Elbow injuries in children are a common presenting complaint to the emergency department. Although radiography is a valuable tool in the diagnosis of this injury, x-rays of the injured elbow are inherently difficult to interpret. As a result, comparison views of the uninjured arm have traditionally been recommended to provide an anatomically “normal” radiograph. Recent studies have questioned the use of comparison views in the pediatric emergency department. The primary objective of this study was to determine current practices of non-pediatric emergency physicians in the use of comparison views for the diagnosis of elbow injuries in children.

A self-administered mail survey was sent to 300 randomly selected emergency physicians, using the Canadian Association of Emergency Physicians database.

Two hundred and forty-two (81%) responses were received; 26 were excluded based on pre-determined criteria. Of eligible respondents, 95% ordered comparison views selectively and 64% of these physicians ordered comparison views infrequently. Eighty-eight percent found the comparison views to be “rarely” to “sometimes” useful. Forty-seven percent of respondents stated that they were only “somewhat” confident when interpreting x-rays of a child's elbow.

This survey demonstrates that non-pediatric emergency physicians are using comparison views selectively for elbow injuries in children, despite being only “somewhat” confident in interpreting the x-rays.

Evidence suggests that symptom-triggered benzodiazepine treatment for patients with alcohol withdrawal reduces complication rates and emergency department lengths of stay. Our objective was to describe the management of alcohol withdrawal in 2 urban emergency departments.

A structured chart audit was performed for patients with alcohol-related problems who presented to 2 Toronto hospitals over a 2-year period.

A total of 209 emergency department charts were audited. Patient characteristics were similar in both hospitals. None of the patients had been assessed using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Patients at one hospital received substantially higher mean diazepam doses (64 mg v. 26 mg; p < 0.001) than did the patients at the other hospital, and the patients at the first hospital had fewer seizures during their emergency department stay (1% v. 9%; p = 0.012). Patients spent an average of 9 hours and 40 minutes in the emergency department.

There is significant variability in the documentation and treatment of alcohol withdrawal. Lower benzodiazepine doses are associated with higher rate of withdrawal seizures and prolonged emergency department length of stay. A standardized approach using symptom-triggered management is likely to improve outcomes for patients presenting with alcohol withdrawal.

Because night shifts disrupt the normal circadian rhythm, sleep management is crucial for emergency physicians. The purpose of the survey was to describe the use of sleep-facilitating substances (SFSs) by emergency physicians before or after a night shift and to evaluate factors associated with their use.

All members of the Canadian Association of Emergency Physicians with a Canadian postal address were mailed a copy of the survey. Canadian physicians were eligible if they worked at least one night shift per month and spent 50% or more of their time in emergency medicine. Logistic regression was used to identify characteristics most predictive of using SFSs before or after a night shift.

Of the 1621 surveys mailed, 805 were returned completed, for a response rate of 49.6%. Of these, 628 respondents met inclusion criteria and 215 respondents (34%) reported consuming at least one SFS in their career to help them sleep around a night shift. The use of an SFS before a night shift was associated with the use of SFSs after a night shift (odds ratio [OR] 3.8; 95% confidence interval [CI] 2.4–5.9) and the use of SFSs at other times (OR 3.8; 95% CI 2.1–6.6). The use of SFSs after a night shift was associated with the use of a sleep-facilitating technique before a night shift (OR 2.1; 95% CI 1.3–3.3); use of an SFS before a night shift (OR 4.0; 95% CI 2.4–6.4); use of SFSs at other times (OR 4.7; 95% CI 2.6–8.4); and success of a nap before the night shift (OR 0.46; 95% CI 0.25–0.83).

The rate of SFS use is similar in emergency physicians and other shift workers. Emergency physicians who use SFSs before or after a night shift are more likely to use them at other times as well, and less likely to use them if they nap successfully prior to a night shift.

Difficulty maintaining physician staffing in emergency departments (EDs) prompted the government of Ontario to offer alternate funding arrangements (AFAs) to replace fee-for-service remuneration for physicians working in EDs.

To analyze the effect of AFAs on physician staffing and practice patterns.

We obtained Ontario Health Insurance Program fee-for-service and shadow-billing records for all physician services provided in EDs one year before and one year after implementation of an ED AFA. Only sites with reliable billing data were retained. Physicians were assigned to small/rural, community or teaching hospital groups based on their billing claims. For each hospital type, and all hospitals combined, we compared the pre- and post-AFA periods in terms of the number of physicians working regularly in the ED and their workload. As a possible unintended consequence of AFAs, we also compared physicians' involvement in primary care.

Overall, 76.2% of eligible hospitals adopted an ED AFA, of which 49 (42.6%) were included in our study (16 small/rural, 27 community and 6 teaching hospitals). In the post-AFA period, the number of physicians working in EDs increased by 7, from 674 to 681, representing a 1.0% increase overall in the workforce (p = 0.84). The change varied by hospital type, from a 5.8% increase in teaching hospitals to a 2.2% decrease in community hospitals, though none was significant. In the post-AFA period, the number of physicians working a moderate number of days per month increased from 190 to 214, representing a 3.2% absolute increase (p = 0.39), and the number working few (<5) or many (>10) days per month decreased. Post-AFA, the number of physicians working in EDs who also provided primary care services decreased by 1.7%, from 544 to 535 (p = 0.10).

Emergency department AFAs have been widely adopted in Ontario, but have not been associated with substantial changes in the overall physician workforce in EDs. However, trends toward increased physician numbers were seen in small/rural and teaching hospitals. There was little evidence of any adverse effects on the provision of primary care services by physicians.

Little is known about factors affecting emergency physician attendance at formal academic teaching sessions or what emergency physicians believe to be the benefits derived from attending these activities.

To determine what factors influence emergency medicine faculty attendance at formal academic rounds, what benefits they derive from attendance, and what differences in perceptions there are between full-time clinical and part-time clinical academic faculty.

A survey was sent to all emergency physicians with academic appointments at one institution. Responses were tabulated dichotomously (yes/no) for checklist answers and analyzed using a 2-person grounded theory approach for open answers based on an a priori analysis plan. Differences between full-time and part-time faculty were compared using the chi-squared test for significance.

Response rate was 73.8% (48/65). Significant impediments to attendance included clinical responsibilities (75%), professional responsibilities (52.1%), personal responsibilities (33.3%), location (31.2%) and time (27.1%). Perceived benefits of attending rounds were: continuing medical education, social interaction, teaching opportunities, interaction with residents, comparing one's practice with peers, improving teaching techniques, and enjoyment of the format. There were no statistically significant differences between groups' responses.

Emergency physicians in our study attend formal teaching sessions infrequently, suggesting that the perceived benefits do not outweigh impediments to attendance. The single main impediment, competing responsibilities, is difficult to modify for emergency physicians. Strategies to increase faculty attendance should focus on enhancing the main perceived benefits: continuing medical education, social interaction and educational development. Faculty learn from themselves and from residents during formal teaching sessions.

To describe the socio-demographic characteristics and clinical outcomes of patients who leave the emergency department (ED) without being seen by a physician.

This 3-month prospective study was conducted at a downtown Toronto teaching hospital. Patients who left the ED without being seen (LWBS) were matched with controls based on registration time and triage level. Subjects and controls were interviewed by telephone within 1 week after leaving the ED.

During the study period, 386 (3.57%) of 10 808 ED patients left without being seen. One-third of these had no fixed address or no telephone, and only 92 (23.8%) consented to a telephone interview. They cited excessive wait time as the most common reason for leaving the ED (in 36.7% of cases). Despite leaving the ED without being seen, they were no more likely than those in the control group to seek follow-up medical attention (70 % in both groups). Among those from both groups who did seek follow-up, the LWBS patients were more likely to do so the same day or the day after leaving the ED. The LWBS patients often lacked a regular physician (39.1% v. 21.7%; p = 0.01) and were more likely to attend an ED or urgent care clinic (34.8% v. 12.0%; p < 0.001). Controls were more likely to follow up with a family physician (37.0% v. 23.9%; p = 0.06). The LWBS and control groups did not differ in subjective health status at 48 hours after leaving the ED, nor in subsequent re-investigation in hospital.

Patients who leave the ED without being seen have different socio-demographic features, methods of accessing the health care system, affiliations and expectations than the general ED population. They are often socially disenfranchised, with limited access to traditional primary care. These patients are generally low acuity, but they are at risk of important and avoidable adverse outcomes.