Antibiotics in emergency medicine

The paper is focused on prediction of loss of consciousness and grey-out during short (up to 5 s) impulses of longitudinal head-to-tail accelerations with high buildup gradients (more than 50 m/s3). This is a poorly explored region of exposure on the borderline between impulsive and maneuvering accelerations of the modern aircraft. On the basis of comparing the prediction with available experimental data, prognostic potentials of various modifications of criterion which includes the maximum allowable values of velocity in this range of exposure are demonstrated.     

Common office problems in pediatric urology and gynecology

The number of genital problems that pediatricians encounter is substantial. The most common ones have been reviewed in this article. Perhaps the most important point to reinforce is the appropriateness of nonintervention in uncircumcised boys whose foreskins have not become retractile during early school years. Without infections or pathologic phimosis, these boys do well, and most foreskins become retractile as they approach puberty. Abnormalities beyond those discussed or those not fitting the anticipated pattern probably warrant specialty referral.     

Evidence-based emergency medicine

Evidence Based (Emergency) Medicine (EB(E)M is a term referring to the application into daily clinical practice of only those methods, procedures, medications etc. which are based on scientific evidence. Where diagnostic and therapeutic principles have not been validated on a prospective, controlled randomised basis, this should be tried out at a later time, if at all possible. This concept may allow to bridge the gap between research and clinical practice, and represents the major goal of EB(E)M. Protagonists of EBEM are at times confronted with criticism that EBEM does not constitute the only but one out of several possible approaches to quality controlled medical care. The fact that more than 50% of all emergency procedures are not evidence based give rise to the question as to whether the performance of randomised controlled studies is ethically justifiable, if control groups are included whose treatment leaves out generally recommended and recognised (though not evidence based) therapeutic and/or diagnostic principles. The following examples may enumerate some of the procedures, methods or medications, respectively, without proven scientific evidence: Medication for resuscitation of cardiac arrest victims. Medication for acute asthmatic attacks Initial treatment of uncontrolled haemorrhagic shock. Endotracheal intubation in VF/VT. The principle need for initial ventilation and the volumes of ventilation in cardiac arrest patients. Effectiveness of ACD- and VEST-CPR. A few typical examples are presented to illustrate the requirements of current study designs which have to be met before results of an evaluation are accepted by the EBEM scientists to obtain approval for application of a procedure, method or medication in clinical practice (large patient numbers, power calculations, ethical issues) as well as their benefits and drawbacks.     

Elegant emergency medicine

Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak is a rare but increasingly recognized cause of postural headaches. The exact cause of these CSF leaks often remains unknown. The authors treated a 32-year-old man with a unique cause of spontaneous intracranial hypotension. He suffered an excruciating headache that was exacerbated by his being in an upright position. The results of four-vessel cerebral angiography were negative; however, magnetic resonance (MR) imaging of the brain revealed pachymeningeal enhancement and hindbrain herniation. A presumptive diagnosis of spontaneous intracranial hypotension was made. Myelography revealed extrathecal contrast material ventral to the cervical spinal cord as well as an unusual midline bone spur at C5-6. The patient's symptoms did not resolve with the application of epidural blood patches, and he subsequently underwent an anterior approach to the C5-6 spur. After discectomy, a slender bone spur that had pierced the thecal sac was found. After its removal, the dural rent was closed using two interrupted prolene sutures. The patient was discharged home 2 days later. On follow up his symptoms had resolved, and on MR imaging the pachymeningeal enhancement had resolved and the cerebellar herniation had improved slightly.     

Quality management in emergency medicine

Although the need for the implementation of a quality management concept for the German emergency medical system (EMS) has been discussed for more than 10 years, such a concept has not been realised on a broad scale. Standardised national data sheets were developed many years ago. They are used by many local agencies, but a data-gathering system on a state or national basis is still lacking. In times of reduced funds for health care expenditures, quality management could be a reliable way to ensure that the EMS provides safe services to the patient based on the current state of medical science in an efficient manner. Based on clear definitions, structure, process, and outcome quality can be analysed, and the results provide the basis for continuous quality-improvement strategies. As not all aspects of the system can be analysed continuously, one has to select areas of special importance. External and internal quality control are equally important. Quality control works on the basis that all EMS team members are motivated to perform on a professional level to ensure that each patient is treated adequately. It evaluates the system to create circumstances that enhance the achievement of this goal. Quality management is not only concerned with mishaps, because areas with documented good performance also provide important information.     

Collaboration in emergency medicine research

This article expands on several key points about collaboration between emergency physicians and other researchers. Nontraditional areas of collaboration are important in broadening the scope of emergency medicine research.     

Family medicine in Minnesota: office costs and productivity

Clinics representing more than half of Minnesota's family physicians participated in a statewide study on the practice of family medicine conducted by the Minnesota Academy of Family Physicians. The survey was designed to provide direction for individual physicians, administrators, and the Minnesota Academy of Family Physicians as an organization. The survey identified some concerns regarding access to care. In the central portion of the state, 71% of the full-time equivalent family physicians were in practices with Medicaid patient restrictions. In the most sparsely populated towns, 35% of the reporting family physicians who provided obstetrical care three years ago discontinued that service due to the cost or availability of professional liability coverage. Statewide in 1989, 57% of the family physician positions recruited for by the practices studies were unfilled at year's end, with 82% unfilled in the most sparsely populated areas.     

The principal physician in emergency medicine

The implementation of an experienced pre-hospital care emergency physician as an on the-scene medical command officer (MCO) within the emergency medical service (EMS) is an essential prerequisite to guarantee qualified medical supervision during mass-casuality incidents (MCI). The MCO has four basic functions. Within the administration of the EMS system, he is responsible for the medical aspects of strategic planning for the MCI response. During the MCI the MCO is responsible for the overall assessment of the situation, triage, and supervision of medical treatment by physician and non-physician providers. Aside from extensive personal experience in pre-hospital care, the MCO needs special training to be qualified for this position. State EMS laws provide the legal basis for the MCO within the EMS system.