The American journal of emergency medicine
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Patients presenting to emergency departments (EDs) for primary management of chronic or recurrent nonmalignant pain conditions and their physicians frequently report dissatisfaction, in part because of the impressions created by a small percentage of such patients that frequently visit EDs requesting opioids. Treating such patients with opioids is contrary to many published guidelines, but refusing them increases dissatisfaction. ⋯ Emphasis will be shifted to home management and the family doctor's office. If successful, the system will minimize ED visits by frequent attendees seeking medication for pain control, and should also decrease overall expenditure to the health care system.
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A nonconcurrent prospective cohort study was conducted to evaluate if National Resident Matching Program (NRMP) rank developed using multivariate regression followed by consensus group activity is associated with perceived general performance during emergency medicine residency. All residents graduating from a university hospital-based residency program between 1990 to 1993 were ranked by university faculty, private attendings, charge nurses, and a clerk. Each evaluator was asked to order (from the strongest to the weakest) a deck of cards that contained only each graduate's name and picture. ⋯ There was moderately strong agreement among evaluators about the relative strength of the 20 residents (W = 0.67, P < .001). The association of perceived rank with NRMP rank was much greater than that expected by chance (r(s) = .35, P < .0001). Applicants with better NRMP ranks were perceived as stronger residents, which supports the strategy of using formal statistical modelling followed by consensus group activity as a method of generating NRMP rank lists.
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The routine use of sodium bicarbonate in patients with cardiac arrest has been discouraged, with the benefit of outcome evaluation. Current recommendations include an elaborate stratification of circumstances in which bicarbonate is to be used. The physiological and clinical aspects of bicarbonate administration during cardiopulmonary resuscitation in animal and human studies were reviewed. ⋯ Likewise, bicarbonate may have adverse effects in each of these areas. The preponderance of evidence suggests that bicarbonate is not detrimental and may be helpful to outcome from cardiac arrest. An objective reappraisal of the empirical use of bicarbonate or other buffer agents in the appropriate "therapeutic window" for cardiac patients may be warranted.
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Outcome after cardiac arrest is strongly related to whether the patient has ventricular fibrillation at the time the emergency medical service (EMS) arrives on the scene. The occurrence of various arrhythmias at the time of EMS arrival among patients with out-of-hospital cardiac arrest was studied in relation to the interval from collapse and whether cardiopulmonary resuscitation (CPR) was initiated by a bystander. The patients studied were all those with out-of-hospital cardiac arrest in Goteborg, Sweden, between 1980 and 1992 in whom CPR was attempted by the arriving EMS and for whom the interval between collapse and the arrival of EMS was known. ⋯ There was a successive decline in occurrence of such arrhythmias with time. However, when the interval exceeded 20 minutes, ventricular fibrillation/tachycardia was still observed in 27% of cases. Bystander CPR increased the occurrence of such arrhythmias regardless of the interval between collapse and EMS arrival.