Annals of emergency medicine
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A comparative study of 30 hospital emergency departments (EDs) and nearly 1,500 individuals associated with them was conducted. Data were obtained from institutional records, physicians, patients, and other sources. The object was to investigate the relationship between the organization and performance of these health service systems. ⋯ They also show a significant relationship between medical and nursing care, but not between the quality of care and economic efficiency. Differences in ED performance are related to medical staffing patterns, medical teaching affiliation, personnel training, scope of emergency services, number of patient visits processed, and hospital size and complexity. Not all of these variables, however, correlate positively with all three criteria of performance, nor are they equally important to each.
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The chest radiographs of 86 patients with suspected aortic rupture from blunt chest trauma were reviewed. Seventy-three patients had no evidence of aortic rupture on aortography or surgical exploration, and 13 patients had surgically confirmed rupture. Sixteen radiographic findings were analyzed for sensitivity and specificity in detecting aortic rupture. ⋯ False positives and false negatives occurred with each radiographic sign, indicating that there is no single finding that is absolutely reliable in predicting or excluding significant injury in every patient with suspected aortic rupture. Analysis of combinations of findings found that when the aortic contour and knob are normal and the nasogastric tube and trachea are not deviated, there was no case of aortic rupture in four consecutive years of experience. These four signs can be used to exclude aortic rupture.
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Coagulation abnormalities can pose a threat to hemorrhaging patients and to attempts at surgical correction. We have shown that 97.2% of our 180 patients who died of trauma had evidence of coagulation defects prior to fluid or blood treatment. Twelve of 180 patients could not be cross-matched due to inability of their blood to coagulate in the tube. ⋯ The greatest degree of coagulation abnormality occurred in patients with head trauma, followed in decreasing order by gunshot wounds, blunt trauma, and stab wounds to the body. Because 97.2% of the patients had abnormal coagulation studies prior to fluid and blood replacement, this abnormality most likely was due to disseminated intravascular coagulation. We propose using the tube-clot test to give a rapid indication of coagulation in traumatized patients while awaiting laboratory test results.
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The availability of complete, accurate, and current medical information is an important aspect of clinical problem solving. As the body of medical information grows and increasingly is reformatted into problem-oriented references, information processing by physicians will grow in importance. ⋯ An emergency medicine clinical problem-solving system containing information recording and processing methodologies is presented. The information processing methodology of this system is highlighted.
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Dipstick results in patients with blunt trauma have not been demonstrated to be predictive of the amount of microscopic hematuria. Our study examined the relationship between dipstick results and the degree of microscopic hematuria in 185 patients admitted to our emergency department following blunt trauma. Urine samples of 169 were dipsticked; the remaining 16 were grossly bloody. ⋯ False positives were recorded seven of 26 times (27%) for 2+, and three of 17 times (18%) for 3+ dipstick readings. We conclude that dipstick results do not correlate well with the presence or absence of hematuria in patients with blunt trauma. Microscopic urinalysis is a better test on which to base the decision to perform further diagnostic tests in the evaluation of the urinary tract.