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Previous studies have proven the success of the EsophagealTracheal Combitube (ETC) as a primary airway, but not as a rescue airway.
The object of this study was to observe success and complication rates of paramedic placement of an ETC as a rescue airway, and to compare success rates with endotracheal tube (ETT) intubation. The primary outcome indicator was placement with successful ventilation. Complication rates, esophageal placement, and return of spontaneous circulation (ROSC) were secondary measures.
A retrospective review of the records of patients who had ETC attempts by Emergency Medical Services (EMS) was conducted for a period of three years. Complications were defined a priori. The ETC is used primarily as rescue airway for a failed attempt at an endotracheal tube (ETT) intubation. A control group for ETT placements was drawn from the EMS quality assurance (QA) database for the same period.
Esophageal-Tracheal Combitube insertion was attempted on 162 patients, of which, 113 (70%) were successful, 46 (28%) failed, and the outcome of three (2%) was not recorded. Inability to place the ETC occurred in 29 (18%) patients, and accounted for 48% (22/46) of failures. The use of the ETC caused dental trauma in one patient, and one placement of the ETC was related to the onset of subcutaneous emphysema. Blood in the ETC from active upper gatrointestinal bleeding occurred in nine patients (6%), and four tubes (3%) became dislodged en route to the hospital. The a priori complication rate was 44/162 (27%). Inability to determine placement of the ETC due to emesis from both ports occurred in 21 cases. Combining these problems with the a priori complications, the overall rate was 40% (65/162). EsophagealTracheal Combitube location was noted in a subset of 90 charts, of which, 76 (84%) were esophageal, and 14 (16%) were tracheal. Thirteen of 126 (10%) patients in cardiac arrest had return of spontaneous circulation (ROSC) in the field after placement of the ETC. An ETT was attempted in 128 control patients, of which, 107 (84%) were successful, 21 (16%) failed (odds ratio (OR) for ETT vs. ETC = 2.1; 95% CI = 1.12–3.86).
Despite a low ROSC rate, the complication and success rates of ETC are acceptable for a rescue airway device. Tracheal placement of the Combitube is uncommon, but requires fail-safe discrimination. Similar to previous reports, the success ratio for ETT was greater than for the ETC.
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 volume of patients and the composition of their injuries and illnesses that presented to an emergency department (ED) close to the epicenter of an earthquake that occurred in a seismically prepared area.
A retrospective analysis of data abstracted from charts and ED logs for patient census and types of injuries and illnesses of the patients who presented in the ED of a community hospital before and after the earthquake (6.8 Richter scale) that occurred in 1994 in Los Angeles. Illnesses were classified as trauma- and non-trauma related. Data were compared with epidemiological profiles of earthquakes in seismically prepared and unprepared areas.
A statistically significant increase in ED patient census over baseline lasted 11 days. There was a large increase in the number of traumatic injuries such as lacerations and orthopedic injuries during the first 48 hours. Beginning on the third day after the event, primary care conditions predominated. When the effects of the LA quake were compared with those of similar Richter magnitude and disruptive capability, the ED epidemiology profile was similar to those in seismically unprepared areas, except for the total number of casualties.
The majority of patients with traumatic injuries presented within the first 48 hours. The increase relative to baseline lasted 11 days. Efforts to develop disaster response systems from resources outside the disaster-stricken area should focus on providing mostly primary care assistance. Communities in seismically prepared areas could require external medical assistance for their EDsfor up to two weeks following the event.
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