SAEM (UAEM) 1978 Annual Meeting Program by Society for Academic Emergency Medicine

University Association for Emergency Medicine 8th Annual Meeting and Workshop ,

on Unloa ~ p u r HoUl d M.y 1 ~ 0 . 1 9 7 8

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Joseph Waeckerle, M.D.

Kenneth L. Mattox, M.D.

In pursuit of excellence in Emergency Medicine ... . . . the University Association for Emergency Medicine has scheduled more than two and one-half days of educational opportunities in one of the world's favorite cities. This year, we have had an exceptional response to our call for scientific papers. We received 1 0 8 abstracts and the 40 papers selected by our review committee are easily the best in our history.

We have assembled a panel of leading spokesmen in the field of burn care to discuss, "The High Risk Burns Patient: A Clinical, Ethical, Psycho-Social and Moral Dilemma." The panel will examine the controversial proposal by Bruce E. Zawacki, M.D., concerning management of burned patients when survival is unprecedented. Senator Alan M. Cranston will join us on Saturday, May 20, to present the Robert H. Kennedy Lecture and afford us an inside look at the federal government's plans for emergency medical services. We are pleased to have you with us and feel certain that you will find this 8th Annual Meeting a worthwhile and pleasurable experience.

Table of Contents Welcome . . . . . . . . . . . . . . . . . . . . . . Inside front cover General lnformation . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Robert H. Kennedy Lecturer . . . . . . . . . . . . . . . . . . . . 2 Honorary Membership . . . . . . . . . . . . . . . . . . . . . . . . . 3 Executive Council and Committee Meetings Schedule . . . . . . . . . . . . . . . . 4 General Session Agenda . . . . . . . . . . . . . . . . . . . . . . . 4 Vade Mecum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Scientific Paper Abstracts . . . . . . . . . . . . . . . . . . . . . . 1 0 Constitution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Bylaws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

REGISTRATION The UA/EM Registration Desk will b e located in the Ballroom foyer of the Hyatt o n Union Square Hotel beginning Thursday, May 18 from 7:30 a.m. until 5:00 p.m. On Friday. May 19 and Saturday, May 2 0 the registration desk will b e open from 7:30 a.m. until 1:00 p.m. Everyone attending the Annual Meeting is required to register. The registration fee includes all planned activities during the meeting.

INFORMATION DESK The Information Desk will be located in the regstration area.

NAME BADGES Name badges are required for all admission to all activities during the Annual Meeting and will be issued upon checking in at the Registration Desk.

PLACEMENT INFORMATION A bulletin board to list positions a n d physicians available will b e located in the registration area.

MESSAGE CENTER Phone messages will b e posted o n a bulletin board near the Registration Desk. Registrants may also post messages o n this board.

PROCEEDINGS Proceedings of the Annual Meeting will not be prepared a s a separate publication. Selected presentations and scientific papers will b e printed in JACEP, the Joumal of the American College of Emergency Physicians and the University Association for Emergency Medicine.

ANNUAL BUSINESS MEETING Saturday, May 20, the Association will hold its Annual Business Meeting immediately following luncheon. Agenda items will include: election of officers; reports from committees: consideration of proposed Constitution and Bylaws amendments; and other items of business presented by the membership.

CONTINUING MEDICAL EDUCATION The Annual Meeting has been approved by the American College of Emergency Physicians for 2 0 ACEP Category 1 credits.

1979 ANNUAL MEETING Program Chairman. Joseph F. Waeckerle. MD. has announced that he will accept abstracts for scientific papers t o b e presented at the 1 9 7 9 Annual Meeting. Members and others in the field are urged to submit original scientific contributions relating t o the field of emergency medicine. Abstracts should b e limited to 2 5 0 words and typed double-spaced o n 8%" x 11" paper. Abstracts must be

authored. co-authored or sponsored by a UA/EM member with the name, title and address of each author appearing on the abstract title sheet. Deadline for submission is January 30, 1979. Three copies of the abstract should be sent to Jospeh F. Waeckerle, MD, Program Chairman, UA/EM. 3 9 0 0 Capital City Boulevard, Lansing. Michigan 48906.

KENNEDY LECTURER Alan Macgregor Cranston is the senior United States Senator from the state of California and holds the prestigious and powerful position of Senate Majority Whip.

As a member of the Subcommittee on Health of the Senate Committee o n Labor a n d Public Welfare. Senator Cranston was a major proponent of the amendments to the Emergency Medical Services Act that have provided Federal support for emergency medicine residency programs, research grants, and training programs for nursing and paramedical personnel. It was Senator Cranston who authored the key amendment - S2548 - that developed the rationale and support for training and research programs in EMS. And it was he who assumed a leadership role during the hearings on the amendments. Those hearings had a major impact on the final decision to extend the EMSS Act for three more years and to provide funding for professional training programs. That funding amounts to $ 3 million annually for three years to finance emergency medicine residencies, along with $7 million for training nurses, technicians and other ancillary personnel. Since his election to the Senate in 1965, Senator Cranston has rapidly risen to a leadership role. He holds key committee assignments with Budget; Banking, Housing and Urban Affairs; Human Resources; and Veterans Affairs. He is also a member of the Majority Steering Committee and an ex-officio member of the Policy Committee. The University Association for Emergency Medicine is pleased and proud to have Senator Cranston present tho civth Rnhort H KonnoAxr I o r h ~ r o

H O N O K A R Y MEMBERSHIP The University Association for Emergency Medicine awards honorary lifetime memberships to persons who have made exemplary and significant contributions to the field of emergency medical services.

Eben Alexander, Jr., MD Professor, Section of Neurosurgery Bowman Gray School of Medicine Wake Forest University Winston-Salem, North Carolina Dr. Alexander is Professor and Chairman of the Section of Neurosurgery of the Bowman Gray School of Medicine and the North Carolina Baptist Hospital. He has also served as Chief of Staff at the North Carolina Baptist Hospital for approximately 2 0 years. On the national level. he has served with distinction in many important positions including, alternate delegate to the Council of Medical Specialty Societies of the American Medical Association and vice-president of the American College of Surgeons. Dr. Alexander has been a significant influence in the development of Emergency Medicine as a specialty. He was one of the first physicians in academics who recognized the need for specialized training in Emergency Medicine and submitted a training application to DHEW in May 1965. The curriculum developed for this application was a prototype for that required in the present training of Emergency Medicine residents at Bowman Gray. Much interest was generated by this application across the country and after two site survey visits, the application was approved, but not funded. This was the first formal training program in Emergency Medicine as noted in a 1966 memo from the AMA Council of Medical Education. On the national level at the American Medcal Association meeting in Chicago in June 1970, Dr. Alexander presented and moderated a symposium on Emergency Medical Training at the Section of Neurosurgery meeting. At a later AMA meeting, in December 1975. Dr. Alexander was of significant influence when Emergency Medicine was being considered for scientific section status. On the local level, Dr. Alexander supported development of the training program at the Bowman Gray School of Medicine and North Carolina Baptist Hospital. He has provided suggestions and criticisms to improve the program and supported the program at upper level committee meetings where policy decisions were being made. Dr. Alexander also took part in the first scientific meeting of the Section of Emergency Medicine of the North Carolina Medical Society in May 1977, during which he recounted some of the past history and provided pertinent suggestions for development of the specialty.

EXECUTIVE COUNCIL AND COMMITTEE MEETINGS Tuesday, May 16. 1978 10:OO a m 11:30 am

11:30 a m 1 . 3 0 pm 2:00 pm 6:00 pm

UA/EM Commifiee Meetings Nominating San Miguel Medical Education Governor's Suite #3 Research Governor's Suite #4 Constitution & Bylaws Review Governor's Suite #5 Program Governor's Suite #6 Executive Council Meeting

Portrero

Liaison Residency Endorsement Committee

Portrero

Wednesday, May 17, 1978 9:00 a m 5:00 pm 5:30 pm 7:30 pm

Executive Council Meeting

Cash Bar Reception

Portrero Ballroom West

GENERAL SESSIONS Thursday. May 18, 1978 8 : 0 0 am 8.45am

Scientific Papers I Ballroom East Carl Jelenko, 111, MD, Moderator 1. "Peritoneal Lavage Without Morbidity" Harrison M. Lazarus, M. D.

2. "Laparotorny in the Emergency Center" Fenneth L. Manox. M.D. 3. "A Statistical Model for Diagnosing Pediatric Abdominal Pain" Donald Brand, Ph.D. Special Presentation Lawrence R. Rose, M.D.

Ballroom East

Coffee Break Scientific Papers I1 Ballroom East David K. Wagner, M.D.. Moderator 4. "An Injuy Severity Scale for Comprehensive Management of Central Nervous System Trauma" Rebecca W. Rimel, R.N. 5. "The Licensed Psychiabic Technician - A New Paraprofessional Member of t h e Emergency Medicine Health Care Team" John A. Mitchell, M.D. 6. "Process and Outcomes in the Emergency Department: A Comparison of Nurse Practitioners and Other Clinician Groups" Joyce Mamon, Ph.D. 7. "Rape: Crisis or Continuum? The Prevalence of Battered Women Among Rape Vict i m s " William Fra7ior M D

8. "Alcohol Use a n d Psychiatric Illness in Emergency Patients" Douglas A. Rund, M.D.

9. "Use of Programable Calculators in Clinical Emergency Medicine" James C. Brill. M.D. 10. "A Developmental Module T o Teach Behavioral Intervention in Psychological Emergencies" Barbara Masters, R.N . M S . 11:30 a m 1:30 pm

STEM Annual Business Meeting

Ballroom West

Election of Officers Activity Reports Focus o n the Future 1:30 pm 2 : 3 0 pm

Scientific Papers Ill Ballroom East H. Arnold Muller, M.D., Moderator

11. "Residency Trained Emergency Physicians. Where Have All The Flowers Gone?" Rebecca A. H. Anwar, Ph.D. 1 2 . "An Orientation Program for First Year Emergency Medicine Residents: An Academic Advancement" Richard Levy, M.D. 1 3 . "Teaching Emergency Department Administration: The In-Basket Exercise" Kenneth V. lserson. M. D.

2:30 pm 5:00 pm

14. "Current Trend of EMSS Research" L a y C R ~ ~ P P WORKSHOP ON CLINICAL Ballroom East RESEARCH *''From Idea to Implementation" S h e l d o n Greenfield, Ph. D. Characteristics of the research project Selection and formulation of the research project "From Doing to Data" S h e l d o n Greenfield. Ph.D. Types of studies Methodology Design and measures Procedures "Dollars to Do-Nots" Larry J. Baraff. M.D. Getting your research funded Writing a clinical research proposal

Friday, May 19, 1978 8:00 a m 9 3 0 am

WORKSHOP ON CLINICAL RESEARCH

Ballroom East

"From Doing to Data" Larry J. Baraff, M.D. Data collection Basic statistics Types of statistics 9.30 am 11:OO a m

"Pearls in Practice" Harvey W.Meislin, M.D. Rules for Riters and the Paper Chase Using the criteria checklist to evaluate a research project Participant critique of 2 research papers

11:OO am 1 2 3 0 pm

"Quiz the Consultants" Rebecca A. H. Anwar, Ph.D., Larry J. Baraff, M.D.. Sheldon Greenfield, Ph.D., Carl Jelenko, 111, M.D., Ronald L. Krome. M.D., Joyce A. M a m o n , Ph.D., Harvey W. Meislin, M.D.. Lawrence R. Rose, M.D.. Joseph F. Waeckerle, M.D. Individual consultation on ctinical research question (bring your problems along)

'This session funded in part by a grant from Marion Laboratories. 1:00 pm 3:00 pm

Scientific Papers IV Ballroom East Kenneth L. Mattox, M.D., Moderator 15. "Incidence, Etiology, and Outcome of Patients with ldioventricular Rhythm During Advanced CPR" Thomas J. Petinga, Jr., D. 0 . 16. "Clinical Assessment of Patients Undergoing CPR in the Emergency Department" Martin Hill, M. D. 17. "Increasing Systolic Blood Pressure During External Cardiac compression by Use of a Medical Anti-Shock Trouser" G. Patrick Lilja. M. D. 18. "Comparison of Blood Levels of Epinephrine and the Metabolites of Epinephrine Achieved Following the Intravenous and Endotracheal Routes of Administration" James R. Roberts. M.D. 19. "Identification of Cardiac Contusions" Marleta Reynolds, M.D. 20. "Metabolic Acidosis with Anti-Shock Trousers in Hypovolemic Dogs" Kenneth Ransom, M.D. 21. "The Value of the 'G-Suit' in the Resuscitation of Patients with Acutely Ruptured or Dissecting Aortic Aneurysms" Thomas L. Evans, M.D. 22. "Development of the Pediatric Esophageal Obturator Airway" Richard J. Melker, M.D., Ph.D.

3:00 pm 5:00 pm

Scientific Papers V Ballroom East Ronald L. Krome. M.D.. Moderator 23. "Characterization of HIS Electrocardiography of the Terminal Arrhythmias of Hemorrhagic Shock in Dogs" Blaine C . White, M.D. 24. "Assessing Vascular Compromise in Trauma" Phillip J. Bendck, Ph.D. 25. "Therapeutic and Economic Implications of Emergency Department Evaluation for Venous Thrombosis" William S. Gross, M.D. 26. "The Management of Peneh-ating Neck Injuries" Dabney R. Yarbrough, I l l . M.D. 27. "The Emergency Treatment of Finger Tip In-

6 0 0 pm 9:30 pm

Reception and Awards Banquet

Ballroom West

Saturday, May 20, 1978 8:00 am 9:30 am

Scientific Papers VI Ballroom East Harvey W. Meislin. M.D.. Moderator

28. "Ketamine Dissociative Anesthesia Emergency Department Use in Children" William Repert, M.D. 29. "Discussion of the Most Common Errors in Radiology" Gabriel Martyak, D.O. 30. "Comparative Evaluation of the Effect of a High Yield Criteria List upon Skull Radiography Utilization in Emergency Departments" Leon A. Phillips, M.D. 31. "The Suspected Esophageal Foreign Body - How to Choose the Appropriate Management" Tim Allen, M.D. 32. "Intravenous Glucagon in the Management of Esophageal Food Obstruction" Jonathan Glauser, M. D. 33. "Guidelines for the Use of Hepatitis B Immune Globulin in the Emergency Department" John E. Conte, Jr.. M.D. 9:30 am 10:15 am

Robert H. Kennedy Lecture Senator Alan M. Cranston

Ballroom East

10:15 am 10:30 am

Special Presentation Ballroom East Allen P. Klippel, M.D. "The Argument for Passive Restraints in Automobiles"

10:30 am 11:45 am

Scientific Papers Vll William L. Tuefel, M.D., Moderator

34. "93 Pediatric Cases of Drowning and the Factors Which Influenced Survival" James P. Orlowski, M.D. 35. "Salicylate Induced Pulmonary Edema" Charles J. Fisher. Jr.. M.D. 36. "Acute Chlorine Gas Exposure" Jenis R. Hedges, M.D. 37. "Regional vs. National Variations in Setting Quality Assessment Standards for Asthma Treatment in Hospital Emergency Departments" Geoffrey Gibson, Ph.D. 38. "Emergency Department Spirometxic Evaluation of Acute Bronchial Asthma" R. M. Nowak, M.D. 1 l:45 am 1:00 pm

Panel Ballroom East "The High Risk Burns Patient: A Clinical, Ethical, Psycho-Social and Moral Dilemma" Carl Jelenko, 111, M.D., Moderator Medical College of Georgia Jack Berger, M.D. University of Chicago Alan R. Dimick, M.D. University of Alabama

Bruce E. Zawacki, M.D. 1:00 prn 3:00 pm

University of Southern California UA/EM Annual Meeting Lunch Ballroom West

VADE MECUM KENNEDY LECTURERS 1973 - Fraser N. Gurd. MD 1974 - Oscar P. Hampton, Jr., MD 1975 - Curtis P. Artz, MD t 1976 - John H. Wiegenstein, MD 1977 - Peter Safar, MD 1978 - Senator Alan M. Cranston

HONORARY MEMBERS 1973 - Robert H. Kennedy, MD Fraser N. Gurd, MD C. Barber Mueller, MD 1974 - John G. Wiegenstein, MD Alexander Walt, MD 1975 - Oscar P. Hampton, MD 1. N. H. McNally, MD 1. Curtis P. Artz. MD 1. 1976 - Anita M. Dorr, RN 1. Eugene L. Nagel, MD 1977 - Peter Safar. MD 1978 - Eben Alexander, Jr.. MD

PAST PRESIDENTS 1970.1971 - Charles Frey, MD 1971-1972 - Alan R. Dimick, MD 1972-1973 - Robert B. Rutherford, MD 1973.1974 - James R. Mackenzie, MD 1974-1975 - George Johnson, Jr.. MD 1975-1976 - Leslie E. Rudolf. MD 1976-1977 - David K. Wagner. MD 1977-1978 - Carl Jelenko. 111. MD

MACKENZIE AWARD 1976 - James R. Mackenzie, MD 1977 - Cyril T. M. Cameron, MD

IMAGO OBSCURA AWARD 1976 - Norman E. McSwain, Jr., MD 1977 - Sung Rock Lee, MD

BEST PAPER

PAST ANNUAL MEETINGS 1st Annual Meeting May 14-15. 1971 Ann Arbor, Michigan Charles Frey, MD, President 2nd Annual Meeting May 12-13, 1972 Washington, DC Alan R. Dimick, MD, President 3rd Annual Meeting May 23-25, 1973 Hamilton, Ontario Robert B. Rutherford. MD, President 4th Annual Meeting May 28-June 1, 1974 Dallas. Texas James R. Mackenzie. MD, President 5th Annual Meeting May 20-24, 1975 Vancouver, British Columbia George Johnson, Jr., MD. President 6th Annual Meeting May 11-15, 1976 Philadelphia, Pennsylvania Leslie E. Rudolf, MD, President 7th Annual Meeting May 15-18. 1977 Kansas City, Mssouri David K. Wagner. MD, President 8th Annual Meeting May 18-20, 1978 San Francisco, California Carl Jelenko. 111. MD, President

University Association for Emergency Medicine Annual Meeting May 18-20, 1978 Scientific Paper Abstracts The following abstracts appear in the same order as presented during the program. Peritoneal Lavage Without Morbidity

Hamson M. Lazarus, MD James A. Nelson, MD Chad Halversen, MD Department of S u r g e y , University of Utah. Salt Lake City, Utah Since its introduction ten years ago, peritoneal lavage has proven to be a useful tool for evaluating traumatic injury. One criticism of its widespread use is the potential complications utilizing the standard dialysis trocar. One such complication, a small bowel perforation, prompted us to develop a safe form of peritoneal lavage. The Seldinger technique, commonly used in angiography, was adapted for use in the peritoneum. After a 3 mm. skin nick, an 18 gauge needle is inserted through the fascia and a floppy tip wire guide is placed through the needle. After removing the needle, a modified teflon catheter is placed over the wire into the peritoneal cavity. The peritoneal lavage is carried out upon removal of the wire. To date, 9 3 cases have been evaluated using this technique without any complications. This experience spans utilization of the lavage system by 4 3 different physicians; therefore, individual expertise does not contribute to the low morbidity. Difficulties encountered with this system of peritoneal lavage include: inability to place the catheter in one patient and failure to get an adequate return of fluid (a non-diagnostic lavage) in 6 patients.

Laparotomy in the Emergency Center

Kenneth L. Mattox, MD Cora and Webb Mading Department of Surgery. Baylor College of Medicine. and the Ben Taub General Hospital, Houston. Texas Reports of advancements in ED operative resuscitative skills have included craniotorny, thoracotorny. cardiorrhaphy, and even cardiopulmonary bypass. The efficacy or advisability of laparotomy in the ED remains in question. Between July, 1972 and July. 1977, adhering to an established protocol, resuscitative laparotomy was performed in the

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-1-wenty-fourpatients were victims ot gunshot wounds, 24 had blunt trauma, and three had abdominal stab wounds. Critical abdominal injuries affected the liver, major vessels and the spleen. Control of hemorrhage by clamps, packs, or pressure was the primary objective of laparotomy. Control of exsanguinating hemorrhage and precise application of vascular clamps was possible in all but 15 patients. Extensive multiple injuries and inability to achieve cardiovascular stability precluded all but 12 from reaching the operating room. Although technically possible, laparotomy in the ED has not statistically altered the outcome among those moribund patients who might benefit from this maneuver.

A Statistical Model for Diagnosing Pediatric Abdominal Pain Donald Brand, PhD William H. Frazier, MD Yale University School of Medicine. New Haven, Connecticut This study analyzed clinical and laboratory data from a 6-month series of children seen in a hospital emergency service with a complaint of acute abdominal pain. The purpose was to identify which combination of clinical variables provides maximum discrimination between appendicitis and non-surgical conditions. Clinical data were recorded by the examining physician on a computer terminal or on a specially designed form, laboratory results were gathered from pathology department files. A total of 270 children were included in the study, 12.6% of whom had appendicitis confirmed by pathology report, and the remainder of whom had non-surgical problems. The first 192 cases were used for model development, and the remaining 78 cases for model testing. The analysis identified 3 variables that, taken together, correctly classified 97.4% of the cases as either appendicitis or non-surgical disease, with a sensitivity and specificity of 92.8% and 98.4%. respectively. The diagnostic accuracy of the 3-variable regression model was slightly higher than that of the clinicians managing the cases. Once the 3 critical variables were identified (abdominal muscular tone, location of tenderness, and white blood cell count), knowledge of additional variables did not improve diagnostic accuracy. This result demonstrates the importance of discovering the best set of discriminators in order to simplify the diagnostic process while minimizing diagnostic errors. The statistical model was converted into a clinical algorithm to help pediatricians decide whether to obtain a surgical consultation and to assist surgeons to decide whether to hospitalize a patient for possible appendicitis.

An Injury Severity Scale for Comprehensive Management of Central Nervous System Trauma Rebecca W. Rimel, RN University of Virginia Medical Center. Charlottesville, Virginia An injury severity scale has been implemented in central and western Virginia for a comprehensive neuro-trauma health care system. Treahnent of head injuries in the pre-hospital setting,

emergency department and neuro-trauma center has been outlined for the entire health care team in the algorithms and decision trees. In these treatment protocols, the Glasgow Coma Scale (GCS) has been employed as an injury severity score for the neuro-trauma patient. This scale provides a standard method of grading severity of progression of the head injured patient. [ t is based on three simple observations by the examiner: best motor response, best verbal response and ability to open the eyes In a series of 300 head injured patients, reproducible measurements were recorded by EMTs, nurses and physicians. Due to the reproducibility, therapeutic decisions made in different treatment settings are based upon the level of the GCS. This scale also correlates well with prognosis for long term recovery. The mean GCS for 15 patients who succumbed was 4, based on observations by the EMT and physician on admission. Overlap between patients in various groups was identified in patients with an ethanol level greater than .15% (present in 55% of the population). In those patients with a GCS of 12 or greater on admission, the mean length of hospitalization was four days, with patients returning to their pre-injury Ife style within one week of discharge. Patients with an admission GCS between 4-12 have also been sorted into similar categories utilizing the GCS for initial assessment of severity of injury, treabnent protocols and prognosis for recovery.

The Licensed Psvchiatric Technician - A New ~ a r a ~ r o f e s s i o n aMember i of the Emergency Health Care Team.

J o h n A. Mitchell, MD Chairman, Department of Emergency Medcine, Kern Medcal Center, Bakersfield. California The Management of the patient with moderate to severe symptoms of emotional dysfunction is a complex, time consuming and poorly understood problem for emergency physicians everywhere. The Kern Medical Center, a 290 bed general hospital in Bakersfield. California, together with the Department of Mental Hygiene, has defined a relatively new occupational group which provides immediate decision-making regarding inpatient admission or referral outpatient services whenever this is appropriate. Crisis Intervention - Mental Health Technicians or Psychiatric Technicians, receives training via a one year intensive training program at a state mental hospital or through a two year program at selected junior colleges. They are then tested and licensed by the State Board of Licensed Vocational Nurses and Psychiatric Technicians In addition to their psychiatric duties, they are also licensed to perform the functions of a Vocational Nurse. A retrospective study shows that referrals to this service include 7 to 9 percent of all emergency department admissions. The number of involuntary admissions decreased from 8 6 percent admitted by physicians to 24 percent admitted by the Psychiahic Technicians Referrals for other mental health or community services increased from 20 percent to 44.6 percent and the rate of completed referrals has increased from a showrate of 1 8 percent to 88 percent.

We feel that this new paraprofessional group has been cost effective and might be expanded into other jurisdictions where 9

Process and Outcomes in the Emergency Department: A Comparison of Nurse Practitioners and Other Clinician Groups Joyce Mamon, PhD Geoffrey Bison, PhD Health Services Research and Development Center, The Johns Hopkins University and Medical Institutions, Boltimore, Maryland The training and utilization of nurse practitioners has increased significantly over the last decade. Findings to date have provided evidence that the quality of care delivered by new health providers, such as nurse practitioners is comparable, under appropriate conditions and supervision, to care rendered by physicians. The objective of the present study was to analyze the performance of nurse practitioners specializing in primary care in an emergency department setting and to determine whether differences exist in the content or effectiveness of care delivered by these practitioners and other clinician groups. The data were obtained from an ongoing surveillance study in the emergency department at the Johns Hopkins Hospital. The study population consists of a systematic 10% sample of all visits to the adult emergency department during the period January 1 - December 30, 1977. For each visit, data have been collected o n provider identification, demographic patient characteristics, complaint, diagnosis, disposition, length of visit and variables of clinical care (laboratory tests, x-rays, medications). In addition, a randomly selected subsample of the study population has been followed up through telephone and household interviews two weeks post ED visit for the purpose of measuring patient outcome. The data are analyzed to examine the variation between provider groups with regard to the clinical and demographic characteristics of their patients, the complexity of the patient load, the processes of care employed for specified conditions and patient outcome and satisfaction. The paper considers the implications of this study in terms of the role of nurse practitioners in the emergency department and the quality of care provided by these new health practitioners.

Rape: Crisis or Continuum? The Prevalence of Battered Women Among Rape Victims William H. Frazier, MD Ann Flitcraft, MD Martha Roper Yale University School of Medicine, New Haven, Conn. An effective means to treat and counsel victims of sexual assault should be available in every ED. Most programs, however, have concentrated o n crisis intervention and have failed to recognize that for many victims, the assault is actually one occurrence in a long history of violent encounters within the domestic arena. The Yale-New Haven Hospital ED developed a Rape Counseling Team (RCT) in 1974, and data was compiled and analyzed for the 171 cases presenting between July 1974 and January 1977. A comparison of RCT and non-RCT treated cases showed a higher rate of compliance with the standard treatment criteria, a higher rate of specimen collection for pros-

ecution pulposes, and a higher rate of follow-up contracts for the RCT treated cases. Both the methods of referral to the ED and familiarity of the victim with the assailant correlated with subsequent reporting of the incident to the police. The assailant was a relative in 17% of cases and a total stranger in only 33% of cases. A complete review of the patient's hospital record showed that 15% of cases were readily classified as battered women, and an additional 6% of "probable" c a s a of battery. The implications of the findings are: an RCT has a positive effect on the quality of care provided to sexual assault victims; victim sociodemographics and assailant characteristics play a n important role in determining whether a case is reported to police: two out of three victims know their assailant and one out of five assaults occurred within the broader context of domestic violence. For this latter group, crisis intervention is probably ineffective and long term intervention and counseling is indicated.

Alcohol Use and Psychiatric Illness In Emergency Patients

Douglas A. Rund, MD William K. Summers, MD Michael Levin, BS Dvision of Emergency Medcine, Ohio S u e University Hospitals. Columbus, Ohio A standardized research interview technique was used to study alcohol use and the relationship of alcohol abuse to other psychiatric illness in a general urban emergency department patient population. Two hundred consenting adult patients underwent a structured Renard Research Interview and the responses were recorded on a standardized form. Night and day time periods were sampled and patients were interviewed consecutively in each time period. The overall prevalence of alcoholism among the emergency patients studied was 20 percent. The prevalence in patients presenting after midnight was 29 percent and those presenting in daytime was 11 percent.

Alcoholism was most frequently associated with anti-social personality, affective disorder and drug abuse when multiple psychiatric disorders were present. The chief complaint of the patient was often helpful in predicting alcohol abuse. Because of the high prevalence and the association with other medical and psychiatric disorders, the diagnosis and treatment of the alcoholic patient is often difficult for the emergency physician.

Use of Programmable Calculators in Clinical Emergency Medicine

James C. Brill, MD Director, Department of Emergency Medicine. Cedars-Sinai Medical Center, Los Angeles, California

Ross Tonkens, MD Senior Medical Resident, Department of Medicine, CedarsSinai Medical Center, Los Angeles. California Numerous articles have appeared describing mathematical models detailing gas exchange. acid base balance, and the behavior of druas in ~ a t i e n t swith com~romisedventilatow, car-

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too complex for bedside application. Yet, in severely compromised patients, small errors in dosage of drugs with a narrow therapeutic index can produce lethal complications. With the advent of fully-programmable hand-held calculators, the above models have been made available for easy bedside use by either physicians or nurses unsophisticated in mathematics or computer science. Clinical examples are provided demonstrating the superiority of machine generated answers to complex emergency patient management problems over habit enforced regimens. Cases are presented using individual programs in the clinical determination of aminophyilline, digoxin, and gentamicin loading and maintenance dosage for patients with a wide variance of general metabolic status a n d body weight. In addition, machine determined dopamine, nitroprusside and oxygen therapy are demonstrated. Prediction of osmolality from simple serum chemistries, as weU as estimation of ethanol blood levels, can become as basic a bedside routine as vital signs. The only inconvenience noted thus far has been the necessity of manually changing program cards - a five second process. The programs written to date are in current use in the emergency department. [t has been a surprise to find that even sophisticated physicians have often prescribed potentially toxic drug doses with standard accepted medication regimens. Subsequent use of the hand held calculator has virtually eliminated such iabogenic misadventures without adding annoying inconvenience.

R e s i d e n c y Trained E m e r g e n c y P h y s i c i a n s : Where Have All the Flowers Gone? Rebecca A.H. Anwar, P h D The Medical College of Pennsylvania, Philadelphia, Pennsylvania Since emergency medicine residency programs began, there has been a controversy concerning career development and commitment in this new specialty. There has been no systematic information gathered to provide a basis for seriously addressing the controversy. A study was undertaken to determine the career paths of residency completed emergency physicians. During the past year, 206 emergency medicine physicians were surveyed by questionnaire, with a response rate of 56.8 percent. The dates of residency completion ranged from 1972 to 1977. Results show that over two-thirds of the respondents have entered academic and/or Emergency Medicine Department director positions. More specifically, 4 5 hold academic rank, 3 4 are ED directors or assistant directors, and eight reported being actively involved in emergency medicine program development as residency directors or assistants. Less than one-third of the respondents said they were working in community hospitals as strictly clinical emergency physicians.

An Orientation Program for First Year EM Residents: A n Academic Advancement Richard Levy, MD, MPH University of Cincinnati Medical Center, Cincinnati, Ohio

Rebecca Anwar, PhD The Medical College of Pennsylvania, Philadelphia, Pennsylvania

H. Thomas Blum, MD Rochester, Minnesota Within the last decade, pioneering efforts have been made in the establishment of emergency medicine as an academic discipline. The development of educational programs in emergency medicine for medical students and currentlypracticing physicians is essential to meet present and future demands for quality emergency medical care. One way of meeting these demands has been the development of residency programs aimed at producing qualified emergency medicine physicians. Unfortunately, there has been little available literature that offers cuniculum guidelines for graduate teaching in this area. Although it is assumed that most residents will learn the subject matter and skills through experience, there is no guarantee that the resident will be adequately trained in emergency medicine. In an attempt to deal with the lack of guidelines for postgraduate training, an orientation curriculum was developed for incoming residents at the University of Cincinnati. The major objectives of the orientation were to identify and delineate the subject matter and to review the basic elements of emergency medicine. This paper describes the orientation program and reports the results of pre- and post-program testing of the experimental group (University of Cincinnati - UC) and a control group (The Medical College of Pennsylvania - MCP). In addition, results of a m e year post-test are presented. The pre-test scores of the study group showed no significant difference at a . 0 5 level of significance. The post-test, however, resulted in a significant improvement in the UC scores (p -= .05), while little change occurred in the MCP scores (p = n.s.). An inter-group evaluation shows the UC group to have out-performed the MCP group significantly ( p -= .05). Results of the one year post-test showed the UC residents scoring an overall average of 6.3 points higher on the test. However, the general difference between the two groups of residents was not significant at the . 0 5 level (at 12 df for a two-tailed Chi-square test). One conclusion is that the experimental intervention is still having an impact, but that this impact diminishes in force over time. Thus, the MCP residents are gradually narrowing the gap as a result of the long-term residency training process, assuming that other variables (e.g., motivation and intervening clinical experiences) are randomly distributed. It is concluded that the orientation program was the primary factor affecting the initial results. These findings suggest that the orientation program may result in better prepared first year emergency physicians.

Teaching Emergency Department Administration: The In-Basket Exercise Kenneth V. Iserson, MD Senior Resident, Division oJ Emergency Medicine. Cincinnati General Hospital, Cincinnoti, Ohio

Clovis R. Shepherd, PhD ProJessor oJ Sociology, Department of Psychiatry. University oJ Cincinnoti Medicol Center, Cincinnoti, Ohio Administration of emergency departments is recognized as a necessary area of competence for emergency physicians. Until

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existing formal training usually dwells only on finances. Borrowing from similar formats which have been successfully used in teaching business. hospital, and nursing administrators, an In-Basket Exercise has been developed for the ED. The exercise is derived from the actual input to directors of three services: a university-based emergency medicine residency, one teaching hospital ED and one non-teaching community hospital ED. Using selected material (memos, personnel applications, notices, phone messages, etc.) and realistic time constraints, the participant is asked to describe the options available to him for each item. He must reason through the benefits of each of these options and come to an action decision. These options and decisions are then discusseed within a group framework. Under the guidance of a group leader, ED physicians, residents, medical students, or other potential ED administrators gain significant insight into, and working knowledge of, ED administration and of the broad spectrum of non-clinical decision making. A potent tool for improving interpersonal communications and managerial expertise, the In-Basket Exercise has been well received as a new tool for teaching ED administration.

A Developmental Module To Teach Behavioral Intervention in Psychological Emergencies Barbara Masters, RN, MS Candy Lockhart, RN, MS Kenneth L. Mattox, MD Texas Woman's University, Houston, Texas This study tested the feasibility of teaching intervention in behavioral emergencies by the means of a developmental module. This approach is unique in that it is designed to assist emergency care practitioners in identifying their own status of good mental health and their feelings of themselves as persons, before proceeding to intervene in psychological emergencies. The developmental module was presented to nurses and emergency personnel in a variety of settings in various areas of the county. Group O n e was presented the content in the traditional teaching manner. Group Two was taught the content using the developmental approach. Group Two shaved consistently significant test score differences on the pre and post test as opposed to Group One. The individuals who were in the experimental approach achieved higher attitudinal ratings than the control group. The results indicate that the utilization of the developmental module to teach intervention in behavioral emergencies is a technique that has significant positive benefits. The module not only imparts the necessary curricular content that is required, but also yields attitudinal changes in ED personnel in a short time.

Incidence, Etiology, and Outcome of Patients with ldioventricular Rhythm During Advanced CPR

Blaine C. White, MD Thomas J. Petinga, Jr., D O Section of Emergency Medicine. Wayne State University School of Medicine, Detroit. Michigan

Robert F. Wilson, MD Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan The report by White of the efficacy of bolus glucocorticoids during advanced resuscitation of patients with persistant pulseless idioventricular rhythm raises questions about the incidence. clinical etiology, and outcome of this entity. This study reviewed cardiac arrest records in 458 patients who received advanced cardiac life support at Detroit General Hospital during the last two years. Persistant pulseless idioventricular rhythm was identified and treated with dexamethazone IV bolus in 2 5 of these cases (6%). Of these 2 5 cases, the resuscitative effort was successful in 13 patients (52%) and three of these became long term survivors (12%). Rhythm ships documenting the arrythmia and the efficacy of the bolus glucocorticoid as a treatment modality remain available on 9 of the 13 patients who were successfully rescscitated. These results are in contrast to the 100% mortality recently reported by lseri et al, for these patients when only conventional drug therapy is used. The underlying pathology was never clarified in several of these patients. Seven of them had myocardial infarctions with four of the arrests secondary to septic shock and three secondary to hemorrhagic shock. Two of the patients arrested as a sequellae to massive narcotic overdose. One had a subdural hematoma and one had multiple pulmonary emboli. This etiological survey suggests that severe hypoperfusion shock may be the common pathway which results in pulseless idioventricular rhythm observed in advanced cardiac life support. The use of bolus glucocorticoids is recommended during the resuscitation of these patients, and it is concluded from the etiologic experience that evaluation of the adequacy of intravascular volume is exceptionally urgent after rhythm correction in these patients.

Clinical Assessment of Patients Undergoing CPR in the Emergency Department

G. Patrick Lilja, MD Martin Hill, MD Ernest Ruiz, MD Hennepin County Medical Center, and North Memorial Medical Center, Minneapolis, Minnesota

A method is described for evaluating the effectiveness of CPR, particularly when it is continued over a period of time. This method makes use of a mechanical cardiopulmonary resuscitator (Thumper", Michigan Instruments) together with early invasive monitoring of pulse and blood pressure. This also allows for frequent monitoring of blood gases. Two patients are presented with long term CPR. (i.e longer than one hour) showing how invasive monitoring conbibutes to their management, as well as to the effectiveness of the total emergency department operation. Results indicate that better management of the clinical status of patients undergoing prolonged resuscitation can be obtained by utilizing continuous blood pressure and pulse monitoring and frequent blood gas analysis. [n addition, information on the clinical status of patients experiencing frequent arrhythmias allows for better determination of appropriate procedures and medications. It i~ holio\,orl that tho oarlrr Ilro n f invasivo nrpsqllro mnnitnr-

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mechanical CPR machines can contribute to the clinical management of patients that are arrested or in low cardiac output states. In addition, it is hoped that such devices may aid in the overall management of multiple resuscitations in the emergency department.

Increasing Systolic Blood Pressure During External Cardiac Compression By Use of Medical Anti-Shock Trouser G. Patrick Lilja, MD Robert S. Long, MD Ernest Ruiz, MD Hennepin County Medical Center and North Memorial Medical Center, Minneapolis, Minnesota External cardiac compression has been shown to effectively circulate blood, but the systolic pressures obtained are less than during normal cardiac functioning. This study was undertaken to determine whether application of the medical anti-shock trouser (MAST) can result in improved systolic blood pressure during cardiac resuscitation using external cardiac compressions. Individuals admitted to the ED in cardiac arrest were placed on constant cardiac compression using a ThumperR (Michigan Instruments). Arterial monitoling was established and baseline systolic blood pressures obtained. The medical anti-shock trouser was then applied and blood pressure measured. This was compared with pressures obtained prior to MAST application and with various vasopressor agents. In eight patients, the average increase in systolic blood pressure utilizing the MAST kouser was 15mm Hg. The implications of these findings, as well as other means to increase cardiac output in the cardiac arrest patient, are djscussed. These findings are related to both the pre-hospital care and care within the ED of cardiac arrest patients.

Comparison of Blood Levels of Epinephrine and The Metabolities of Epinephrine Achieved Following Intravenous and ~ndotrachealRoutes of Administration James R. Roberts, MD Michael 1. Greenberg, MD Marilyn Knaub, BS Steven 1. Baskin, PharmD, PhD The Medical College of Pennsylvania, Philadelphia, Pennsylvania It has been suggested that epinephrine may be of clinical value when administered endokacheally. Its use in cardiac arrest has been advocated. However, few actual investigations have studied the metabolism of the drug or quantified the blood levels achieved following adminiskation of the drug by the endotracheal route. Our group has studied the pharmacologic effe& of the drug when it is given both intravenously and endotracheally. It was concluded that epinephrine produces clinically significant effects o n blood pressure and pulse rate when it is instilled in the kachea of anesthetized dogs. The purpose of the present study is to compare the blood levels of the drug and its metabo-

lites, which are obtained when the drug is given by both the intravenous and endotracheal route. Eight anesthetized dogs were subjected to radioactive epinephrine in various doses. The drug was given by intravenous injection and by instillation in the bachea via an endotracheal tube. Blood levels were obtained at various time intervals and analyzed for specific radioactivity. Thin layer chromatography was employed to study the metabolites of epinephrine. It was found that intravenously administered epinephrine reaches peak concentration rapidly and is rapidly metabolized in a biphasic fashion. When the drug is given by the endotracheal route, peak concentration of proportionally less magnitude is similarly rapidly achieved, but high concentrations are sustained for a much longer time interval. This paper displays and discusses the information obtained for epinephrine and its metaboiites and explores the possible clinical significance of the results.

Identification of Cardiac Contusions Marleta Reynolds, MD James W. Jones, MD Norman E. McSwain, Jr., MD Dept. of Surgey. Tulane University, New Orleans, Louisiana A frequently overlooked and underdiagnosed traumatic injury, cardiac contusions are associated with life-endangering complications that make their early recognition important. Attention to other injuries has made the admission electrocardiogram the first clue that leads the physician to suspect a cardiac injury. In an effort to identify the most sensitive screening test for cardiac contusions, a series of thirty-five patients with blunt chest trauma were evaluated with serial electrocardiograms, CPK isoenzymes, and serum enzymes (SGOT, LDH, and CPK). Nine of the thirty-five patients had diagnoses of cardiac contusions by electrocardiogram; two of the patients with contusions developed complications of the injury. Although isoenzyme elevation is present in the majority of patients sustaining blunt chest trauma, n o complications of the injury were seen in patients with elevated enzymes and normal electrocardiograms. The ease of obtaining electrocardiograms and their reliability in identifying those patients who will have complications, makes it the best screening procedure for the diagnosis of cardiac contusions.

Metabolic Acidosis with Anti-Shock Trousers in Hypovolemic Dogs Kenneth Ransom, MD University of Kansas Medical Center, Department of Surgey. Kansas City, Kansas

Norman McSwain, MD Tulane University School of Medicine, Department of Surgey, New Orleans, Louisiana Inflated medical anti-shock trousers may create significant ischemia in the lower extremities with an accumulation of anaerobic byproducts. Release of these byproducts into general circulation will result in adverse physiologic changes. To study these changes. 20 dogs were divided into two groups. FoUowing general anesthesia, the carotid artery, femoral vein and central venous system was cannulated in all dogs. The ten animals in G r n ~ ~A nwere hled tn a sustnlic nressllre of 80 mm Ha.

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hours while the other five dogs served as controls. Group B dogs were bled to 120 mm Hg, five had trousers and five served as controls. Since the anti-shock suit inflates to a pressure of 100 mm Hg, each group represents a systolic pressure of 2 0 mm Hg either above or below that pressure imposed by the trousers. Central venous blood gases (Vph), lactic acid (LA), and potassium (K); and femoral LA and K samples were obtained prior to inflation of the trousers, at hourly intervals for three hours, and ten minutes following deflation in experimental animals, and at hourly intervals in the controls. The decrease in central Vph, and increase in central and femoral LA and K was significantly more severe in the Group A experimental animals compared to their controls ( p < ,005) and compared to the Group B experimental animals ( p < ,, .Ol). Group B experimental animals had significant changes in Vph, LA and K compared to their controls (p < .01). Both experimental groups had large drops in blood pressure following deflation of the trousers (30 to 5 0 mm Hg). Medical anti-shock trousers do augment lower extremity ischemia at systolic pressures both above and below the pressure imposed by the trousers. Accumulated anaerobic byproducts are released into the central circulation counteracting some of the resuscitative benefits achieved with the trousers.

The Value of the "G-Suit" in the Resuscitation of Patients with Acutely Ruptured or Dissecting Aortic Aneurysms Thomas L. Evans, MD G. Patrick Lilja, MD Ernest Ruiz, MD Hennepin County Medical Center and North Memorial Medical Center, Minneapolis. Minnesota A retrospective study was conducted in an effort to determine if the "G-Suit" (MAST trousers) was beneficial in the resuscitation of patients suffering from acutely ruptured or dissecting abdominal aortic aneulysms. Of the forty cases reviewed, thirty-five were initially hypotensive (systolic blood pressure less than 90mm Hg). The G-Suit was used on thirteen patients along with fluid replacement and occasionally, pressor agents. The remaining twenty-two were resuscitated with fluids and pressors only. Systolic blood pressures were compared initially and subsequent to the resuscitative efforts. In patients receiving only fluids, blood, and/or pressors, seven of 2 2 responded with an increase in systolic blood pressure ranging from 2 0 to 120mm Hg (average 58mm). Application and inflation of the G-Suit during fluid resuscitation in twelve of thirteen patients resulted in an increase of systolic blood pressure from 15 to 120mm Hg, (average 59mm). The circumferential counterpressure G-Suit is indeed a valuable adjunctive resuscitation device indicated in the treatment of hypotension due to acutely ruptured or dissecting abdominal aortic aneurysms. In addition, there is evidence that the G-Suit delays or slows the rate of blood loss from dissecting abdominal aneurysms. Though not intended as a substitute for aggressive surgical treatment in the treatment of abdominal aneurysms, the G-Suit should be considered as an aid in the stabilization of these critical patients until definitive surgical therapy can be provided.

Development of the Pediatric Esophageal Obturator Airway Melker, Richard J., MD, PhD University of Florida College of Medicine, Dept. of Pedatrics, Gainesville, Florida The esophageal obturator airway (EOA), a widely accepted adjunct in Advanced Life Support. is restricted in use to patients over 1 6 years old because of lack of appropriate smaller EOAs. Because the EOA is a simple, safe instrument for emergency intubation, development of pediatric sizes is desirable. Two major problems exist in using EOAs in children: 1) If too long, the tip may reach the stomach, preventing occlusion of the esophagus and allowing regurgitation. 2 ) If too short, the balloon could be inflated above the carnia causing airway obstruction by external compression. Thus several sizes of pediatric EOAs are necessary. In order to select the appropriate size in an emergency situation, an easily and rapidly determined external guideline was needed. This study compared age, weight and height with: tracheal length from the anterior maxillary alveolar ridge to the carina (200 patients), esophageal length horn the anterior maxillary alveolar ridge to the lower esophageal sphincter (83 patients) and aicoidxyphoid length (48 patients) in children ranging from 2 to 1 4 years old (height 8 0 to 140 cm). Three sizes of EOAs have been constructed and marked with 3 indicator lines for use as follows: the single proximal line is placed o n the cricoid cartilage, and the xyphoid notch palpated. If the 2 distal lines straddle the xyphoid notch, the tube is of proper size. If the notch is above the distal lines, a shorter EOA is necessary to avoid gastric intubation. If the notch is below the distal lines, a longer EOA protects against airway compression above the carina. One of these three tubes can be used in all children two years and older. This study also established that two sizes of face masks are adequate in conjunction with these three EOAs

Characterization of HIS Electrocardiography of the Terminal Arrhythmias of Hemorrhagic Shock in Dogs Blaine C. White, MD Thomas J. Petinga, Jr., DO Section of Emergency Medicine, Wayne State University. School of Medicine, Detroit, Michigan

John Moeser Emergency Department, Henry Ford Hospital, Detroit, Michigan

Robert F. Wilson, MD Department of Surgery. Wayne State University. School of Medcine, Detroit, Michigan The increasing recognition of pulseless idioventricular rhythm du~ingCPR raises major questions about the etiology of this terminal arrhythmia. Review of patients with this arrhythmia in our ED d u ~ i n gthe last two years suggests a variety of major underlying pathology with a common pathway of severe hypoperfusion prior to cardiac arrest. This paper characterizes the terminal arrhythmias of hypoperfusion horn hemorrhagic shock in a controlled laboratory environment. Eleven dogs weighing at least 2 5 kg were anesthetized with thiopental. The animals were ventilated with room air on a volume ventilator at a tidal volume of 12.5 cc/ka. Ventilator rates

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rial pressure was monitored by intra-arterial lines. Right atrial pressures and Lead I1 surface EKG's were also monitored. An Elecath hexapolar His electrocardiographic catheter was inserted via the right femoral vein, and positioned to obtain the best H signal on a Honeywell photorecorder with filters excluding signals below 50 Hz and above 500 Hz. Serial oxygen consumptions were determined on a mass spectrophometer. Serial arterial and right atrial blood gases were drawn. and serial cardiac outputs were calculated by the Fick method. Serum Na+, K+, Glucose. Ca+ +, Hb, and Mg+ +, were also studied. Two dogs were fully instrumented for eight hours as controls and were stable for that period. Three dogs were acutely exanguinated by arterial bleeding. Three dogs were subjected to an irreversible shock preparation by reducing their mean arterial pressure to 50 mm Hg for three hours and then reinfusing all shed blood. The last group of three dogs was bled to 5 5 mm Hg mean arterial pressure and kept at this pressure without reinfusion until their vital signs further decayed and they died. Dogs in all three shock models displayed a consistent pattern of terminal conduction dysfunction ending in a period of pulseless idioventricular bradycardia. While moderate metabolic acidosis was consistently present. no pH was observed below 7.1. Significant hyperkalemia did not develop. In the irreversible shock group. 0 2 consumption and cardiac output nzver returned to preshock levels. This study supports the conclusion that idioventricular rhythm in clinical arrest is a terminal arrhythmia of severe hypoperfusion, and this study provides detailed characterization of the progressive conduction system failure leading to the appearance of this arrhythmia.

Assessing Vascular Compromise in Trauma

Philip J. Bendick, PhD J. R. Mayer, MD J. L. Glover, MD Department of Surgery, Indiana Uniuers~tySchool of Medcine, Indianapolis, Indiana

A variety of types of trauma may lead to vascular compromise unless treated effectively and promptly. In addition to direct trauma to a major vessel. crushing injuries, fractures, and burn injures give rise to an ischemia-edema cycle and subsequent muscle necrosis and tissue loss. Objective adjuncts to clinical impressions, such as isotope clearance muscle blood flow or the ultrasound Doppler flowmeter, are generally not suitable for continuous, unintempted monitoring of the degree of vascular compromise. A technique which appears to be promising in this respect is that of photoplethysmography. which makes use of a small LED infrared emitter-detector array. Blood volume changes in the illuminated vascular bed produce variations in the amount of reflected light sensed by the detector: after appropriate electronic amplification, pulsatile blood flow ( i f present) and its change with time are displayed on the monitor. We have applied this technique on more than 20 trauma patients thus far with good results, avoiding unnecessary compartmental decompression in some cases and using it as a strong indicator for prompt intervention in others. It has proved to be a simple technique which requires little or no training for interpretation. provides continuous monitoring, is non-invasive and atraumatic in nature, is very portable and is relabvely inexpensive.

Theraoeutic and Economic I m ~ l i c a t i o n sof Emergency Department Evaluation for Venous Thrombosis William S . Gross, MD Department of Surgery, University Hospital, Ann Arbor, Michigan. Patients with suspected deep venous thrombosis present a continuing diagnostic and therapeutic challenge to ED physicians. Records of 1 5 0 patients with lower extremity complaints were reviewed to determine the economic and therapeutic impact of noninvasive venous impedance testing. Venograms obtained in 6 6 extremities were utilized to determine diagnostic accuracy. The incidence of pulmonary thromboembolic events, post-phlebitic syndrome and complications of anticoagulation were ascertained. Outflow impedance testing correctly identified all patients with deep venous thrombosis. Overall diagnostic accuracy was 94%. In 1 2 3 patients (33 positive results, 9 0 negative) therapeutic decisions were based solely o n test results. Examination required 2 0 to 3 0 minutes at a cost of $35. Follow-up ranging from 4 to 5 2 weeks failed to reveal documented thromboembolic complications or recurrence of lower extremity symptoms. In 2 7 patients (3 positive results, 2 4 negative) impedance tests results were ignored and inpatient work up including invasive venography was undertaken. Hospital charges for these patients averaged $1500. The ease of performance and high degree of accuracy demonstrated by this technique indicate its use in facilitating therapeutic decisions. Comparisons with inpatient evaluation document its cost effectiveness.

The Management of Penetrating Neck Injuries

William H. Stroud, MD Dabney R. Yarbrough, 111, MD Department of Surgery, Medical University of South Carohno, Charleston, South Carolina. Few anatomic areas concentrate as great a density of vital structures in as small a space as the neck. Consequently, penetrating wounds of this area present a taxing technical and diagnostic challenge. Current opinion holds that these wounds should undergo prompt exploration. Personal experience and critical analysis of the literature, however, reveals an extremely high incidence of unnecessary neck explorations. In this light, a review was undertaken of 6 8 cases of penetrating neck wounds in this institution. The wounding agent was gunshot (38 cases), knife (21), broken glass (3), ice pick ( I ) , and miscellaneous (5).Presenting findings included hematoma (20 patients), neurologic deficit (131, shock (8),pneumothorax and hemothorax (7), subcutaneous emphysema (7), bruit (2), and n o major findings in 2 4 patients. Nineteen patients were managed nonoperatively with n o complications. The remainder of the group underwent exploration with negative results in 2 6 instances. Findings at exploration included major injuries in 9 patients and esophageal inju~iesin 6 patients. There were no deaths in the series. It was concluded from this study and an analysis of the literature that ~xnlnratinn nf all npnptratinn npck w n ~ ~ n diss nnt

I I I ~ I I U ~ L UL IU~I .I ~ I I LI I I U L ~ L I U I I Iur ~ buryery incluae gunsno1 wounds and other wounds associated with one or more of the following findings: hematoma, active bleeding or shock, hemoptysis, hematemesis and subcutaneous emphysema. Close observation for 48 hours is indispensable in patients managed nonoperatively. Angiography, bronchoscopy and esophagoscopy are valuable diagnostic procedures in selected patients.

The Emergency Treatment of Finger Tip Injuries Dean S. Louis, MD Richard E. Bumey, MD Department of Surgery, University of Michigan Medical Center. Ann Arbor, Michigan Current texts regarding the management of finger tip injuries propose many involved and sophisticated techniques for coverage of digital defects. Little attention is given to the nonemergent treatment of such injuries by conservative measures which rely upon the natural processes of wound contracture and epithelialization. The compulsion to close and cover all wounds of this nature requires a rational re-analysis. Patients seen over the past six years have been treated by means of non-adherent dressings for digital injuries which would, according to other published dictums, have been treated by some method of distant coverage. The results of this form of treatment have been uniformly salutary in terms of function, time lost from work and ultimate cosmetic result. Two point discrimination and the preservation of functional length have been most satisfactory in this group of very common injuries. Over 100 patients with soft tissue injuries alone and those with bone exposed compose the data base from which the report is composed. A conservative approach to these injuries is advocated.

"Ketamine Dissociative Anesthesia Emergency Department Use in Children" Richard Stone, MD Dept. of Emergency Medicine, Valley Medical Center, Fresno. California

William Repert, MD Ft. Collins, Colorado Results of an on-going study to determine the efficacy and safety of Ketamine dissociative anesthesia for children under 1 0 years of age in the emergency department are presented. Indications for use of this anesthetic include: lacerations of hands and face, requiring complete patient cooperation, debridement of burns, intraoral procedures such as laceration repair or intra-maxillary fixation with wire, foreign body removal from eyes, ears extremities, orthopedic procedures such as introduction of Steinmann Pins and drainage of abscesses. Contraindications include: loss of consciousness, history of seizures, psychotic behavior or hypertension, severe nasal congestion and full meal eaten within 3 hours of procedure. Ketamine HCI has been used only in locations having equipment for airway management and only by physicians experienced with pediatric intubation. Vital signs are monitored

every five minutes during the procedure and every 15 minutes after, until the child is fully awake and for a minimum of two hours. Dsscciative anesthesia was achieved in all 3 0 cases studied; three cases required a single repeat dose. In 2 4 cases, there was an average increase in diastolic blood pressure of 20mm Hg lasting less than one hour. Heart rate increased 10-20 beats/minute lasting up to two hours. Nightmares were reported in three cases ( l o % ) , each occuning one time only. Emesis occurred in two patients after each was fully awake. Specifically, there were no cases of seizures or laryngospasm. Preliminary results suggest that Ketamine HCI Dissociative Anesthesia may be safe for emergency department use. It certainly allows the physician a near-optimum environment for minor surgical procedures. Patient resistance is not encountered and better technical and cosmetic results are achieved.

Discussion of the Most Common Errors in Radiology Gabriel Martyak, MD John Skiendzielewski, MD Geisinger Medical Center, Danville, Pennsylvania Radiology plays an ever increasing role as a n aid in diagnosis of the emergency department patient. The study discusses the most common and not s o common misinterpretations of radiological studies at Geisinger Medical Center. Analysis is made of several hundred preliminary readings with physician error, technical error, incidental findings and request of additional films. Results indicate: reviewer experience decreases error; many errors are seen in retrospect which were not immediately present; additional views in trouble areas such as neck, chest, shoulder, wrist, skull, and pelvis are extremely helpful; and knowledge of technical difficulties can improve interpretation and decrease errors. Emergency department radiology is of great value in aiding a diagnosis. A good understanding of what an x-ray can do, its limitations, the value of additional films and awareness of variations of anatomy will contribute greatly to the overall care of the ED patient.

Comparative Evaluation of the Effect of a High Yield Criteria List upon Skull Radiography Utilization in ~ m e r ~ e Rooms nc~ Leon A. Phillips, MD Department of Radiology, University of Washington, Seattle, Washington Perhaps the most over-utilized examination performed by U.S. radiologists is skull radiography. This excessive utilization is particularly manifest in emergency departments where physicians commonly request skull films on patients presenting with any history or signs of skull trauma, seizures, headaches or disordered mentation. A three month sample review of skull radiography at one hospital revealed 579 skull examinations requested from the emergency service and only 1 9 positive radiographic reports. 5 of which represented findings that were already known. Thus,

only one out of 41 exams actually provided helpful information. A listing of "High Yield Criteria for Skull Radiology Following Trauma" was developed and implemented by two hospitals with the following results: 1. A 40% reduction in Emergency Department sku1 radiography has been maintained at the University Hospital during the past three years utilizing a policy containing a high yield criteria list and concurrent monitoring by the Utilization Review Committee.

2. During this same interval, and with no controls, skull film radiography at Harborview Medical Center-Trauma Center has increased 64%. 3. Outcome analysis of positive reports documents a significant improvement in rate of yield when a high yield criteria list is employed.

4. Inexperienced physicians do change their utilization profiles following exposure to a high yield criteria list. 5. An effort to control skull film radiography may produce a health care cost savings of more than one hundred million dollars each year

The Suspected Esophageal Foreign Body How to Choose the Appropriate Management Tim Allen, MD Hugues Archambault, MD De'partement d'Urgence, Centre Hospitalier d e 1'~niuersite' Laual, Sainte-Foy, Qugbec, Canada A swallowed object may be eliminated spontaneously, or may require endoscopic or surgical removal. In order to identify the key factors in choosing appropriate management for such patients. 40 consecutive cases of swallowed foreign body which presented at an ED were studied retrospectively. The 22 cases of probable esophageal or pharyngeal foreign body were studied in detail, using fifteen (15)predetermined factors, chosen to detect or anticipate the acute consequences of foreign body ingestion. Three findings were particularly important: foreign body visualized directly or on plain X-rays; hypersalivation; and obstruction or foreign body image in the esophagus on barium swallow. No patient with none of these three abnormal findings, even in the presence of localised pain increased by swallowing, required further treatment, and no complications developed. All patients with any one of these three findings required direct foreign body removal (4 cases) or esophagoscopy (11 cases). Three esophageal foreign bodies passed spontaneously into the stomach before esophagoscopy; four foreign bodies were removed; two esophagi were abnormal (stricture, myasthenia gravis); two found no foreign body. Hypersalivation was the only finding always associated with an abnormal esophage =COPY. Particular attention must be paid to the interpretation of plain X-rays, with regard to probable foreign body location (cricopharyngeus muscle) and to indirect signs (fluid levels, soft tissue swelling, free air) if small foreign bodies are not to be missed. Using these criteria, the correct management of suspected esophageal foreign bodies can be selected rapidly and economically in most emergency departments.

Intravenous Glucagon in the Management of Esophageal Food Obstruction Jonathan Glauser, MD G. Patrick Lilja, MD Bernard Greenfeld, MD Hennepin County Medical Center and North Memorial Medical Center, Minneapolis, Minnesota Esophageal obstruction is a problem encountered in the emergency department. The use of intravenous glucagon in patients with obstructing esophageal food impaction has recently been described. In all of the previously reported cases, the obstruction was present for at least twenty-four hours. A case will be presented of a young male with acute esophageal obstruction. This was relieved by intravenous infusion of one mg of glucagon within ten minutes. Barium swallow performed both before and after glucagon administration confirmed the original obstruction and the passage of the food bolus.

Therapy for bolus obstruction of the esophagus has classically included proteolytic enzyme digestion, a s well a s esophagoscopy with manual extraction. Each of these entail risk of esophageal perforation and mediastinitis with their consequent complications. Since the dosage of proteolytic enzymes, such as papain may take several hours to administer, and since endoscopic examination is generally not feasible as an out-patient emergency procedure, it is felt that intravenous glucagon is the modality of choice for acute esophageal obstruction by food bolus. It has the further advantage of safety in the population in which anticholinergics, another occasionally employed therapy, are contraindicated. The patient described in the case report was managed as an out-patient, and discharged home after the repeat barium swallow. A protocol for management of these patients will be included in the report.

Guidelines for the Use of Hepatitis B Immune Globulin in the Emergency Department John E. Conte, Jr., MD University of California, Division of Emergency Medicine, Son Francisco, California Hepatitis B immune globulin (HBIG) is now commercially available for general use. It is prepared similarly to immune serum globulin (ISG) using pooled human serum; however, only donors with high titers of antibody to hepatitis B surface antigen (HBsAg) are used. Clinical studies indicate that this preparation is useful as a prophylactic agent in individuals with possible hepatitis B exposure. Because of the high cost of HBlG ($300 per adult), an algorithm for its use has been developed by an ad hoc advisory committee at the University of California, San Francisco. The algorithm directs the user to verify the type and certainty of the contact; identify the inoculum source and determine the HBsAg and liver function status of the source; if indicated, determine the HBsAg and anti-HBsAg in the contact and, finally, institute HBIG, ISG or n o treatment. The present recommendation as defined by the algorithm limits the use of HBlG t o definite parenteral contacts, for example, needle sticks, or definite ingestions or mucosal splash with hepatitis B antigen positive material. HBlG may have additional annlication and studies are now in nrocxess to define its

use in prevention of vertical transmission of HBsAg from infected mothers to newborns, non-parenteral transmission of HBsAg a m o n g dialysis patients a n d staff and transmission of HBsAg between spouses a n d intimate contacts including venereal q o a t r e s . Until these studies are complete and the costs and benetits more fully defined, HBlG is not recommended in these circumstances.

93 Pediatric Cases of Drowning and the Factors Which Influenced Survival James P. Orlowski, MD Pedatric Intensive C a r e Unit, Rainbow Babies a n d Childrens Hospital, Cleveiand, Ohio Ninety-three cases of drowning or near-drowning in the pediatric age group were reviewed between the years of 1 9 7 2 a n d 1976. Of these 9 3 cases, 7 0 were male a n d 2 3 were female. The average age was 3 . 9 years, with the average age of the male patients being 4 . 3 years and the average age of the female patients being 2 . 6 years. Four of the submersions occurred in salt water; the other 8 9 submersions occurred in fresh water. Sixty-seven of the ninety-three patients received m o u t h - t e mouth resuscitation; 1 4 received n o attempts a t mouth-tomouth or any other type of resuscitation, a n d in four patients there was insufficient data to estimate whether resuscitation had been attempted. T h e maximum estimated time of submersion was less than five minutes in 6 2 patients. greater than five minutes in 18 patients a n d unknown in 13 patients. Thirty-two of the 9 3 patients presented in the ED in coma. 1 7 of these 3 2 having fixed and dilated pupils (all of these seventeen patients died). A prognostic scoring system was developed whereby o n e point was given for each of five unfavorable factors involved in the drowning or near-drowning of each of these patients. The prognostic factors were a s follows: a g e less than three years; estimated maximum submersion time of greater than five minutes; no attempt at mouth-to-mouth resuscitation; patient in coma with fixed and dilated pupils upon admission; arterial blocd gas p H 5 7.10. T h e outcome of each patient was then evaluated with respect to the prognostic scoring system. Seventy patients attained full a n d complete recovery a n d 2 3 patients died. A prognostic score 5 2 points predicted a 9 0 percent chance of recovery whereas a score 5 2 correlated with only a 5 percent potential of recovery. Other factors in the survival or the demise of the patients were evaluated None of these factors seemed to influence the final prognosis other than the arterial pH, where an arterial pH 5 7 . 1 0 was found to directly correlate with chances of survival. A prognostic scoring system based o n five unfavorable prognostic factors was found to b e quite valuable in assessing the eventual recovery or death of patients who had experienced the post-submersion syndrome. T h e early institution of resuscitative efforts is the most important single factor influencing survival in drowning.

Salicylate Induced Pulmonary Edema Charles J. Fisher, Jr., MD Heahh Sciences Centre. Respiratory Investigution Unit, Winrdpeg, Manitoba, Canada

Salicylate intoxication is a well described clinical entity. Mild intoxication commonly causes tinnitus and vertigo. More severe intoxication causes complex metabolic alterations including hypovolemia, hyperthermia and acid-base imbalance. Rare case reports have described the association of salicylate intoxication a n d pulmonary edema. The purpose of the present study is to determine the mechanism and incidence of salicylate induced pulmonay edema Retrospective review of the medical records of the University Hospital for the two year period ending July 1976 found 4 2 consecutive patients with salicylate levels greater than 25mg%. Four out of 42 patients had pulmonay edema based o n three or more of the following criteria: physical examination, radiographic evidence, increased AaD02, intrapulmonary shunt and increased lung weight at post mortem. Heart failure was excluded as a cause by normal pulmonay capillary wedge presmre (PCWP) less than 1 0 torr in three of the patients and normal radiographic cardiac silhouettes in all four. Salicylate levels ranged from 38 mg% to 1 1 1 mg% in these four patients and were not different from the other 38 patients. Two of the four patients with salicylate pulmonay edema died. All patients without pulmonary edema survived. Salicyclate pulmonary edema is low pressure (non-cardiogenic) in origin secondary to pulmonay capillary leak. It is more common than has previously been reported.

Acute Chlorine Gas Exposure Jerris R. Hedges, MD Section of Emergency Medicine, The Medical College of Pennsyloania, Philadelphia, Pennsyloania The heavy use of chlorine gas in industy and water purificahon poses the constant threat of mass gas poisoning. Recent experience with a chlorine gas disaster involving over 1 0 0 pat~entsis discussed. Sixty-four patients, including six admissions, were treated in the main emergency unit facility while the remainder were triaged to a safe area from the emergency unit waiting room with instructions for symptomatic treatment. Injuries were limited to four organ systems: pulmonary. gastrointestinal. ophthalmic, and cutaneous. Of the out-patients, the following signs and symptoms were noted: red eye (34%), cough (26%), sore throat (22%), wheezing (19%), nausea/vomiting (17%), chest pain (12%), dyspnea (10%) and headache (970). Of the admitted patients, the following signs a n d symptoms were noted: dyspnea (100%). wheezing (83%), cough (67%). chest pain (67%), red eye (50%), sore throat (33%), and nausea/ vomiting (33%). No cases of pulmonary edema were found and n o deaths occurred. Treatment of pulmonary injuries consisted of high-flow humidified 0 2 , bronchodilators (inhaled and parenteral), and antitussives. Gashointestinal symptoms were treated by diet regulation a n d antiemetics. Conjunctivitis was treated with copious eye imgation followed by use of wetting ophthalmic agents. No corneal defects requiring ophthalmic consultation were found. One cutaneous burn was heated with bum cream after tetanus prophylaxis and cleansing with saline solution. This report emphasizes the nature of acute chlorine gas exposure and suggests steps which can be made to prepare for management of the disaster in the emergency unit. Current treatment methods are compared with those in the literature --A

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Regional vs. National Variations in Setting Quality Assessment Standards for Asthma Treatment in Hospital Emergency Departments

Geoffrey Gibson, PhD Health Services Research and Development Center, Department of Emergency Medicine, The Johns Hopkins University and Medical Institutions. Baltimore, Mayland The issue of whether there can or should be regional or national standards to evaluate the quality of medical care is emerging as an important programmatic and methodologic question. Traditionally, standards have been set by individual chiefs of service, are facility specific, vary greatly between hospitals and regions and may not represent a regional or national consensus as acceptable care. As a result, regional variation in agreeing to process standards and weighting each in terms of clinical significance have not been examined systematically. This paper reports on a s h d y which examined local, regional and national differences in standard-setting behavior by emergency physicians and allergy/pulmonary medicine specialists for asthma care. Sixty-nine quality assessment standards were generated by a project physician on physical exam. history taking, diagnosis and therapy activities of asthma care. These standards were submitted to a random sample of members of the American College of Emergency Physicians and a similar sample of physicians certified as specializing in allergy or pulmonary medicine. They were asked to rate each standard on a 7 point scale rating from excellent practice/absolutely necessary to poor practice/unnecessary. Standards were then screened to eliminate those where there was no consensus and those where the consensus was that they were clinically insignificant. Results indicate littie regional variation among both specialists and emergency physicians, although professional characteristics of physician respondents led to substantial variation. It seems both methodologically and conceptually possible to develop and apply assessment standards for asthma care which a r e universal rather than parochial.

Emergency Department Spirometric Evaluation of Acute Bronchial Asthma

Richard M. Nowak, MD M.C. Tomlanovich, MD K.R. Gordon, MD D.A. Wroblewski, MD P.A. Kvale, MD Henry Ford Hospital, Detroit. Michigan To evaluate their usefulness in the emergency department, spirograms were obtained before and after treatment in 8 7 patients presenting with acute bronchial asthma. All patients were evaluated by the same investigators 4 3 hours after discharge or hospitalization. Patients studied were divided into three groups: admissions, discharges Lcith successful outcomes and discharges with continued difficulties (i.e., inability to resume normal activities, nocturnal dyspnea, and physical examination demonsb.ating significant airway obstruction). The mean initial FEVi o was 0.47 L for admitted patients. 0 . 7 2 L for problem discharges and 0 . 9 8 L for successful d s charges ( p < 0 05). Eighty percent of those patients whose initial FEVl o was 5 0 . 6 L either required hospitalization or de-

veloped significant respiratory problems within forty-eight hours after discharge. After treatment completion, the mean FEVi o was 1.0 L for those admitted. 1 . 5 4 L for problem discharges and 1 . 9 1 for successful discharges (p < 0.05). Thirty-eight of fifty-one patients ( 7 5 % ) whose FEVi 0 after completior. of therapy was 1 . 1 . 6 L were either hospitalized or developed significant respiratory problems within forty-eight hours. Thus, most admitted and problem discharge patients had significantly different spirogrametric values than successfully discharged patients (i.e., an initial FEVI o 5 . 6 L or an FEVi o 5 1 . 6 L after therapy) Spirometry in the emergency department can help differentiate subgroups of patients with bronchial asthma, thus indicating those patients requiring hospitalization or close physician supervision over the ensuing forty-eight hours.

LVIY~IIIUIIUIY

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OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I - NAME The name of this organization shall be, "The University Association for Emergency Medicine." hereinafter referred to as, "The Association."

ARTICLE 11: - OBJECTIVES Section 1: The primary objective of this Association shall be improvement in the quality of care of the acutely ill and injured. Section 2: The Association shall pursue this objective by (a) collecting and disseminating information concerning the operation of emergency medical services, (b) providing a forum for the discussion of problems in emergency medical care and their proposed solutions. (c) aiding the university physician in the planning, administration and provision of emergency medical services, (d) fostering education a n d research in the field of emergency medicine, ( e ) encouraging the university physician to take an active role, at the local, state and national levels, in regional planning of emergency medical services, ( f ) recommending guidelines for: location, size, functional design, intra-hospital relationships, staffing, educational programs and performance of hospital emergency services, (g) providing, on request, assistance in the waluation and planning of emergency medical services, (h) recommendng appropriate changes in national, regional, state and local policies influencing or regulating emergency medical services and (i) encouraging recognition of the academic value of service in this field. Section 3: No part of the assets of the Association, nor any income or gains therefrom, shall inure to the benefit of its members. In the event of dissolution of this Association, or if for any reason the objectives of this Association should become impossible of performance, all assets remaining after all liabilities and obligations of the Association have been paid, satisfied and discharged, or adequate provision made therefore, shall be disMbuted to one or more organizations, designated by the Executive Council of this Association, which is or are organized and operated for purposes similar to the aims of this organization.

ARTICLE I11 - MEMBERSHIP Section 1: Classijcations: There shall be three classes of membership: active, associate and honorary. Section 2: Qualifications: (1) Candidates for active membership in this Association shall be physicians of university or university-affiliated hospitals who hold

medcal school faculty appointments and who are continuing to participate actively in the field of emergency medical care and services, whether in an administrative. teaching, or clinical capacity. (2) Associate Membership - Residents-in-training. and senior or inactive members by their own request, may be elected to associate membership. In addition. any official, representative or leading member of government agencies, lay or civic groups or other medical care and services, who would not otherwise qualify for active membership, may be elected to associate membership. (3) Honorary membership outstanding medical or lay contributors in the field of emergency medical services.

ARTICLE IV - OFFICERS The officers of this organization shall be the President, Vice-President, Secretary-Treasurer. and an Executive Council consisting of the above officers, the last three presidents and three Councilmen-at-Large.

ARTICLE V - COMMITTEES The standing committees of the Association shall be: Membership Committee, Nominating Committee, Program Committee, Committee on Local Arrangements, Constitution and Bylaws Committee, Education Committee, and Auditing Committee. Additional committees may be created by the Executive Council and ad hoc committees may be created by the President to aid in the Association efforts to achieve and further its goals.

ARTICLE VI - ANNUAL MEETING There shall be an annual meeting of this Association. This meeting shall consist of an education program and a business session, which shall be open to members of this Association and invited guests.

ARTICLE VII - BYLAWS The Association shall adopt bylaws for the conduct of its affairs not inconsistent with this constitution. Such bylaws may be adopted, repealed or amended at the business session of any annual meeting provided that any proposed amendment, addition or deletion to the bylaws shall have been jointly proposed in writing to the Secretary-Treasurer by three active members at least 90 days before, and in turn transmitted by the SecretaryTreasurer in writing to all voting members at least 60 days before the annual meeting at which time it is to be considered and voted upon by the membership. In addition, the Executive Council, by its own volition, at any regular or special meeting held prior to such annual meeting, may propose amendments to the bylaws for consideration by the membership at such annual meetings. If, in the opinion of the Executive Council, circumstances require more immediate action, they may, .

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of all active members. Adoption by mail ballot shall be achieved by affirmative vote of the majority of active members responding within one month of the mailing date of the ballots. Similarly, adoption of an amendment to the bylaws presented at the annual meeting requires a majority of the active members present and voting.

ARTICLE VIII - ADOPTION OF AMENDMENTS TO THE CONSTITUTION This constitution shall be deemed in effect upon its adoption by a majority of persons eligible to be active members, present and voting at the charter meeting of the Association, such persons automatically being also designated as "charter members." Proposed amendments to the constitution must be submitted, in writing. to the Secretay-Treasurer by three active members at least 90 days before, and transmitted by the SecretaryTreasurer in writing to all active members at least 60 days before, the annual meeting at which they are to be considered and voted upon by the membership of the Association. Affirmative vote of two-thirds of the members present and voting at that meeting shall be necess a y for the adoption of such an amendment.

BYLAWS OF THE UNIVERSITY ASSOCIATION FOR EMERGENCY MEDICINE ARTICLE I - MEMBERSHIP Section 1: Application and Election to Membership Application forms may be obtained from the SecretayTreasurer of the Association. The applicant must return the completed application forms to the SecretaryTreasurer of the Association at least one month prior to the annual meeting in order to be considered for membership at that time. Any letter supporting the application must also be filed with the Secretary-Treasurer of the Association at least one month prior to meetings of the Executive Council to be considered with the application. The qualifications and recommendations of candidates for active or associate membership will be reviewed by the Membership Committee at each meeting of the Executive Council and their approval shall constitute election to membership, which will become effective immediately. No limits will be set to restrict the size of the active membership. Nomination for honorary membership may be submitted by any active member of the Association in a letter to the Secretay-Treasurer which must be received at least one month before the mid-year meeting of the Executive Council. Nominations may also be personally

presented to the Executive Council at that meeting. The Executive Council may choose a maximum of two honorary members annually who shall be recognized at the subsequent annual meeting. Section 2: Rights, Privileges, and Obligations of Membership Active members may vote and hold office and shall pay dues. The Executive Council may establish procedures and policies regarding non-payment of dues and assessments. Associate and honorary members may neither vote nor hold office. Associate members shall pay annual dues.

ARTICLE I1 - OFFICERS Section I : Election of Officers The President and VicePresident shall each be elected for one year, with automatice succession from Vice President to President. The Secretary-Treasurer, and Councilmen-at-Large-shall each be elected to three year terms, the terms being staggered for the latter. Nominees for the above offices shall be selected by the Nominating Committee and must have agreed to stand for election prior to their formal nomination for election at the business session of the annual meeting. Alternative nominations from the floor shall be solicited. Such nominees must also agree to stand for election. Election shall be by majority vote of the active members present and voting at the business session of the annual meeting. Section 2: Duties of the President The President shall preside over both the educational program and business session of the annual meeting of the Association, and the meetings of the Executive Council. It shall be the duty of the President to see that the rules of order and decorum are properly enforced in all deliberations of the Association, and to sign the approved proceedings of each meeting. The President shall appoint active members to fill vacancies and unexpired terms on the Executive Council, Standing and Ad Hoc Committees and the positions of regional chairmen. The President shall serve as ex-officio member of all standing committees. ~

Section 3: Duties of the Vice-President In the absence or illness of the President, the Vice-President shaU preside. The Vice-President shall serve as Chairman of the Nominating Committee. Coordinator of Regional Chairmen and ex-officio member of all standing committees. Section 4: Duties of the Secretarv-Treasurer It shall be the duty of the Secretary-Treasurer to preside in the absence of both the President and Vice-President, to keep a true and correct record of the proceedings of the meeting, to preserve all books, papers and articles belonging to the Association, to keep an account of the Association with its members, to keep a register of the members with the dates of their admission. and current professional addresses, the latter to be circulated annually to the membership within a month prior to the annual meeting. He shall report unfinished business from previous r.

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vise and conduct aU the correspondence of h e Association. He shall collect the dues of the Association, make disbursements of expenses, maintain the financial accounts and records of the Association and present the financial accounts and records of the Association for review by the Auditing Committee within 24 hours prior to the business session of each annual meeting, at which time he shall present an annual report of the financial condition of the Association to the membership. He shall be reimbursed for such expenses as he may incur in the proper execution of his duties. He shall serve as exofficio member of all standing committees. Section 5: Regional Directors The Directors for each of 20 designated regions within the United States and Canada shall be appointed by the President to a term of three years. These regions consist of the three regions in Canada bounded by the east and west borders of Ontario and 1 7 regions in the United States conforming to existing U.S. Public Health Service Districts or their subdivisions. The Regional Directors shall (a) actively solicit representative membership and encourage active participation by all qualified faculty members of the medical schools within his region, (b) represent and promote the interests and wishes of the members of his region to the Executive Council through the coordinator of regional directors, (c) solicit program suggestions and participants from the membership of his region for recommendations to the Program Committee and (c) organize and preside over regional workshop meetings. These regional activities will be coordinated by the Vice-President who will preside at a meeting of the Regional Directors at the time of the annual meeting.

ARTICLE 111 - MEETING Section 1: The Association shall be governed by the actions taken by a majority vote of the active members present and voting at the business session of its annual meetings. The presence of 15% of the active members shall constitute a quorum at any meeting of the Association. In the interim, within the policies established by its membership, the Association shall be governed by the Executive Council. Actions of the Executive Council shall be determined by a majority vote of those of its members present at its meeting, five members constituting a quorum. Section 2: The annual meeting and any additional meetings of the Association shall be held at times and places fixed by the Association. or in the absence of action by the Association, by its Executive Council. Programs for the annual meetings shall be arranged by the Program Committee and approved by the President. A final notice of the time, place and program of each meeting shall be sent to all members of the Association by the Secretary-Treasurer at least 60 days before the meeting, but the tentative time and place for the next two annual meetings shaU ordinarily be announced during the business session of each annual meeting. The

site of the annual meetings shall be chosen by the Executive Council at its annual session immediately prior to the second previous annual meeting. The education program of the annual meeting shall be opened to all Association members, to invited guests in the company of, or upon presenting a written invitation by, an Association member and to any visiting physician upon approval of the Secretary-Treasurer or an Association member of the Committee on Local Arrangements, upon payment of the registration fee. The latter requirement may be waived by the SecretaryTreasurer or his designate for students, housestaff, postgraduate fellows and other such worthy exceptions

ARTICLE IV - FINANCES Section 1: The annual membership dues for all members shall be determined by the Executive Council, subject to approval by a majority of the active members present and voting at the business session of the next annual meeting. In the event of no action by the Executive Council or failure of a recommended change to gain approval by the membership, these dues will continue to be levied at the previous established level. The annual membership dues will be payable within 30 days of request by the Secretary-Treasurer.

ARTICLE V - PARLIAMENTARY AUTHORITY Section 1: Rule of Order Any question of order or procedure not specifically delineated or provided for by these bylaws and subsequent amendments shall be determined by parliamentary usage a s contained in Roberts Rules of Order (Revised).

ARTICLE VI - STANDING COMMITTEES Section 1: The Nominating Committee shall consist of the Vice-President, as chairman, the two most recent past presidents and two elected members who may not be members of the Executive Council. The latter shall setve staggered two-year terms. It shall be the task of this committee to select a slate of officers to fill the naturally occurring vacancies on the Executive Council and the standing committees not otherwise designated and provided for by these bylaws, and having obtained each candidate's permission to do so, place their names in nomination before the membership for election at the business section of the annual meeting. Section 2: The Executive Council shall constitute the Membership Committee. It shall be the SecretaryTreasurer's duty to review the qualifications and recommendations of each applicant for presentation and approval by the majority of the Membership Committee. Section 3: The Program Committee shall be composed -1

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Councilmen-at-Large with the greatest remaining tenure. The Chairman of the Committee on Local Arrangements shall be an ex-officio member of this committee. Its duties shall be to arrange, in conformity with instructions from the Executive Council, the program for the annual meeting and select its formal participants. Section 4: The Committee on Local Arrangements shall ordinarily consist of all active Association members who live in or near the city in which the meeting is held, its chairman shall be appointed by the President. The committee shall be expected to make all necessary local provisions to assure the success of the annual meeting, coordinating their efforts with the Program Committee and informing the Secretary-Treasurer of such details of their arrangements as may be required for information of the Executive Council and membership. Section 5: The Constitution and Bylaws Committee shall consist of a chairman and two other members, elected for staggered three year terms so that the member with the least remaining tenure shall serve as Chairman during his final year on the Committee. This Committee shall study the potential merits, adverse consequences and legal implications of all proposed constitutional amendments or changes in the bylaws and report their findings and recommendations to the President and Executive Council prior to the time of formal consideration of the proposed changes by the membership. In addition, they may themselves suggest appropriate constitutional amendments and bylaws changes to the President and Executive Council upon stud^ of problems arising out of the existing constitution a n d bylaw. Section 6: The Aud~tingCommittee shall consist of two members appointed by the President to audit the financial accounts and records of the Association at the time of the annual meeting.

ARTICLE VII - DISSOLUTION OF THE ASSOCIATION Section 1: Dissolution of this Association can only be initiated by a two-thirds vote of all members of the Executive Council and must be approved by two-thirds of the active membership responding within one month to a mail ballot. Upon dissolution the remainder of the Association's funds shall be distributed to charity, as stipulated by the constitution, such distribution to be determined by a majority vote of the Executive Council.

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3900 Capital City Boulevard Lansing, Michigan 48906 (517) 321-7060