Trained Emergency Physicians Research Articles

Interobserver agreement in the evaluation of B-lines using bedside ultrasound

PurposeWe evaluated agreement among trained emergency physicians assessing the degree of B-line presence on bedside ultrasound in patients presenting to the emergency department (ED) with acute undifferentiated dyspnea. We also determined which thoracic zones offered the highest level of interobserver reliability for sonographic B-line assessment. Materials and methodsWe evaluated a prospective convenience sample of adult patients presenting with dyspnea to an academic ED. Two consecutive bedside lung ultrasounds were performed on 91 patients by a pair of physician-sonographers. The lung ultrasounds were structured 10-zone thoracic sonograms, documented as videos. Sonographer pairs were expert/expert (>100 lung ultrasounds performed) or expert/novice pairs (novices performed 5 supervised examinations after structured training) and blinded to clinical data. Sonographers reported B-line concentration with 3 assessment methods: (1) normal (<3 B-lines) or abnormal (≥3 B-lines); (2) ordinal (normal, mild, moderate, or severe), and (3) counting B-lines (0-10; >10) in each zone. All statistical analyses were performed using SPSS version 18.0 (Chicago, IL) and Stata 12.1 (College Station, TX). We evaluated interrater and intrarater agreement using Intraclass correlation coefficients (ICCs). ResultsThe right and left anterior/superior lung zones showed substantial agreement in all assessment methods and demonstrated best overall agreement (ICC for right: counting, ordinal, and normal/abnormal, 0.811 [0.714-0.875], 0.875 [0.810-0.917], and 0.729 [0.590-0.821], respectively). Furthermore, both expert/expert pairs and expert/novice pairs showed substantial agreement in the right and left anterior/superior thoracic zones (expert/expert, 0.904 and 0.777, respectively; expert/novice, 0.862, and 0.834, respectively). Second best agreement was found for the lateral/superior lung zones (right: counting, ordinal, and normal/abnormal, 0.744 [0.612-0.831], 0.686 [0.524-0.792], and 0.639 [0.453-0.761], respectively; and ICC left: counting, ordinal, and normal/abnormal, 0.671 [0.501-0.782], 0.615 [0.417-0.746], and 0.720 [0.577-0.815], respectively). When comparing agreement to distinguish “normal vs abnormal” B-line findings, our results showed significant agreement in all zones with the exception of the right and left inferior/lateral lung fields and left posterior lung. Reinterpretation by 2 experts of all their own randomized video clips at a later date showed agreement of 0.697 (n = 733 zones) and 0.647 (n = 266) zones for ordinal assessment of B-line concentration. ConclusionInterrater agreement was best in the anterior/superior thoracic zones followed by the lateral/superior zones for both expert/expert and expert/novice pairs. Agreement in the lateral/inferior lung zones was overall inferior. Intrarater agreement was highest at extreme high or low numbers of B-lines.

Patient Safety Perceptions in Pediatric Out-of-Hospital Emergency Care: Children's Safety Initiative

To characterize emergency medical service (EMS) providers' perceptions of the factors that contribute to safety events and errors in the out-of-hospital emergency care of children. We used a Delphi process to achieve consensus in a national sample of 753 emergency medicine physicians and EMS professionals. Convergence and stability were achieved in 3 rounds, and findings were reviewed and interpreted by a national expert panel. Forty-four (88%) states were represented, and 66% of participants were retained through all 3 rounds. From an initial set of 150 potential contributing factors derived from focus groups and literature, participants achieved consensus on the following leading contributors: airway management, heightened anxiety caring for children, lack of pediatric skill proficiency, lack of experience with pediatric equipment, and family members leading to delays or interference with care. Somewhat unexpectedly, medications and communication were low-ranking concerns. After thematic analysis, the overarching domains were ranked by their relative importance: (1) clinical assessment; (2) training; (3) clinical decision-making; (4) equipment; (5) medications; (6) scene characteristics; and (7) EMS cultural norms. These findings raise considerations for quality improvement and suggest important roles for pediatricians and pediatric emergency physicians in training, medical oversight, and policy development.

The Paul Allan prize for the best paper in Ultrasound.

Many of you will have heard the sad news that Dr Paul Allan died suddenly in January this year, shortly before he was due to retire as Clinical Director of Radiology in Edinburgh. Paul was well known to us through his many publications in ultrasound. He authored many peer-reviewed papers and book chapters and was an editor of several well-known books, including the third edition of Clinical Ultrasound, published in 2011. Paul also made many contributions to the British Medical Ultrasound Society (BMUS), including serving as Honorary Treasurer and then President from 1998 to 2000. He was made an honorary member of BMUS in 2010. For many years, Paul was also an active member of the Shadows Radiological Travelling Club, a club founded in 1946, which meets twice a year at different locations around the UK. In recognition of Paul’s many contributions to the Shadows, the club has offered to sponsor a prize each year for the best paper published in Ultrasound. The prize of £100 will be awarded to the lead author of the best paper published in Ultrasound in each calendar year as judged by BMUS. All authors and categories of paper will be considered and the prize winner will be announced at the BMUS Annual Scientific Meeting. There is no need to apply, but you will need to submit an article via http://mc.manuscriptcentral.com/ult! We begin this August issue of Ultrasound with a research article by Martin et al. on the results of an online survey of transvaginal ultrasound (TVUS) practice in the UK. The survey was publicised through several organisations, including BMUS, and is part of a programme commissioned by the Department of Health aimed at assessing safety and clinical practice in TVUS. The safety of TVUS in early pregnancy scanning is of particular concern as the transducer can be placed close to the fetus, which may then be exposed to heat generated both by ultrasound absorption and by the transducer itself. The survey showed that although most users had a general understanding of thermal and mechanical indices, some were not aware of their meaning or purpose and 40% of respondents rarely or never monitored them during scanning. This article highlights the importance of continued ultrasound safety training and promotion of safety guidelines to users. Purohit and King give a comprehensive review of the use of ultrasound in lower limb sports injuries. This article describes the mechanisms of sports injuries in muscles, tendons and ligaments, followed by well-illustrated descriptions of their ultrasound appearances. This article will be a very useful learning resource for musculoskeletal (MSK) sonographers and is available as a BMUS CPD article via the BMUS website members’ area. Hoskins and Kenwright then review the principles and development of four commercially available ultrasound technologies for vascular applications. Three-dimensional (3D) ultrasound, vector Doppler, wall motion estimation and shear wave elastography have all contributed to the understanding of vascular disease, but it seems they have not been adopted widely into clinical practice. A third review, by Abe et al. studies the literature on morphological and functional relationships of ultrasound measured muscle thickness in the leg. It seems that muscle thickness measurements can be used to predict muscle cross-sectional area and volume in several thigh and lower leg muscles. However, there is little evidence relating muscle function with muscle thickness. A further article in the long running PoCUS series, by Lewis et al. reviews the accuracy of ultrasound in detecting foreign bodies and describes ultrasound techniques for identifying and guiding the removal of various types of foreign body materials. Ultrasound is a cost effective tool for dealing with foreign bodies in the emergency department and can be accurate in the hands of trained emergency physicians. This issue concludes with two case studies. Drought et al. describe the finding of bilateral congenital cataracts in a fetus during a second trimester anomaly scan. They propose that examination of the face and orbits should become a routine part of the fetal anomaly survey, especially where there is a risk of genetic syndromes. Brownfoot et al. describe a rare case of persistent reversed end diastolic flow in the fetal middle cerebral artery. Few such cases have ever been reported and the outcome is normally poor, but this case demonstrates that treatment may be possible if an urgent follow up is made.

Epidemiology of Road Traffic Injuries Treated in a Large Romanian Emergency Department in Tîrgu-Mureş Between 2009 and 2010

Objective: Road traffic injuries are one of the leading causes of preventable unintentional injury. The European Injury Database estimated that in European Union (EU)-27 countries, road traffic injuries account for 10% of all injuries treated in the emergency department or admitted to the hospital, accounting for 4.2 million victims each year. We examined the characteristics and outcomes of road traffic injuries treated in a large emergency department in Romania by different types of road users.Methods: Secondary data analysis was conducted on a sample of patients who suffered a transport-related injury and received care at the Emergency Department of Mures County Emergency Hospital in Romania. Data was collected by 2 trained emergency physicians between March 2009 and July 2010, as part of the European Injury Database project. Information about demographics, mechanism, nature, place of occurrence, and activity of injury; treatment and follow-up; and mode of transport were described for 5 different categories of road users: animal-drawn vehicle (operator and passenger), passenger car (driver and passenger), motorcycle (driver and passenger), bicyclist, and pedestrian.Results: A total of 2,782 patients were treated in the emergency department, of which 718 (25.8%) were road traffic injuries. The male-to-female ratio was 2:1. The highest percentage of patients were injured in passenger cars (49%), followed by motorcycles (16.7%). For both types of road users, the majority of patients were between the ages of 18 and 29. Pedestrian injuries accounted for 14.6%, of which a third were children up to the age of 17 and 40% were adults and elderly over the age of 50. The majority of patients were injured due to contact with a moving object (48.1%), followed by contact with static object (23.5%), then falling, stumbling, jumping, or being pushed (19.6%). Contusion and bruises (54.9%) were the most common diagnosis, followed by fractures (20.1%) and open wounds (10.2%) for all road user categories. The most common part of the body injured for all road user categories was the head region (42.3%). Of the 34.9% patients treated and admitted to the hospital, 30% had a length of stay between 4 and 7 days.Conclusions: Understanding the extent, nature, and characteristics of road traffic injuries may help to identify vulnerable road users in specific settings and implement the most effective prevention strategies targeting the most affected populations.

Incidence of difficult airway situations during prehospital airway management by emergency physicians—A retrospective analysis of 692 consecutive patients

IntroductionIn the prehospital setting, advanced airway management is challenging as it is frequently affected by facial trauma, pharyngeal obstruction or limited access to the patient and/or the patient's airway. Therefore, incidence of prehospital difficult airway management is likely to be higher compared to the in-hospital setting and success rates of advanced airway management range between 80 and 99%. Methods3961 patients treated by an emergency physician in Zurich, Switzerland were included in this retrospective analysis in order to determine the incidence of a difficult airway along with potential circumstantial risk factors like gender, necessity of CPR, NACA score, GCS, use and type of muscle relaxant and use of hypnotic drugs. Results692 patients underwent advanced prehospital airway management. Seven patients were excluded due to incomplete or incongruent documentation, resulting in 685 patients included in the statistical analysis. Difficult intubation was recorded in 22 patients, representing an incidence of a difficult airway of 3.2%. Of these 22 patients, 15 patients were intubated successfully, whereas seven patients (1%) had to be ventilated with a bag valve mask during the whole procedure. ConclusionIn this physician-led service one out of five prehospital patients requires airway management. Incidence of advanced prehospital difficult airway management is 3.2% and eventual success rate is 99%, if performed by trained emergency physicians. A total of 1% of all prehospital intubation attempts failed and alternative airway device was necessary.

Accuracy of bedside emergency physician performed ultrasound in diagnosing different causes of acute abdominal pain: a prospective study

ObjectiveAbdominal pain is a common complaint in the emergency department and accurate diagnosis of its etiology may affect the patient's outcome. MethodPatients with abdominal pain underwent ultrasound study first by trained emergency physicians and then by radiologists blinded to emergency physician's results. ResultEmergency physician who performed bedside ultrasound had 78% diagnostic accuracy. Emergency physicians showed better results in diagnosing some entities (abdominal aortic aneurysm and renal stones) than the others (acute appendicitis, cholelithiasis, and cholecystitis). ConclusionBedside ultrasound can accurately identify the etiology of acute nontraumatic abdominal pain in the hands of emergency physicians.

Knowledge and confidence of a convenience sample of australasian emergency doctors in managing dental emergencies: results of a survey.

Background. We aimed to determine Australasian Specialist Emergency Physicians' and Emergency Physicians in Training (Trainees') level of knowledge of common dental emergencies. We also explored confidence in managing dental emergencies; predictors of confidence and knowledge; and preferences for further dental education. Methods. A questionnaire was distributed electronically (September 2011) and directly (November 2011) to Fellows and Trainees of the Australasian College for Emergency Medicine. It explored demographics, confidence, knowledge of dental emergencies, and educational preferences. Results. Response rate was 13.6% (464/3405) and college members were proportionally represented by region. Fewer than half (186/446; 42%) had received dental training. Sixty-two percent (244/391, 95% CI 57.5–67.1) passed (>50%) a knowledge test. More than 60% incorrectly answered questions on dental fracture, periodontal abscess, tooth eruption dates, and ulcerative gingivitis. Forty percent (166/416) incorrectly answered a question about Ludwig's Angina. Eighty-three percent (360/433) were confident in the pharmacological management of toothache but only 26% (112/434) confident in recognizing periodontal disease. Knowledge was correlated with confidence (r = 0.488). Interactive workshops were preferred by most (386/415, 93%). Conclusions. The knowledge and confidence of Australasian Emergency Physicians and Trainees in managing dental emergencies are varied, yet correlated. Interactive training sessions in dental emergencies are warranted.

Adverse events in patients with return emergency department visits

ObjectivesThis study describes the proportion of emergency department (ED) returns within 7 days due to adverse events, defined as adverse outcomes related to healthcare received.DesignProspective cohort study.SettingWe used an electronically...

Simulation as possible training for palliative emergencies: prospective initial data analysis of participants from two simulation training sessions

Palliative emergencies describe an acute situation in patients with a life-limiting illness. At present defined curricula for prehospital emergency physician training for palliative emergencies are limited. Simulation-based training (SBT) for such palliative emergency situations is an exception both nationally and internationally. This article presents the preparation of recommendations in the training and development of palliative care emergency situations. A selected literature search was performed using PubMed, EMBASE, Medline and the Cochrane database (1990-2013). Reference lists of included articles were checked by two reviewers. Data of the included articles were extracted, evaluated und summarized. In the second phase the participants of two simulated scenarios of palliative emergencies were asked to complete an anonymous 15-item questionnaire. The results of the literature search and the questionnaire-based investigation were compared and recommendations were formulated based on the results. Altogether 30 eligible national and international articles were included. Overall, training curricula in palliative emergencies are currently being developed nationally and internationally but are not yet widely integrated into emergency medical training and education. In the second part of the investigation, 25 participants (9 male, 16 female, 20 physicians and 5 nurses) were included in 4 multiprofessional emergency medical simulation training sessions. The most important interests of the participants were the problems for training and further education concerning palliative emergencies described in the national and international literature. The literature review and the expectations of the participants underlined that the development and characteristics of palliative emergencies will become increasingly more important in outpatient emergency medicine. All participants considered palliative care to be very important concerning the competency for end-of-life decisions in palliative patients. For this reason, special curricula and simulation for dealing with palliative care patients and special treatment decisions in emergency situations seem to be necessary.

The Development of Sustainable Emergency Care in Ghana: Physician, Nursing and Prehospital Care Training Initiatives

BackgroundGhana's first Emergency Medicine residency and nursing training programs were initiated in 2009 and 2010, respectively, at Komfo Anokye Teaching Hospital in the city of Kumasi in association with Kwame Nkrumah University of Science and Technology and the Universities of Michigan and Utah. In addition, the National Ambulance Service was commissioned initially in 2004 and has developed to include both prehospital transport services in all regions of the country and Emergency Medical Technician training. Over a decade of domestic and international partnership has focused on making improvements in emergency care at a variety of institutional levels, culminating in the establishment of comprehensive emergency care training programs. ObjectiveWe describe the history and status of novel postgraduate emergency physician, nurse, and prehospital provider training programs as well as the prospect of creating a board certification process and formal continuing education program for practicing emergency physicians. DiscussionSignificant strides have been made in the development of emergency care and training in Ghana over the last decade, resulting in the first group of Specialist-level emergency physicians as of late 2012, as well as development of accredited emergency nursing curricula and continued expansion of a national Emergency Medical Service. ConclusionThis work represents a significant move toward in-country development of sustainable, interdisciplinary, team-based emergency provider training programs designed to retain skilled health care workers in Ghana and may serve as a model for similar developing nations.

Diagnostic accuracy of ultrasonography for hand bony fractures in paediatric patients

ObjectiveHand fractures are common in childhood, and radiography is the standard diagnostic procedure. US has been used to evaluate bone injuries, mainly in adults for long-bone trauma; there are only...

Emergency physician perspectives on central venous catheterization in the emergency department: a survey-based study.

The objective was to assess clinician experience, training, and attitudes toward central venous catheterization (CVC) in adult emergency department (ED) patients in a health system promoting increased utilization of CVC for severely septic ED patients. The authors surveyed all emergency physicians (EPs) within a 21-hospital integrated health care delivery system that had recently instituted a modified Rivers protocol for providing early goal-directed therapy (EGDT) to patients with severe sepsis or septic shock, including CVC if indicated. This initiative was accompanied by a structured, but optional, systemwide hands-on training for EPs in real-time ultrasound-guided CVC (US CVC). EPs' responses to questions regarding self-reported experience with CVC in the ED are reported. Data included frequency of CVC (by type) and US CVC training opportunities: both during and after residency and informal ("on-the-job training involving actual ED patients under the oversight of someone more experienced than yourself") and formal ("off-the-job training not involving actual ED patients"). The survey also asked respondents to report their comfort levels with different types of CVC as well as their agreement with possible barriers (philosophical, time-related, equipment-related, and complication-related) to CVC in the ED. Multivariable ordinal logistic regression was used to identify provider characteristics and responses associated with higher yearly CVC volumes. The survey response rate among eligible participants was 365 of 465 (78%). Overall, 154 of 365 (42%) respondents reported performing 11 or more CVCs a year, while 46 of 365 (13%) reported doing two or fewer. Concerning CVC techniques, 271 of 358 (76%) of respondents reported being comfortable with the internal jugular approach with US guidance, compared to 200 of 345 (58%) with the subclavian approach without US. Training rates were reported as 1) in residency, formal 167 of 358 (47%) and informal 189 of 364 (52%); and 2) postresidency, formal 236 of 359 (66%) and informal 260 of 365 (71%). The most commonly self-reported barriers to CVC were procedural time (56%) and complication risk (61%). After multivariate adjustment, the following were significantly associated with greater self-reported CVC use (p < 0.01): 1) informal bedside CVC training after residency, 2) male sex, 3) disagreement with complication-related barrier questions, and 4) self-reported comfort with placing US-guided internal jugular catheters. In this cross-sectional survey-based study, EPs reported varying experience with CVC in the ED and reported high comfort with the US CVC technique. Postresidency informal training experience, male sex, negative responses to complication-related barrier questions, and comfort with placing US-guided internal jugular catheters were associated with yearly CVC volume. These results suggest that higher rates of CVC in eligible patients might be achieved by informal training programs in US and/or by disseminating existing evidence about the low risk of complications associated with the procedure.

Validation of a Script Concordance Test Combined with ECG during an Emergency Medicine Clerkship Rotation

One of the emergency physician's challenges is to think, to act, and to treat patients with a high level of uncertainty (for instance: incomplete past history of the patient, life-threatening decisions with poor clinical information). In recent years, Script Concordance Tests (SCTs) are increasingly used by educators to assess clinical reasoning, especially in situations of uncertainty. They compare the responses of examinees (students, trainees, or residents) with those of a panel of experts (PE). The examinee's answers are scored based on the level of agreement with responses provided by a PE. In recent years, teachers in Emergency Medicine (EM) also use SCTs. In emergency situations, the interpretation of an electrocardiogram (ECG), which is a commonly performed test, encounters a certain level of uncertainty. A last point could not be forgotten: according to the recent literature, the training of future emergency physicians remains challenging. Facing these three corner stones (uncertainty among emergency situations, uncertainty among ECG's interpretation, and challenge in training), the authors decided to construct and validate an SCT combined with an ECG (SCT-ECG) by submitting it to students, trainees, and residents during their emergency medicine clerkship rotation.

Treatment Costs of Traffic Accident Casualties in a Third-level Hospital in Iran; a Preliminary Study.

The costs of traffic accidents in low- and middle-income countries are estimated to add up to $65 billion annually, which is a little higher than the amount they receive as a final aid for development. The present retrospective study aims to evaluate the treatment costs of the hospitalized injured individuals in traffic accidents. The present study was carried out in Imam Hossein Hospital, Tehran, Iran. The study population consisted of all the individuals injured in traffic accidents, admitted to the hospital wards. Data were collected by a trained emergency physician. Demographic data, injury mechanism, the type of vehicle, the admission ward of the patient, and treatment costs were collected. 200 patient files were evaluated (males: 89%). The results showed that 54% of the patients were in the 18-40-year age group and collisions between cars and motorcycles were the most frequent accidents (47%). The mean hospitalization cost for each patient was estimated to be $1622.1. Statistical analyses showed that treatment costs in the neurosurgery ward was significantly higher than orthopedic and general surgery (df: 3; F=9.5, P=0.008). The results of the present study showed that the mean cost of each traffic accident victim in Tehran is approximately $1622.1 and these patients sustain significantly higher costs in neurosurgery ward.

The Training and Performance of Emergency Physicians as Anesthetists for International Medical Surgical Response Teams: The Emergency Physician’s General Anesthesia Syllabus (EP GAS)

Background: The availability of an anesthesiologist is often a limiting factor in the number of operations that can be performed by International Medical Surgical Response Teams (IMSuRT). Because emergency physicians (EPs) possess skills in airway control, management of moderate and deep sedation, and ventilator management, we propose that with proper training in general anesthesia, EPs can serve as anesthetists for IMSuRT with anesthesiologist supervision. Methods: During a 10-week period, a board-certified EP administered general anesthesia to 60 patients prior to a surgical medical mission trip. The breakdown of surgical cases was: 11 orthopedic, 2 genitourinary, 20 ear, nose, and throat, 8 obstetrics and gynecological, 13 general surgery, and 6 vascular. A simplified protocol for induction, maintenance, and emergence was adhered to for all cases. Results: Fourteen orthopedic cases using general anesthesia were performed in a one-week period in Haiti. These cases involved open reduction and internal fixation (ORIF), hemiarthoplasty, hardware removal, tendon transfer and external fixation of fractured bone. Conclusion: We demonstrate the feasibility of a model curriculum to train EPs in the basics of anesthesia. The EP can safely and effectively deliver general anesthesia for major cases on surgical medical mission trips under the auspices of an anesthesiologist in an austere environment.

Mock Court: A Novel Curriculum Element to Teach Chart Review, Improved Care, and Better Documentation

Chart review and morbidity and mortality conferences are important opportunities for interactive reflection in residency training. These activities allow for reflection on quality of care, systems-level delivery of care, and quality of documentation. Such concepts are critical to the training of future emergency physicians.

Performance comparison of lung ultrasound and chest x-ray for the diagnosis of pneumonia in the ED

ObjectiveThe aim of our study was to assess the potential of bedside lung ultrasound examination by the attending emergency physician in the diagnosis of acute pneumonia. Material and MethodsThis observational single-center study was conducted between January 2010 and June 2012 in the emergency unit of a general hospital, and analyzed 144 adult patients. The ultrasound examination was performed by one of five trained emergency physicians, and a chest radiograph interpreted by a radiologist. The primary end point was the diagnosis of hospital discharge. ResultsWe found a sensitivity of 0.95 for the ultrasound examination against 0.6 for radiography (P < .05). The negative predictive value was 0.67 against 0.25 for radiography (P < .05). ConclusionThese results exhort to promote the use of thoracic ultrasound in the first-line diagnosis of pneumonia.

Emergency medicine in Egypt: Current situation and future prospects

Introduction Emergency medicine is in the early development phase in Egypt. It was first registered in 2001 and although there are about 250 physicians finished their training in the specialty, less than 20 still work in Egypt and others moved to work through the world, mainly to Arab Gulf region. There is not a specialty society in emergency medicine, although there is an Egyptian Society of Intensive Care Medicine and Trauma (ESICT) with an interest in emergency medicine. Emergency care The Emergency Medical Services Department of the Ministry of Health (MOH) is involved in the pre-hospital aspects of emergency medicine. Over the past three years, the MOH has acquired approximately 1200 new full equipped ambulances greatly expanding its pre-hospital capabilities and response. This service provider through basic life support practitioners. In the meantime, personnel within the MOH continue to provide Hospital Emergency departments through the country with new equipment and episodic short training programs for staff in the care of trauma patients and cardiac life support. Emergency medicine training programs The Egyptian specialty board is a 4year formal training program is considered the leader institute in emergency medicine training in Egypt which started early of 2001 with more than 200 graduates until now. The most disadvantage of the program is lacking of specialist trainers and it mainly depends on skilled personnel from other specialities in each hospital, most of them are unaware of the specialty curriculum and updated guidelines in Emergency medicine. There are three university hospitals give academic master degree in Emergency medicine but they are away behind the basic training requirements although they have good approved curriculum did not come to real practice yet. The future Although Egypt was one of the first countries outside USA which considered Emergency medicine as specialty, immigration of trained Emergency physicians, leaving the positions for unqualified personnel from other specialities and lacking of resources had affected the specialty badly. For Emergency to move forward, we should depend on specialists to build the emergency society with annual international conference and local policies and guidelines and outreach programs to rural and borders regions.

Surgical Critical Care Training for Emergency Physicians: Curriculum Recommendations

Received March 16, 2013; Revised May 28, 2013; Accepted May 2 From the Departments of Critical Care Medicine (Tisherman, Surgery (Tisherman), and Emergency Medicine (Emlet), University burgh, Pittsburgh, PA, Department of Surgery, University of M Ann Arbor, MI (Alam), Department of Surgery, University of M Baltimore, MD (Chiu), Department of Acute Care Surgery, So Hospital/Northshore LIJ Trauma Network, Bay Shore, NY (Gro Department of Surgery, Loyola University, Maywood, IL (Lu Departments of Emergency Medicine and Neurology, Yale U New Haven, CT (Marcolini), and Departments of Surgery and Em Medicine, Virginia Commonwealth University, Richmon (Mayglothling). Correspondence address: Samuel A Tisherman, MD, FACS, Department of Critical Care Medicine, University of Pittsburg 1215, Lillian S Kaufmann Bldg, 3471 Fifth Ave, Pittsburgh, PA email: tishermansa@upmc.edu

Erfolgreiche präklinische Thorakotomie bei einem 17-jährigen Mann

We report the case of a 17-year-old man who sustained multiple stab wounds after a knife attack. After arrival of the emergency medical team the patient suffered a cardiac arrest caused by cardiac tamponade. After emergency thoracotomy and open heart massage the patient developed ROSC and could be discharged 13 days later without neurological deficits. Prehospital thoracotomy is rarely performed in Austria but is the only realistic chance for survival in cases of hematopericardium and tamponade. Better training of emergency physicians in Austria concerning surgical resuscitation could increase survival rates especially after penetrating thoracic trauma.