoin overdose, which is defined as a peak level of 40 micrograms/mL or more. METHODS: Case records were reviewed retrospectively for symptoms and signs of phenytoin toxicity, especially circulatory effects. Baseline and toxic 12-lead ECGs, when available, were reviewed in detail. Continuous variables were compared using either paired or unpaired t tests, as appropriate. Significance was taken as P less than or equal to .05. RESULTS: Mean peak phenytoin level was 49.4 +/- 7.7 micrograms/mL. Continuous single-lead ECG monitoring in 36 patients (63%) for a mean of 26.5 +/- 21.6 hours revealed no incidents of dysrhythmia requiring treatment. ECGs recorded during toxicity in 52 cases (91%) revealed no clinically significant abnormalities attributable to phenytoin. ECGs during toxic and baseline states were available for detailed analysis in 15 cases. Ten patients exhibited an increase in PR interval (mean, 19 +/- 10 ms) when toxic, whereas five had a decrease (mean, 18 +/- 11 ms) compared with nontoxic records. No change in heart rate, QRS duration, or corrected QT interval was observed. There were no circulatory complications and no deaths. CONCLUSION: Cardiovascular toxicity is rarely a manifestation of oral phenytoin overdose. Routine management of stable patients with severe phenytoin overdose in a monitored setting is not mandatory.