1) To describe injuries experienced by the male prisoner population in the Kingston, Ontario area, and to compare them with those observed in the general population; and 2) to compare the incidence and patterns of prisoner injuries seen in emergency departments (EDs) before and after the introduction of a prison injury triage system.

A chart review.

The catchment area surrounding 2 hospital-based EDs in Kingston, Ontario, which includes 8 federal and provincial prisons for adult males.

Injuries to male prisoners (ages 18–75 years) who were treated in the ED during 1996–98 were compared with injuries to the general male population of the same age range. An on-site emergency care triage system was introduced to area prisons in 1993. Prisoner injuries seen in the ED during 1996–98 were compared with those seen during a similar period prior to the introduction of the triage system (1981–84). Available comparators included patient demographics, disposition, intent and nature of injury, the need for surgery, and lengths of hospital stay.

148 prisoner injuries were identified for 1996–98. Prisoner injuries seen in the ED were relatively severe when compared with the general male population, as indicated by the higher frequency of fractures (31.8% prisoner vs. 13.4% general, p < 0.001), blunt head injuries (10.1% vs. 2.2%, p < 0.001), hospital admissions (42.6% vs. 4.1%, p < 0.001) and deaths (2.7% vs. 0.6%, p < 0.001). Since the introduction of the triage system there has been a reduction in the rate of prisoner injuries seen in local hospital EDs (6.1/100/yr [before] vs. 1.6/100/yr [after], p < 0.001). There has been an increase in the relative severity of prisoner injuries seen in the EDs as indicated by the increased hospital admission rate (42.6% vs. 22.7%, p < 0.001), increased rate of surgical intervention (27.7% vs. 12.1%, p < 0.001), and increased length of hospital stay (4.0 days vs. 2.1 days, p < 0.05). The mortality rate has remained low and unchanged (0.7% vs. 1.1%, p = 0.99).

The introduction of the new triage system appeared to be associated with a decrease in the total number of ED visits by prisoners. The relative acuity of prisoner injuries seen in the EDs appeared to increase following introduction of the triage system.

Previous studies have shown a low but meaningful survival rate in cases of prehospital cardiac arrest with an initial rhythm of asystole. There may be, however, an identifiable subgroup in which resuscitation efforts are futile. This study identified potential field criteria for predicting 100% nonsurvival when the presenting rhythm is asystole in a Basic Life Support-Defibrillation (BLS-D) system.

This prospective cohort study, a component of Phases I and II of the Ontario Prehospital Advanced Life Support (OPALS) Study, was conducted in 21 Ontario communities with BLS-D level of care, and included all adult arrests of presumed cardiac etiology according to the Utstein Style Guidelines. Analyses included descriptive and appropriate univariate tests, as well as multivariate stepwise logistic regression to determine predictors of survival.

From 1991 to 1997, 9899 consecutive cardiac arrest cases with the following characteristics: male (67.2%), bystander-witnessed (44.7%), bystander CPR (14.2%), call–response interval (CRI) ≤ 8 minutes (82%) and overall survival (4.3%) were enrolled. Of 9529 cases with available rhythm strip recordings, initial arrest rhythms were asystole in 40.8%, pulseless electrical activity in 21.2% and ventricular fibrillation or ventricular tachycardia in 38%. Of 3888 asystolic patients, 9 (0.2%) survived to discharge; 3 of these cases were unwitnessed arrests with no bystander CPR. There were no survivors if the CRI exceeded 8 minutes. Logistic regression analysis demonstrated that independent predictors of survival to admission were “CRI in minutes” (odds ratio [OR] = 0.87; 95% confidence interval [CI], 0.77–0.98) and “bystander-witnessed” (OR = 2.6; 95% CI, 1.5–4.4).

In a BLS-D system, there is a very low but measurable survival rate for prehospital asystolic cardiac arrest. CRIs of over 8 minutes were associated with 100% nonsurvival, whereas unwitnessed arrests with no bystander CPR were not. These data add to the growing literature that will help guide ethical decision-making for protocol development in emergency medical services systems.

Acute upper gastrointestinal (UGI) hemorrhage is a common, often serious condition encountered in the emergency department (ED). Previous research has suggested that transfusion of blood products may interfere with the hypercoagulable state induced by significant blood loss. Our objective was to determine whether the frequency of rebleeding is higher in patients with UGI bleeding who have received early blood transfusion.

The study was a retrospective chart review of patients admitted to hospital through the ED with a diagnosis of UGI hemorrhage. Inclusion criteria limited analysis to patients presenting with hematemesis, melena, or bloody nasogastric aspirate, in whom a UGI lesion was confirmed endoscopically during admission.

A total of 214 charts were analyzed. Baseline demographic characteristics were similar in transfused and non-transfused patients. Presenting hemoglobin level was lower in the transfused group (86.5 v. 119.2 g/L, p < 0.001). Recurrent bleeding occurred in 99 (46%) patients and was more common in transfused patients (67 [66%] v. 33 [29%], p < 0.001). Logistic regression analysis revealed that transfusion and presenting hemoglobin level were the only variables with a statistically significant independent association with bleeding recurrence (p < 0.001 and p < 0.05 respectively).

Our results support previous research suggesting that transfused UGI bleed patients have a higher rate of rebleeding. However, because of the retrospective design, causality cannot be inferred.

To determine Canadian emergency physicians’ estimates regarding the safety and efficiency of chest discomfort management in their emergency department (ED), and their attitudes toward and perception of the need for a chest discomfort clinical prediction rule that identifies very low risk patients who are safe to discharge after a brief ED assessment.

300 members of the Canadian Association of Emergency Physicians (CAEP) were randomly selected to receive a confidential mail survey, which invited them to provide information on current disposition of patients with chest discomfort and their opinions regarding the value of a clinical prediction rule to identify patients with chest discomfort who are safe to discharge after a brief (~2 hour) assessment.

Of the 300 physicians selected, 288 were eligible for the survey and 235 (82%) responded. Only 5% follow discharged patients to measure safe practice. Overall, 165 (70%) felt the proposed prediction rule would be very useful and 43 (18%) felt it would be useful. Almost all (94%) believed a prediction rule would be useful if it identified patients safe for discharge without increasing the current rate of missed acute myocardial infarction (estimated at 2%). Most respondents (59%) believed that a clinical prediction rule should suggest a course of action, while 30% felt it should convey a probability of disease.

Canadian emergency physicians support the concept of a clinical prediction rule for the early discharge of patients with chest discomfort. Most believe that such a rule would be useful if it identified patients who are safe for discharge after a brief assessment, while maintaining current levels of safety. Future research should be aimed at deriving a clinical prediction rule to identify low risk patients who can be safely discharged after a limited emergency department evaluation.

Although some studies have tried to assess the factors leading to choice of specialty, none have been specific to emergency medicine (EM). With a doubling of the number of EM residency programs in the past decade, an assessment of the career motivations of residents is in order.

To identify and rank the factors that lead candidates to choose EM as a career. Methods: Fifty-four participating EM programs returned a total of 393 anonymous surveys completed by their 1996 National Residency Matching Program (NRMP) interviewees. The survey asked respondents to rank 12 factors on a 5-point (0–4) Likert scale.

Respondents ranked the 12 motivating factors in the following descending order of importance: diversity in clinical pathology, emphasis on acute care, flexibility in choice of practice location, flexibility of EM work schedules, previous work experience in EM, greater availability of EM faculty for bedside teaching, strong influence of an EM faculty advisor or mentor, relatively shorter length of training, better salaries for EM than for primary care specialties, the presence of an EM residency at the student’s medical school, perception that EM residents have more time to moonlight and popularity of EM among medical students.

US applicants appear to choose a career in EM largely because of clinical factors (diversity of clinical pathology and emphasis on acute care) and practice-related factors (flexibility in practice location and schedule).

Clavicle fractures are commonly encountered in the emergency department (ED). Our objective was to determine whether emergency physicians can clinically predict the presence and location of a clavicle fracture prior to obtaining x-rays.

Over a 16-month period we prospectively studied ED patients who had injuries compatible with a clavicle fracture. Following clinical examination and prior to obtaining radiographs, ED physicians or senior emergency medicine (EM) residents were asked to predict whether the clavicle was fractured and, if fractured, the location of the fracture. Clinical predictions were later compared to the radiologist’s report.

Between April 1999 and August 2000, 184 patients with possible clavicle fracture were seen and 106 (58%) were enrolled. Of these, 94 had an acute fracture, and all 94 fractures were predicted on clinical grounds prior to x-ray. In 6 cases, physicians predicted a fracture but the radiograph was negative. In 6 additional cases, physicians were clinically unsure and the radiograph was negative. Physicians correctly predicted fracture location in 83 of 94 cases (88%; 95% confidence interval [CI], 82%–95%). In the 64 cases where physicians predicted a middle third fracture, they were 100% accurate (95% CI, 95%–100%). Errors made by physicians were conservative; that is, they occasionally predicted fractures in patients with only soft tissue injury, but they did not “miss” existing fractures.

The results of this pilot study suggest that ED physicians can clinically predict the presence and location of clavicle fractures with a high degree of accuracy. It may be that x-rays are not always necessary in patients suspected of having a clavicle fracture. Future studies should define the indications for diagnostic radiography in patients with suspected clavicle fractures.