The American journal of emergency medicine
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A retrospective study was conducted to determine the outcome of out-of-hospital cardiac arrests by one prehospital system in New York City from January, 1986, through December, 1993. The results were recorded consistent with the Utstein Style. Of 481 attempted patient resuscitations 406 were of cardiac etiology, with 382 patients having arrested prior to EMS arrival; their overall survival rate was 2.1% (8/382). ⋯ Of the 7 survivors who were discharged from the hospital, 71.4% (5/7) had a good cerebral performance/good overall performance. Of 24 patients who arrested in the presence of EMS, the survival rate was 12.5% (3/24). This study confirms a poor survival rate for patients suffering out-of-hospital cardiac arrests in New York City.
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The incidence of this previously rare disorder, cocaine-associated agitated delirium, appears to have increased drastically within the last 18 months. The underlying neurochemical abnormalities have recently been characterized, but most clinicians have had little experience with management of agitated delirium. The basic clinical and pathological features of this disorder are reviewed, and common pitfalls in diagnosis and management that frequently lead to needless but very expensive litigation are discussed.
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Clinical Trial
A prospective evaluation of the safety and efficacy of methohexital in the emergency department.
A prospective observational study in an inner-city teaching hospital was conducted to evaluate the safety and efficacy of intravenous methohexital (MTX) in the emergency department (ED). Pulse oximetry, vital signs and Glasgow Coma Scale (GCS) scores were recorded serially for 30 minutes after the administration of MTX to 76 adult patients. Likert scales of 1 to 5 were used to record the physician's assessment of the adequacy of sedation and the patient's assessments of recall and pain of the procedure. ⋯ Patients reported little recall (1.3 +/- 0.9) or pain (1.3 +/- 0.8). It was concluded that MTX caused clinically insignificant changes in hemodynamics or oxygenation, although respiratory depression did occur; significant respiratory depression was brief and easily managed. MTX provided rapid and excellent levels of sedation with little or no patient recall or pain.
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Comparative Study
Performance of a system to determine EMS dispatch priorities.
Inappropriate use of emergency medical services (EMS) for nonemergencies strains EMS resources and limits efficiency. Protocol-driven dispatch systems attempt to correct the imbalance that exists between demand and available resources by prioritizing 911 calls. This study compared dispatch priority decisions with apparent patient need, based on emergency department (ED) presentation, by matching 320 ED charts with corresponding EMS dispatch and run information. ⋯ There was only 43% agreement on the more detailed 4-level classification system. The system assigned the highest level of dispatch utilizing combined ALS and first responders to a significantly greater degree than did the physicians. It was concluded that protocol systems for setting dispatch priorities utilize EMS resources to a higher degree than actually required based on ED presentation.
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This study reviewed 549 malpractice claims filed against emergency physicians in Massachusetts from 1975 through 1993, with a total of $39,168,891 of indemnity and expense spent on the 549 closed claims. High-risk diagnostic categories (chest pain, abdominal pain, wounds, fractures, pediatric fever/meningitis, epiglottitis, central nervous system bleeding, and abdominal aortic aneurysm) accounted for 63.75% of all closed claims and 64.23% of the total indemnity and expense spent on closed claims. Missed myocardial infarction (chest pain) claims accounted for 25.47% of the total cost of closed claims but only 10.38% of closed claims. ⋯ The frequency of high-risk claims decreased in the post-1988 group, largely because of the decline in fracture and wound claims. The category of missed myocardial infarction had a larger percentage of claims closed with indemnity payment than without indemnity payment. This parameter may serve as a marker for the overall seriousness of claims associated with a particular allegation, unlike the average cost per claim, which may be skewed by a few large awards.