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.

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.

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).

To assess the current level of development of emergency medicine (EM) systems in the world.

Survey of EM professionals from 36 countries during a 90-day period from Aug. 25 to Nov. 24, 1998.

Thirty-six EM professionals from 36 countries and 6 continents completed the survey. Thirty-five (97%) were physicians, of whom 25 (69%) gave presentations at 1 of 4 international EM conferences during the study period. Three potential participants from 3 countries were excluded because of language barriers. Five additional participants from 5 other countries did not respond within the study period and were excluded.

Respondents completed a 103-question questionnaire about the presence of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries.

The overall response rate was 88%. Nearly all respondents (97%) stated that their countries had hospital-based emergency departments (EDs). More than 80% of respondents reported that their countries have emergency medical services (EMS), national EMS activation phone numbers and ED systems for pediatric emergency care. More than 70% stated that their countries had national EM organizations, EM research, ED systems for patient transfer and peer review and emergency physician (EP) training in Advanced Cardiac Life Support (ACLS) and the ability to perform rapid sequence intubation. More than 60% reported ED systems for trauma care and triage and EP training in Advanced Trauma Life Support (ATLS) and the ability to perform thrombolysis for acute myocardial infarction. Fifty percent reported EM residency training programs, official recognition of EM as an independent specialty, and EM journals.

Basic emergency medicine components now exist in the majority of countries surveyed. These include many specialty, academic, patient care and administrative systems. The foundation for further EM development is widely established throughout the world.