University Association for

Emergency Medical Services

PROGRAM Annual Meeting

Dallas, Texas May 28 - June 1, 1974

Bring this program

to the Annual Meet ing

with you. . . .

Welcome To Dallas . . . . . . for the Annual Business and Committee Meetings of the University Association for Emergency Medical Services. It seems fitting, son~ehow, that we should be meeting in the Big Country to talk about the Big Challenge of im- proving emergency medical care through the development of more effective educational programs.

Our organization has made significant strides in defining areas of educational need in the field of Emergency Medical Services. At this, our Fourth Annual Meeting, the caliber of the presentations is indicative tha t UA/EMS is zeroing in on the specifics of an educational system responsive to the needs of emergency medicine.

We t rus t t h a t you will find the sessions stimulating and worthwhile. More importantly, it is our hope tha t when you leave Dallas you will take with you a better understanding of this dynamic field of medicine as well as a resolve to work in your area for the organization of a truly effective system of emergency medical service.

James R. Mackenzie, M D President, UA/EMS

About UNEMS

The University Association for Emergency Medical Services had its inception in 1968 when a small group of physicians who served as Emergency Department directors in teaching hospitals decided that the problems of emergency medical care required a con- certed approach if they were to be solved.

Since that time, U A E M S has grown to a thriving organization of over 300 members from the United States and Canada. The membership requirements are simple; a medical school faculty appointment and active participation in the delivery of emergency medical care.

The objectives of UAIEMS are defined in its con- stitution, which states that improvements in the quality and delivery of emergency medical care shall be pursued by: collecting and disseminating informa- tion regarding E M S problems; providing a n annual forum to discuss these problems; aiding and en- couraging the university physician in his participa- tion in the field of EMS; developing guidelines and consulting in matters of emergency department staf- fing, administrat ion, design and performance; recommending appropriate changes in E M S legisla- tion a t the local, regional and national levels; and en- couraging academic recognition for work in this field by teaching physicians.

The University of Texas . . . . . . Health Science Center a t Dallas was formed in 1972 to encompass Southwestern Medical School and its sister components for graudate and allied health education. Founded in 1943 as a private medical school, Southwestern became a part of the University of Texas system in 1949.

Its current enrollment of 516 medical students and 80 graduate students will be enlarged in the fall of 1974 when expansion plans call for a n entering class of 200 students. Long known for its academic ex- cellence, Southwestern Medical School has the sup- port of 16 clinical facilities for its broad-based program of medical education.

Leadership

President James R. Mackenzie, MD Vice President George Johnson, MD Secretary William E. Matory, MD Treasurer Ronald L. Krome. MD

Executive Council

Alan R. Dimick, MD Gerald L. Looney, MD Charles Frey, MD Leslie Rudolf, MD Carl Jelenko, MD Robert Rutherford, MD

Committee Chairman

STANDING COMMITTEES

Nominat ing Membership Program Constitution

and Bylaws Auditing

George Johnson, MD Carl Jelenko, MD

Peter Canizaro, MD

Tom Piemme, MD Frederic Platt, MD

SPECIAL COMMITTEES

Economics of Emergency Medicine

E D Organization and Planning

Medical Education Paramedical Education

Pit blic Information Public Information

in C'anada Publication,$ Publicity Regional Planning Resources

Karl Mangold, MD

Paul James, MD Edmond Monaghan, MD

Gerald Looney, MD William Carey, MD Allen Klippel, MD Trevor Sandy, MD

William Ghent, MD Carl Jelenko, MD

Christine Haycock, MD Fred Vogt, MD

Harlan Root, MD

Annual Business and Committee

Meetings

Sheraton-Dallas Hotel All Members of UA/EMS are Cordially

Invited to Attend and Participate P

Tuesday, M a y 2 8 , 1 9 7 4

1:30 p.m. to Executive Committee Cafe D'Or 5:30 p.m. Meeting

Wednesday, M a y 2 9 , 1 9 7 4

8:30 a.m. to Continuation of Cafe D'Or 12:OO noon Executive Committee Meeting

12:OO noon Luncheon Chaparral Club to 1:00 p.m. 1:00 p.m. to lJA/EMS Committee Meetings

4:00 p.m. Economics of London Room Emergency Medicine

ED Organization State Room and Planning

Medical Education S.F. Austin Room Paramedical Education Trinity Room Publications Pioneer Room Public Information Brazos Room Puhlicity San Jacinto Room Resources 0. Henry Room

2:00 p.m. to Registration Ballroom Lobby 6:00 p.m. 4:00 p.m. to Continuation of Cafe D'Or 6:00 p.m. Executive Committee Meeting

7:00 p.m. Reception (Cash Bar) W.B. Travis Room

Thursday, M a y 3 0 , 1 9 7 4 - General Sessions

Ballroom Foyer 7:30 a.m. Registration Ballroom Lobby 8:25 a.m. Opening Remarks

Ronald C. Jones, M D

8:30 a.m. The Rohert H . Kennedy Lectureship in Emergency Medical Care Emergency Medicine as a Specialty

Oscar P. Hampton. M D Panel Discussion

George Johnson, J r . , MD, Moderator Oscar P. Hampton, M D James D. Mills, M D H. David Root, M D David K . Wagner, M D

10:30 a.m. Coffee Break

11:OO a.m. Emergency Department Design and Organization

Paul M. James, Jr., MD, Moderator

Construction and Planning Robert B. Rutherford, MD

Function ,James R. Mackenzie, MD

Conlrnl~nications and Transportation David R. Boyd, MD

12:30 p.m. Luncheon South Ballroom Presidential Address

James R. Mackenzie, MD

2:00 p.m. SCIENTIFIC PAPERS SESSION I Peter C. Canizaro. MD, Moderator

1. Cause of Death in 425 Consecutive Hospitalized and Non-Hospitalized Trauma Deaths

Donald D. Trunkey. MD 2. Major Surgery in the Emergency

Center Kenneth L. Mattox, M D George L. Jordan, .Jr., M D

3. Amelioration of Prehospital and Ambulance Death Rates from Coronary Artery Disease by Pre- hospital Emergency Cardiac Care

(Sponsored hy Leslie E. Rudolf, MD) Richard S . Crampton, M D ,John R. Miles, Jr., MD Joseph A. Gascho, MD Robert F. Aldrich, MD Roy Stillerman, MD

4. Cardiac Arrest Outside the Hospital: The Yield of an EMS System Without Telemetry

G. S. Gordon, MD Cleve Trimhle, MD

5. The Use of Peritoneal Lavage as a Diagnostic Tool in the Emergency Department

Christine E. Haycock, MD George Machiedo, M D

6. Potential Sources of Error in the Use of Peritoneal lavage as a Diagnostic Tool

P . C. Breen, MD L. E. Rudolf, MD

3:30 p.m. Coffee Break

3:45 p.m. SCIENTIFIC PAPERS SESSION I1 Carl Jelenko, 111. MD, Moderator

7. A Burn Team Looks at Child Abuse Patricia S . Phillips, RN Elaine Pickrell, MSW Thomas S . Morse, MD

11. Accidental Hypothermia: Core Re- warming with Partial Bypass

Per Wickstrorn, MU Ernest Ruiz, MD G. Patrick Lilja. MD J . Peter Hinterkopf, MD John J . Haglin, MD, Ph.D.

9. Complications o f Subclavian Sticks William F. Mitty, Jr., MD Thomas Nealon, Jr . , MD

10. Ambulance Critique Review David B. Pilcher, MD

I I . The Emergency Department Record George R. Schwartz, MD

12. Types o f Arterial Trauma William E. Evans, MD

5:15 p.m. Adjourn

6:00 p.m. Busses depart Sheraton-Dallas Hotel (Live Oak Street Entrance) to Country Dinner Playhouse for Cocktails, Dinner and "No Hard Feelings," a three-act play.

Busses will return to Sheraton-Dallas Hotel a t conclusion of play.

Friday, May 31,1974 - General Sessions

Ballroom Foyer 7:30 a.m. Regional Directors Breakfast State Room

8:30 a.m. Telemetry and Advanced Care Panel Discussion

Eugene L. Nagel, MD, Moderator Fred B. Vogt, MD Col. Gaylord Ailshie Donald S. Gann, MD

10:30 a.m. Coffee Break

11:OO a.m. SCIENTIFIC PAPERS SESSION 111 C. Richard Baker, MD, Moderator

13. Teaching Cardiovascular Physiology in the Emergency Room

Rae R. Jacobs, MD James S. Carter, MD William Sosnow, MD David Cobb, MD

13. Focal Motor Seizures in Patients with Alcoholism I

Howard S. Schwartz, MD Philip R. Yarnell, MD Gary Vander Ark, MD

15. Development of a New Surgical Tape for Sutureless Wound Closure

Richard F. Edlich, MD, PhD George Rodeheaver, PhD Milton T. Edgerton, MD

16. Value of the G Suit to Control Hemorrhagic Shock in Patients with Severe Pelvic Fracture

Daryl J . Batalden, MD Per H. Wickstrom, MD Ernest Ruiz, MD Ramon B. Gustilo, MD

I T . Emergency Treatment of High Pressure Injection Injuries of the Hand

B. J. Parks, MD R. L. Horner, MD Cleve Trimble, MD

18. The Injured Diaphragm, A Diagnostic Emergency

Anatole Gourin, M D

12:30 p.m. Luncheon and Annual Business Meeting South Ballroom

2:00 p.m. Description of Parkland Memorial Hospital Emergency Facilities

Erwin R. Thal , M D

Dallas Ambulance System Chief Bill Roberts

Ambulance Division Dallas Fire Department

3:00 p.m. Busses depart Sheraton-Dallas Hotel (Live Oak Street Entrance) for tour of Parkland Memorial Hospital

5:00 p.m. Busses depart Parkland Memorial Hospital to Dallas-Fort Worth International Airport and to Sheraton-Dallas Hotel

Third Annual Emergency Residency Workshop

Sheraton-Dallas Hotel

Saturday, June 1,1974 Cafe D'Or 9:15 a.m. Introduction - Robert H. Dailey, M D

9:30 a.m. Problems and Solutions in Establish- ing the Residency Program - Residency Directors Panel

Gail V . Anderson, M D H. Arnold Muller,MD H . Thomas Blum, M D Peter Hosen, MD William J . Czrey, M D C. C. Roussi, MD Albert J . Lauro, MI) Ernest Ruiz, M D W. tiendall McNah- Donald M. Thomas,

ney, M D M 1)

11 :00 a.m. Questions and Answers

12:30 p.m. Lur~chrorl - Vaquero Room

1:30 p.m. Problems and Solutions in Resident Training - Present and Past Residents Panel

James Alexander, James T. Lemay, M D MI) David M. Maxwell,

Pamela P . Bensen, MD M D Jeffrey Selevan, MD

Richard M . Goldberg. ti. L. Shapiro. M D M D Others t,o be named

3:00 p.m. Questions and Answers

5:30 p.m. Adjourn

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Patients arriving with pre-terminal respiratory cerehral anti resl'iratory patterns whose injuries were limited to in- (rat horac,ic organs denionstrated a 6 7 ' ~ survival. Cardiac in- juries were successt 'ully control led in 23 pa t ien ts . I,;i[xirotoniy anti cardiopulmonary hypass were less ~~1ccc~hs1'ul in controlling extensive multiple organ injuries. ;2;l;rjor surgery in the emergency center environnlent may be rccluired Sor the lraumatizeti patient who is too critical to he (ransportrtl to the operating room. Autotransfusion, fine screen tillration t r f transfused blood and radiography intrin- sic. to I he resuscitation room have served as adjuncts to nia- lor cniergency surgery.

3. Amelioration of Prehospital and Ambu- ,

lance Death Rates from Coronary Artery Disease by Prehospital Emergency Car- diac Care RICHARDS. CRAMPTON, M.D. .JOHN R. MILES, . J R . , M.D. .JOSEPH A. GASCHO, M.D. ROAEKI F. ALDRICH, M.D. Roy S'I.II.I.ERMAN, M .D.

Irniversity of V i r g ~ n i a Medical Center , C'harlottesville. Virginia

111 :r co~lirnunity of 80,000 people living in 745 square i~iil's, a survey (196G-1970) of' prehospital deaths from pure coron;iry artery disease (CAD) in people aged 30-69 years stiowc~ci that $4 of 282 (29.8l ;) died in the presence of am- lnilance personnel before and during transport. A pre- hospilal c~lrdiopulmonary resuscitation (CPR) and emer- gency cardiac care (ECC) system was added to the extant rrnergency medical service in March 1971. Of 243 calls I'r.0111 the community managed from 1 March 1971 to 31 Occclnber 1972, 71 patients had acute myocardial infarction and 21; exlxrienced prehospital cardiac arrests. 23 with ven- tric,ulnr I'ihrillntic~n and 3 with asystole. Two additional I):rt icnts hat1 venrricular tachycartiia abolished by precordial thuml)~version with the fist. Fifteen of these 28, were treated Irss than 5 rninutes aft,er onset, and 10 (67' ;) returned t o ac- 11j.e lilb. 'l'wenty of25 (80'0 major CPK-ECC interventions w ~ r c necehsary 1)efore and dnring ambulance transport. An ;rtiditional hut unqumitifiable number of fatalities may have been prevented by routine prehospital ECC: relief of pain and abolilicln of dysrhythmias. Chi square testing showed that average annual CAD death rate in ambulances, 0.5 per 1000 people aged :30-:3Y years (1966-1971). fell 6 0 5 to 0.2

( 197" 11, = 0.007) in the first full vear of'F,(:C. Likewise CAD dewt ll in an arnhulnn<.e per 1000 nmhulances dispatched fell (il", I'rc)ni 4.8 per 1000 people aged 30-69 years (1966-1971) to 1.8 (1972, p = 0.007). Prehospital CAD deaths per 1000 peo- ple aged 30-69 years declined 28.65 from 1.96 (1966-1971) to 1.40 (1972, p = 0.04). Data for 1973 will be added. The initia- tion of ' a prehospital ECC system significantly reduced CAD death in ambulances and in the prehospital phase for the 30- 69 vear age group in this community.

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4. Cardiac Arrest Outside the Hospital; The Yield of an EMS System Without Telemetry G. S. GOKIION, M.D. CLEVE TKIMRLE. M.1).

Department of' En~ergenry Medical Services, T h e Denver Genera l Hospi ta l , Denver , ( ' o lo rado

'l 'hr ( ' i t? a n d ( ' i~un ty I I ~ I lenver ' s Ambulance Division covrrs 117 hciuare rniles a n d over 700,000 consumers a t daily ri.k. 'l'kr~h systern incllides:

I . pat ienr access t11 a r n e d i ~ a l emergency response center ~ l i r o u g h '911' or other common entr ies ( 'O', fire, ~) l l l lc~r l ;

2, c l ~ ~ p a t c h i n g which fully integrates wi th fire a n d police;

:i 11re-l)osit ioriirig (dispersal i11'arnl)ulances a t five points to n l ~ n ~ m i z c response tirnes (1 minu tes or less in over !)Orf 01 r~nergcsnclehl:

I , i r ~ ~ e ~ ~ s i v t ~ t ra ining ant1 1111gradit1g i~ t 'wn~ t ) r~ lnnce and fire rt>hc~it* 1)t3rsorinrl ( r r icI~r( l~ng constant cr i t ique) ;

.-I, returning c , r~t ical ~ ) ; ~ t i r n t > (wi th radio torewarning) t o tlic, nt,tirt>st of l ou r highly-categorizec1 regional I l o h l ~ ~ t n l ~ . I h r r r 01 which t r iangulate t he centra l ly- I i ~ c , a ~ r d Ot311ver (;ener;rl t iospi ta l ( I ) ( ;H) ;

l i , r l ~ r r c t 5i1l)ervision 01 all activities t)y a t'ulltirne r a r - ~ I l O I O ~ i ~ t

I{c.~c,lir ~)c.rsonnt>l ;ire t,cjr~ipprd only wi th bag-valve-tnasks. ~ ) ~ r l ; t i ] l c oxyyc.11. [ ) i~ r t a l ) l e s u c t i o n , p l a s t i c a i rways . I ~ ; i ( ~ k l ~ t ~ n r d h . :tnd fu r id ;~ rn t~ r l~a l life suppor t skills. Hiomedical tc~lc.nlc~~r.\ h;rh Iwen absent l'ror~l these resources a l though lic,ltl ~ullc~rvlslorl I? ~)hysic,i;rns 15 always available by radio. ~ l ' h i s rcl)orl rr\.icws our r sp r r i ence wi th cardiopulmonary ;Irrt3hth orilsidr ~ h t , I)(;H dur ing 197:i. 01'2.1.511 ambu lance rc.>lxln>rs. .->!Mi cases w r r r s r l rc ted l'or s tudy wherein t h e l,;illc,nr \v;r.; witlro~it bital signs \r.hen first seen in t h e field. l ' I ~ ~ ~ ( L r i t i lirkc.ri to p i ~ r t i c i l ~ ~ t i r i g h i~sp i t a l s o ther t h a n the I ) ( ; H 1l;rt.t. ~ h r n I ~ c r n excluded a s have those whose cardiac ;rr.rc,lh wc,rc2 n11t d i ~ r t c ~ ~)r im;rry cardiopulrnirnary disease - I . ? . t r ; ~ u r i i ; ~ , clnig ovrrtlose, ('0 poisl~nirlg, drowning, e tc . 01' ~ h o i c ;lrrr>lh d u e t i , proven primary cardic~pulrnonary 11at IioIi~:'.. 27 1 were recrir.r(I iind ninnaged tiv I)(;H. Of t l i i~ ic 1,;llic,llts. 17'( wrr r : ~ d m i l t e d 111 Intensive r a r e lJni ts \villi ;~ccc.l)tal)lr \ iial higns and IS '< survived to tie discharg- ed . Th i s experience cornpares very favorably wi th t h a t of other systerns employing mobile coronary care uni ts util izing either telemetry and/or physicians. These d a t a suggest t h a t conipulsc~ry a t tent ion to t he basic prehospital sys tem is a t least a s important t o resuscitative endeavors a s is current technical sc~phiatication.

5. The Use of Peritoneal Lavage as a Diag- nostic Tool in the Emergency Depart- ment CHRISTINE E. HAYCOCK, M.D. GEORGE MACHIEDO, M.D.

College of Medicine and Dentistry of New Jersey, Martland Hospital Unit, Newark, New Jersey

With the introduction of peritoneal lavage to replace the oulrnotied I'our quadrant needle t a p of the abdominal cavity Ii)r diagnostic purposes, this procedure has heen found to be a n iricreasinyly valuahle tool, hoth in diagnosis and in the f r i > a l l ~ ~ ~ n t 01 patients with conditions such as acute pan- criv~ti t~x. I t ih I)articularly useful in the diagnosis of blunt tra11111a I O the ahdornen with internal injury, and in differen- list 111g between penetrating and non-penetrating wounds of the abdomen. Concurrent to the diagnostic use of the peritoneal dialysis catheter in the Emergency Department, peritoneal lavage has heen used in the treatment of acute pancreatilis based upon enzyme (lactic dehydrogenase, lac- I ; I I ~ . 1)e1;1 gIuc.uro~~idase. and amylase) studies carried out in ~ h c rchc.;ln.l~ la1)oratory. Early results of this technique have I ) ~ U V C ' I I I I I I I S ~ tricouragir~g. '1'0 increase the routine use ofthis 111otl;rlity l)y resitlent staffs, a protocol defining the exact t echn~que to be used was circulated to all surgical and rl~cdical residents in the hospital. A request was made that thib procedure be carried out in acute abdominal cases, and that klwcirller~s be obtained for both diagnosis and research. 1)iagnostic specimens are sent to the hospital laboratory, arid research specimens to the clinical research laboratory. Statistics will he presented to show the results of using this procedure in the Emergency Department, and a s a contin- uoils treatment modality. (Slides illustrating the technique i l l performing the lavage will be shown).

6. Potential Sources of Error in the Use of Peritoneal Lavage as a Diagnostic Tool P. C. BHEEN, M.D. L. E. RUDOLF, M.D.

Department of Surgery, University of Virginia Medical Center, Charlottesville, Virginia

Peritoneal lavage has been of increasing value in the early diagnosis of' intraperitoneal injury. This modality has been particularly helpful in cases of multiple trauma, or when the patient is unahle to cooperate with the examining physician. Notwithstanding the usef'ulness of this technique, there are hcavcral pu~rt i t ial sources of error in its application which I I I ; ~ ~ lead 111 unriecehbary laparotorlly.,A report of a series c~f r r a u ~ ~ ~ a [ ~ a t i c ~ ~ t s who were been in the llniversity of Virginia 1'nlrrgrnc.y 1too111 is presented. In each case, peritoneal I;rv:~gc~ \vas i.n~l)luyetl as a diayrlostic routine. Also presented arc ~ ) u ~ e n ( ~ ; ~ l and real sources of' misinterpretation of this test, partic~i~larl> with regard to falsely positive results. ,Ilclliods ol' ;j\oiding this occurrence are discussed.

7. A Burn Team Looks at Child Abuse P A T H ~ ~ I A S. PHILLIPS, R.N. ELAINE PICKRELL, M.S. W. THOMAS S. MORSE, M.D.

Children's Hospital, Columbus, Ohio

Intentional burning is a severe form of child abuse. The abusers need help, and the children need protection from fi~rther abuse. Many physicians do not know the limits of' their responsibility, and because of ignorance or fear of hecoming entangled, fail to initiate the needed chain of events. 'l'he mortality from repeated abuse is high. Clues to recognition can be found in the history. physical and x-ray examination, and in the hehavior o f t h e parents and child. 'l'hese clues include evidence of old or recent injuries to soft tissues or I~ones, burns which do not fit the history, especial- ly burns of ' the I)uttocks, perineum, feet or hands, contact burns and deep scalds resulting from trapping in hot water. I'arcnts may delay seeking hurn care and give conflicting stories. They rnay describe family strife, a lonely mother, in- ,juries to other children or to themselves when they were children. They may exhibit extremes of concern or in- dil'l'erence. Children are frequently fearful, withdrawn, and undernonstrati~e. Many exhibit delayed emotional or in- tellect.ual cievelopment. There is often a striking lack of tvarn~th between the child and one or both parents. Twentv recent cases of' intentional burning will be reviewed. All il- lustrative cases will be followed through identification and initial reporting. investigation by the hospital Department ol' S ~ ~ c i a l Service. reporting to the Juvenile Bureau of the 1'olic.r I)epartment and to the Children's Services Board, the legal protection agency of the county, court proceedings. coun.ielIirlg ol'the parents and eventual returq of the child to the familv.

8. Accidental Hypothermia: Core Re- warming with Partial Bypass PER WICKSTROM, M.D. ERNEST HCIIZ. M.D. (;. PATRICK LIL.JA, M.D. ,I. PETER HINTEHKOPF, M.D. JOHN .J. HAGLIN, M.D., PH.D.

Departments of Emergency Medicine and Surgery, Hennepin County General Hospital, Minneapolis, Minnesota

Accidental hypotherrnia due t o exposure is not an uncom- mon pmhlem and it can result in a high mortality. Most alrtho1.s now agree that the chance of developing one of the detrimental systemic effects of' hypothermia increases with the duration ol' hypothermia. Three patients with profound 11y1)othermia were treated by rewarming on partial bypass a t Hennepin County (;enera1 Hospital. Two survived and have norrnal mental and metabolic functions. This method of resuh(.~lation is effective and safe and i~ provides circulatory

\ul11~urt in t h e event of' ventricular fibrillation. The resuhcitatio~i of the hypothermic patient should be con- tinued until the patient is completely rewarnled since the outct~me is olten niuch hetter than might be expected from initial vital signs and neurological examination. To avoid ventricular fibrillation. the patient should be handled gent- ly. Blood gases should be measured often and corrected for temperature. An effort should be made to keep the patient wcxll oxygenated and at a normal pH. l i + concentration and hydration status of the patient should also he monitored (.los(.ly. Altrr the resuscitation, pulmonary care should he ernl~hahized.

9. Complications of Subclavian Sticks WILLIAM F. MI'ITY, JR. , M.D. THOMAS NEALON, JR., M.D.

S t . Vincent's Hospital and Medical Center, New York, New York

Important modalities in treating and resuscitating patienth in Emergency Depart ments have been the recording and monitoring of the central venous pressure and the sub- sequent administration of large volumes of fluids via a sub- clavian venotomy. These procedures, usually performed by the younger members of' the house staff under emergency conditions, have carried a significant morbidity at the St . Vincent's Htrspital and Medical ('enter of New York. The major complication recorded was pneurnothorax. In the past I'ive years, sixty cases 01' pneurnot horax have been diagnosed in the Emergencv r)epart rnent as a result of a percutaneous huhclavian puncture for caval cannulation. Another com- pliration seen has been the n~isdirection of the subclavian catheter into areas other than t he superior vena cava. A series 01' radiographs will be denionstrated showing the various Iocat~crns of the misdirected catheters. It is now the 1)u11(.. 01' the Emergency Ilepartment not to allow this ~ o r t h w h ~ l r procedure to IJC done under emergencv con- tiitions 1,. junior members ol' the house staff in the Emergen- cy 1)epartrnent. Il'caval catheter~zation is thought necessary in the Eniergrncv Department, i t has to be performed via a ~reril~heral vein. Otherwise, it must he performed in an in- t r~isive care unit of the hospital or in the ol~erating room un- der sterile conditions I)y more experienced menlhers of the ho~lse htal'l'. This exller~ence is heing reported to show how a tile-saving tec,hnlcjue can quickly develop into a life- t hreaten~ng situatic~n.

10. Ambulance Critique Review DAVID B. PILCHER, M.D.

Department of' Surgery. University of Ver- mont, Burlington, Vermont

I'eer rcv~cw hy anlt~ulance personnel can be best ac- c~rn~l)l i ihed Iry ol)servation I I E actual performance by other mrr~llrerh 01 the health team with immediate critique. 'l'his is ol)viorlhly rarely possit)le. On-scene supervision hy state

ellleryency service coordinators a s well as open exchange of critique and inli~rmation in the Emergency Department dur- ing the [)re-hospital phases of care are sometimes possible. A regularly schetiuled review with regional ambulance per- honnel and Emergency Department personnel can result in a n rilucational experience for the ambulance personnel and ruemt)ers of' the Emergency Department health team. Prerequisite to such critique sessions is an ambulance report forni which lends itself to the critique. This type of report form will be presented. Critique review sessions have been carried out in one ambulance district three times a month lor I tlc past t w ~ ) years. 'l'he pre-hospital phase of care is prescntetl 11y the involved am0ulance personnel and follow- up I.; given hy Erneryencv 1)epartnient physicians and nurse>. (;ivr-antl-take discussion is rriutually beneficial to ; i l l I)rrsvnt and, in I he university hospital, is also educational tor metlical students and housestaff. Examples of recent cr~ricllie session>. a s sent to all ambulance personnel, will he ~)wirntet i . 'I'his has heen a successl'ul forrn of peer review ;lncl has gained illcreasing acceptance hy all concerned. It hhoulti I)e applicable to rural, urban, and university cLliieryc,ncy services.

1 1 . The Emergency Department Record GEORGE R. SCHWARTZ, M.D.

Medical College of Pennsylvania, Philadel- phia, Pennsylvania

Emergency Uepartrnent records serve both medical and administrative needs. Analysis of fifty different Emergency Ilepartment records, frorn university as well as community hospitals. showed significant deficiencies in meeting the 1netlica1 needs. Each record was analyzed for how we11 the lollowing were met:

1 ) Initial triage information. 2) Space for history and phys- ical examination. 3) Test results. 4) Diagnosis. 5) Physi- c i a n ' ~ orders. 6) Treatment. 7) Procedures performed. HJ I'lans and li)llow-up. 9) Nurse's observation. 10) Consul- tation notes. 11) Space for monitoring patients with specific k ~ n d s of' pr~)t)lems. 12) Patient instruction. 13) Ease of review. None of' the records proved to be satisfactory in meeting all the medical needs. In fact, in almost all cases, the roorn for ntlministrative data consumed a dispropor- tionate arnc~unt of available space. Based on this analysis, a rnodcl Emergency Department record was designed. t3ecause of' ~ t s slrnplicity it may have widespread applicabili- t y . or iit least, serve to focus attentionon Emergency Depart- riicnt records which meet physician's as well as ad- rninistrator's requirements.

12. Types of Arterial Trauma WILLIAM E. EVANS, M.D.

Department of Surgery, T h e Ohio S t a t e University Hospital, Columbus, Ohio

Vasculi~r injury to the extremities can be quite variable in terms of' cause, resulting pathology, presentation, and mode

of therapy. In this nonstatistical study, vascular injury of the extremity has been classified as blunt, penetrating, or iatrogenic. 'l'he variations in pathology, presentation, and treatment will be discussed.

13. Teaching Cardiovascular Physiology in the Emergency Room RAE R. .JACOBS, M.D. JAMES S. CARTER, M.D. WIILIAM SOSNOW, M.D. D ~ c l n COBB, M.D.

Ilniversity of' Kansas Medical Center, Kansas City, Kansas

Proper resuscitation of the patient in hypovolemic shock. cardiogenic shock, or septic shock requires an understanding of cardiovascular physiology. Appropriate patients are inter- Saced with an eight-channel monitor and recorder equipped with an ECC. cardiotachometer, two pressure channels, and a cardiovascular analyzer which integrates, differentiates, ~nult i l~l ies , and divides. In addition a cardio-green com- puterized cardiac output unit and a n intravascular PO2 analyzer are used. This allows measurement of heart rate, pulsatile and mean arterial pressure, central venous pres- sure, pulsatile and mean pulmonary artery pressure, dP/dt, dP/dt + P, mean cardiac output, continuous arterial and venous PO,, oxygen delivery, and oxygen consumption. Us- ing a transfemoral pressure-flow catheter and square wave electromagnetic flow meter, it is possible to monitor pul.;atile flow and instantaneo~is vascular impedance (P/Q) along with its integral. A detailed record of infusions, drugs, and clinical response allows an evaluation of the effects of therapy. A slow speed recorder provides a continuous hard copy of the entire resuscitation. A detailed analysis of' the resuscitations at a weekly conference provides a successful learning experience for the student. The patient also benefits from more intelligent therapy based on objective data. Interested nurses, house staff, and 24-hour biomedical elec- tronic technician support make this program possible.

14. Focal Motor Seizures in Patients With Alcoholism HOWARD S. SCHWARTZ, M.D. PHILIP R. YARNELL, M.D. GARY VANDER ARK, M.D.

Department of Emergency Medical Services, T h e Denver Genera l Hospi tal , Denver , Colorado

Alcohol withdrawal seizures have been assumed to be of a generalized nature. Focal seizure activity in an alcoholic has Oeen considered an infrequent manifestation of withdrawal anti, when present, thought to represent significant underly- i n g organic pathology. While post-traumatic injuries have heen firund to cause Socal seizures in 15'; of a non-alcoholic

pol~ulation. previous studies of' focal seizures have not separated nl(~oholics. A focal r~iotor seizure is produced by an electrical discharge in the fiontal lobe cortex. Clinically, this i> n~anil'ested by rnovement in the contralateral extremities, 11ustrrral al)n~)rnralities, or turning toward the opposite direc- tion. 'l'he seizr~re may begin in one area of the motor system anrl trlarch (progressively involve other areas) and may then I~ccotne generalized. In the past two vears, a group of 24 alcr~holi(, patients who experienced one or more focal seizures were sturlied with cerebral arteriography. 0peral)le subdural I r rn~~~rrhage or ernpyerna was found in 1 7 ' ' ~ . In 20'; there was tie~nonstrahle pathology which would not have been an~enable to hurgical correction. Arteric~grams were normal in the remaining 63 '1 . Of this latter group (15 patients), 13 hat1 the onset ol' li~cal seizures within 36 hours of their last drink (the same time frame a s for alcohol withdrawal seizrrres) and five had histories of either past head trauma or previor~s evac.uation of sut)dural hemorrhage. While it may he p o s t ~ ~ l a t e d that these are simple alcohol withdrawal 5eizrrres. there were no clinical distinctions from idiopathic epilepsy or polentiation of an underlying traumatic seizure t'oc.us. 'l'he alcoholic may have focal seizures as part of his withtlrawal complex 1,111 this is a diagnosis of exclusion ahlch requires c,erel~ral arteriography.

15. Development of a New Surgical Tape for Sutureless Wound Closure RICHARD F. EDI.ICH, M.D., PH.D. GEORGE RODEHEAVER, PH.D. MILTON T. EDGERTON, M.D.

Department of Plastic Surgery, University of Virginia Medical Center, Charlottesville, Virginia

The superiority 01' tape for closure of contaminated wounds has been confirmed by experimental studies. Con- taminated wounds closed by tape exhibit significantly less infection than sutured wounds. Despite this demonstrated advantage of tape closure, surgical tapes have not gained wide acceptance chiefly because of difl'iculties encountered in achieving and maintaining a secure closure. Heretofore, the comn~ercially available surgical tapes were susceptible to t~reakage and did not adhere securely to the skin. For these reasons, a surgical tape has been designed specifically for closure c~f contaminated wounds. This tape has a microporous structure which limits bacterial growth (122 f 8 bacteria/in" such as is encountered under the cloth tape (1035 f 9 bacteria/in2). This new microporous tape has an aggressive adhesive tha t ensures adhesion of the t,ape to the skin. The adhesion of this new tape to skin is twofold greater than adhesion of the cloth tape to skin. Reinforcing rayon I'ilaments have been added to the new tape t o prevent tape breakage. The development of the reinforced microporous tape should greatly facilitate sutureless worlnd closure and allow the merits o f th i s technique to be realized by civilian and military surgeons in the care of' the injured patient.

16. Value of the G Suit to Control Hemor- rhagic Shock in Patients with Severe Pelvic Fracture DAIIYI, .J. BATAI.IIEN, M.1). PER H . W I C K S ~ R U M , M.1). ERNEST RII IZ , M . D . RAMON B. GI.S,I.ILO, M.D.

E m e r g e n c y M e d i c i n e a n d O r t h o p e d i c S e r vices. H e n n e p i n C o u n t y Genera l Hospi ta l , Minneapol i s , M i n n e s o t a

Severe hemorrhage and snbsequent fatal shock frequently are present following a massive pelvic fracture. Uncontrolled Illeeding accounts for a significant mortality in this type of Iraunna. 1)uring the past nine rnonths six patients with severe (life t tircatrning) pelvic fracture have been treated a t the Hennc~l~in ('ounty (;enera1 Hospital with applicationof a (; suit shortly al'ter the patient arri~zed in the emergency stal~ilization rr~c~nl hut tollowing initial evaluation. Clinical ohservution indicates an inmediate improvement in blood pressure and c.;rrdiovascular slal~ility as pressure in the in- Il;ltal)le suit is increased to 20 mm of mercury. This simple ;ind inexl~ensive device has provided sustained and satisfac- tory b l o ~ ~ d pressure in several patients where shock ensued, i r i spite ol'rapiil infusion of blood, whenever the pressure was released. Five 111'the initial six patients survived and the G suit W A S i n place for a nlinimum of 24 hours in each case. Sevcariil patients were treated in this manner for 48 hours I'ollo~vi~rg irrJury. Irr a well controlled nretropolitan emergen- cy care ~ ~ r o g r a n r i t is prclposed that the C; suit can he used at t 1 1 ~ scene 01 :in accident by properly trained people resulting in the s ; ~ l v ; l ~ e of lives. I'ossil~le physiologic and anatornic trrcchanislns resj~~rrrsil~le for the imr~rediate improvement in the pat lent on nl)plication of the G suit will be discussed.

17. Emergency Treatment of High Pressure Injection Injuries of the Hand H. .I PARKS. M . D . K 1,. H O R ~ R H . M . D . ( ' I ~11.: TRIMHI,I.:, M.1).

1) rpar t w e n t of E ~ n e r g e n c y M e d i c a l S e r v ~ c e s . ' I ' h r I ) e n \ e r ( i e n e r a l H o s p ~ t a l , D e n v e r , ( 'olorado

( ; ~ E : I S C : ~ n d paint g111r inject ions of' the hand may be ex- trt~irrely s e r i o ~ ~ s . .Al~lrough the chen~ical nature of the in- ,jec,tcd ~i~;r ler ial Ira5 an inlluerrce on the extent of damage, the cril ic, ;11 1':1ctor ill reducing disal~ility and morbidity appears 1 1 1 1 1 ~ ~ Ilrc inlrrviil Irrlnr injury to perat at ion. 'l'he pertinent l'eature of' 1.1 c,;iscs 01' high pressure injection injuries of the hnnti will he presented to emphasize the need for prompt decompressioli 01' the injured part and removal of foreign substance. Only five 1 1 1 ' the 1 1 patients underwent operation within 24 hours o l ' i n j ~ ~ r y . Six patients endured between one

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UA' EMS

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University Association for Emergency Medical Services Post Office Box 1241 East Lansing, Michigan 48823