This clinical policy from the American College of Emergency Physicians is a revision of the 2010 "Clinical Policy: Critical Issues in the Evaluation and Management of Emergency Department Patients With Suspected Appendicitis." A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the following clinical questions: 1) in ED patients with possible acute appendicitis, can a clinical prediction rule be used to identify patients for whom no advanced imaging is required? 2) in ED patients with suspected acute appendicitis, is the diagnostic accuracy of ultrasound comparable with computed tomography or magnetic resonance imaging for the diagnosis of acute appendicitis? 3) in ED patients who are undergoing computed tomography of the abdomen and pelvis for suspected acute appendicitis, does the addition of contrast improve diagnostic accuracy? Evidence was graded, and recommendations were made based on the strength of the available data.

OBJECTIVES:Plain chest x-ray (CXR) is often the initial screening test to identify pneumothoraces in trauma patients. Computed tomography (CT) scans can identify pneumothoraces not seen on CXR ("occult pneumothoraces"), but the clinical importance of these radiographically occult pneumothoraces in children is not well understood. The objectives of this study were to determine the proportion of occult pneumothoraces in injured children and the rate of treatment with tube thoracostomy among these children.METHODS:This was a planned substudy from a large prospective multicenter observational cohort study of children younger than 18 years old evaluated in emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network (PECARN) for blunt torso trauma from May 2007 to January 2010. Children with CXRs as part of their trauma evaluations were included for analysis. The faculty radiologist interpretations of the CXRs and any subsequent imaging studies, including CT scans, were reviewed for the absence or presence of pneumothoraces. An "occult pneumothorax" was defined as a pneumothorax that was not identified on CXR, but was subsequently demonstrated on cervical, chest, or abdominal CT scan. Rates of pneumothoraces and placement of tube thoracostomies and rate differences with 95% confidence intervals (CIs) were calculated.RESULTS:Of 12,044 enrolled in the parent study, 8,020 (67%) children (median age=11.3 years, interquartile range [IQR]=5.3 to 15.2 years) underwent CXRs in the ED, and these children make up the study population. Among these children, 4,276 had abdominal CT scans performed within 24 hours. A total of 372 of 8,020 children (4.6%; 95% CI=4.2% to 5.1%) had pneumothoraces identified by CXR and/or CT. The CXRs visualized pneumothoraces in 148 patients (1.8%; 95% CI=1.6% to 2.2%), including one false-positive pneumothorax, which was identified on CXR, but was not demonstrated on CT. Occult pneumothoraces were present in 224 of 372 (60.2%; 95% CI=55.0% to 65.2%) children with pneumothoraces. Tube thoracostomies were performed in 85 of 148 (57.4%; 95% CI=49.0% to 65.5%) children with pneumothoraces on CXR and in 35 of 224 (15.6%; 95% CI=11.1% to 21.1%) children with occult pneumothoraces (rate difference=-41.8%; 95% CI=-50.8 to -32.3%).CONCLUSIONS:In pediatric patients with blunt torso trauma, pneumothoraces are uncommon, and most are not identified on the ED CXR. Nearly half of pneumothoraces, and most occult pneumothoraces, are managed without tube thoracostomy. Observation, including in children requiring endotracheal intubation, should be strongly considered during the initial management of children with occult pneumothoraces.

Study objective: We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma.Methods: This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention.Results: Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% Cl 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% Cl 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% Cl 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% Cl 99.7% to 99.9%).Conclusion: In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.

OBJECTIVESThe objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma.METHODSThis was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement.RESULTSA total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation.CONCLUSIONSObservers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.

Introduction: Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.Methods: We surveyed pediatric and general emergency physicians (EP), pediatric neurosurgeons (PNSurg), general neurosurgeons (GNSurg), pediatric surgeons (PSurg) and trauma surgeons regarding care of two hypothetical patients: Case 1: a 9-year-old who fell 10 feet and Case 2: an 11-month-old who fell 5 feet. We presented various CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis adjusting for hospital and ED characteristics and clinician experience. Pediatric EPs served as the reference group.Results: Of 2,341 eligible surveyed, 715 (31%) responded. Most would discharge children with linear skull fractures (Case 1, 71%; Case 2, 62%). Neurosurgeons were more likely to discharge children with small subarachnoid hemorrhages (Case 1 PNSurg OR 6.87, 95% CI 3.60, 13.10; GNSurg OR 6.54, 95% CI 2.38, 17.98; Case 2 PNSurg OR 5.38, 95% CI 2.64, 10.99; GNSurg OR 6.07, 95% CI 2.08, 17.76). PSurg were least likely to discharge children with any CT finding, even linear skull fractures (Case 1 OR 0.14, 95% CI 0.08, 0.23; Case 2 OR 0.18, 95% CI 0.11, 0.30). Few respondents (< 6%) would discharge children with small intraventricular, subdural, or epidural bleeds.Conclusion: Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.

Emergency medicine (EM) is the only medical specialty that has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of six organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project; the American College of Emergency Physicians (ACEP); the Council of Emergency Medicine Residency Directors (CORD); the Emergency Medicine Residents’ Association (EMRA); the Residency Review Committee for Emergency Medicine (RRC-EM); and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department (ED) visits and several expert panels.1 The resulting product was first published in 20012,3 and has successfully served as the common source document for all EM organizations. One of its strengths is incorporating the reality that EM is a specialty driven by symptoms, not diagnoses, requiring simultaneous therapeutic and diagnostic interventions. The task force that developed the EM Model recommended that a new task force, composed of representatives from all six organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of EM, to consider alterations to the EM Model suggested by the collaborating organizations, and to recommend changes to the six sponsoring organizations. The initial 2-year review occurred in 2003, with representatives from each of the six organizations suggesting changes and reporting how their respective organizations had used the document. This initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005.4,5 Subsequently, a task force met every 2 years, to review the EM Model and make suggested changes.6–9 This article provides a brief review of the original EM Model, a listing of the conditions and components that include the changes made before and during the 2007 review, a summary of the changes made to it as a result of the 2009 review conducted by the current task force, and an update on current uses of the EM Model by the six collaborating EM organizations. The EM Model is a three-dimensional description of EM clinical practice. The three dimensions are patient acuity, physician tasks, and the listing of conditions and components. All of these dimensions are interrelated and employed concurrently by a physician when providing patient care. The EM physician’s initial approach is determined by the acuity of the patient’s presentation. While assessing the patient, the physician completes a series of tasks collecting information. Through this process, the physician is able to select the most likely etiology of the patient’s problem from the listing of the conditions and components. Through simultaneous application of all three components, the physician is able to arrive at the most probable diagnosis and implement a treatment plan for the patient. Hence, the three dimensions of the EM Model are interrelated and applied concurrently in the practice of EM. The three dimensions, as revised in 2005, are included in Tables 1–4. The Accreditation Council for Graduate Medical Education (ACGME) is implementing the ACGME Outcome Project to assure that physicians are appropriately trained in the knowledge and skills of their specialties. The ACGME has identified six general (core) competencies thought to be essential for any practicing physician: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and systems-based practice. The six general competencies are an integral part of the practice of EM and are embedded in the EM Model.10,11 The EM Model is designed for use as the core document for the specialty. It will provide the foundation for developing medical school and residency curricula, certification examination specifications, continuing education objectives, research agendas, residency program review requirements, and other documents necessary for the definition, skills acquisition, assessment, and practice of the specialty. In conjunction with the EM Model, these six general competencies construct a framework for evaluation of physician performance and curriculum design to further refine and improve the education and training of competent emergency physicians. The six competencies and the Model also form the core of ABEM’s maintenance of certification program, Emergency Medicine Continuous Certification (EMCC; for further information on the EMCC program see ABEM’s website, http://www.abem.org. The 2009 EM Model review task force met to consider changes based on feedback received from the six collaborating organizations. Each organization was asked to comment on how it was using the Model and to recommend changes in the document that would address any perceived deficiencies. Table 5 lists the changes recommended by the 2009 EM Model Review Task Force and accepted by the six organizations. The ABEM uses the EM Model to define its test and examination specifications. Each question or structured case used in any ABEM examination is referenced to the EM Model. Every test and examination that ABEM develops is based on a blueprint derived directly from the EM Model. It also uses the conditions and components section to structure the lifelong learning and self-assessment component of its EMCC program. The ACEP uses the EM Model primarily as the basis for its educational activities. In addition, the ACEP Academic Affairs Committee used the EM Model to survey EM residency program directors and recent residency graduates to identify curricula gaps and educational needs. This information has been used to develop a comprehensive list of Web-based educational resources that can be incorporated into residency curricula. The integration of the competencies in the EM Model meets the program requirements of the RRC-EM that the six core competencies are included in residency training. The EM Model is a major tool for CORD and EM program faculty to use when integrating the competencies into the training, residency curricula, and evaluation of residents. In summary, the EM Model is accomplishing the intended purposes for which it was developed. The 2009 review of the EM Model resulted in only minor changes and clarifications (see Table 5). Several EM organizations are using the EM Model to support the ongoing development of the specialty of EM. The complete updated 2009 EM Model can be found on the websites of each of the six collaborating organizations.

[Ann Emerg Med. 2011;57:e1-e15.]OverviewEmergency medicine is the only medical specialty that has a scientifically derived and commonly accepted description of the domain of its clinical practice. That document, The Model of the Clinical Practice of Emergency Medicine (EM Model), was developed through the collaboration of 6 organizations: the American Board of Emergency Medicine (ABEM), the administrative organization for the project, the American College of Emergency Physicians (ACEP), the Council of Emergency Medicine Residency Directors (CORD), the Emergency Medicine Residents' Association (EMRA), the Residency Review Committee for Emergency Medicine (RRC-EM), and the Society for Academic Emergency Medicine (SAEM). Development of the EM Model was based on an extensive practice analysis of the specialty. The practice analysis relied on both empiric data gathered from actual emergency department visits and several expert panels.1Hockberger R.S. LaDuca A. Orr N.A. et al.Creating the model of a clinical practice: the case of emergency medicine.Acad Emerg Med. 2003; 10: 161-168Crossref PubMed Google Scholar The resulting product was first published in 20012Core Content Task Force IIThe model of the clinical practice of emergency medicine.Ann Emerg Med. 2001; 37: 745-770Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar, 3Core Content Task Force IIThe model of the clinical practice of emergency medicine.Acad Emerg Med. 2001; 8: 660-681Crossref PubMed Scopus (37) Google Scholar and has successfully served as the common source document for all emergency medicine organizations. One of its strengths is incorporating the reality that emergency medicine is a specialty driven by symptoms, not diagnoses, requiring simultaneous therapeutic and diagnostic interventions.The task force that developed the EM Model recommended that a new task force, composed of representatives from all 6 organizations, be formed every 2 years to assess the success of the document in accomplishing its objective of supporting the ongoing development of the specialty of emergency medicine, to consider alterations to the EM Model suggested by the collaborating organizations, and to recommend changes to the 6 sponsoring organizations.The initial 2-year review occurred in 2003, with representatives from each of the 6 organizations suggesting changes and reporting how their respective organizations had used the document. This initial 2-year update was published in Annals of Emergency Medicine and Academic Emergency Medicine in 2005.4Hockberger R.S. Binder L.S. Chisholm C.D. et al.The model of the clinical practice of emergency medicine: a 2-year update.Ann Emerg Med. 2005; 45: 659-674Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 5Hockberger R.S. Binder L.S. Chisholm C.D. et al.The model of the clinical practice of emergency medicine: a 2-year update.Acad Emerg Med. 2005; 12: 543-558Crossref Google Scholar Subsequently, a task force met every 2 years to review the EM Model and make suggested changes.6Thomas H.A. Binder L.S. Chapman D.M. et al.The 2003 model of the clinical practice of emergency medicine: the 2005 update.Ann Emerg Med. 2006; 48: e1-e17Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 7Thomas H.A. Binder L.S. Chapman D.M. et al.The 2003 model of the clinical practice of emergency medicine: the 2005 update.Acad Emerg Med. 2006; 13: 1070-1073Crossref PubMed Scopus (22) Google Scholar, 8Thomas H.A. Beeson M.S. Binder L.S. et al.The 2005 model of the clinical practice of emergency medicine: the 2007 update.Acad Emerg Med. 2008; 16: 776-779Crossref Scopus (28) Google Scholar, 9Thomas H.A. Beeson M.S. Binder L.S. et al.The 2005 model of the clinical practice of emergency medicine: the 2007 update.Ann Emerg Med. 2008; 52: e1-e17Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar This article provides a brief review of the original EM Model, a listing of the conditions and components that include the changes made before and during the 2007 review, a summary of the changes made to it as a result of the 2009 review conducted by the current task force, and an update on current uses of the EM Model by the 6 collaborating EM organizations.The EM ModelThe EM Model is a 3-dimensional description of emergency medicine clinical practice. The 3 dimensions are patient acuity, physician tasks, and the listing of conditions and components. All of these dimensions are interrelated and used concurrently by a physician when providing patient care. The emergency physician's initial approach is determined by the acuity of the patient's presentation. While assessing the patient, the physician completes a series of tasks, collecting information. Through this process, the physician is able to select the most likely cause of the patient's problem from the listing of the conditions and components. Through simultaneous application of all 3 components, the physician is able to arrive at the most probable diagnosis and implement a treatment plan for the patient. Hence, the 3 dimensions of the EM Model are interrelated and applied concurrently in the practice of emergency medicine. The 3 dimensions, as revised in 2007, are included in Table 1, Table 2, Table 3, Table 4.Table 1Matrix of physician tasks by patient acuity.Physician TasksPatient AcuityCriticalEmergentLower AcuityPre-hospital careEmergency stabilizationPerformance of focused history and physical examinationModifying factorsProfessional issuesDiagnostic studiesDiagnosisTherapeutic interventionsPharmacotherapyObservation and reassessmentConsultation and dispositionPrevention and educationDocumentationMultitasking and team management Open table in a new tab Table 2Patient acuity definitions.CriticalEmergentLower AcuityPatient presents with symptoms of a life-threatening illness or injury with a high probability of mortality if immediate intervention is not begun to prevent further airway, respiratory, hemodynamic, and/or neurologic instability.Patient presents with symptoms of an illness or injury that may progress in severity or result in complications with a high probability for morbidity if treatment is not begun quickly.Patient presents with symptoms of an illness or injury that have a low probability of progression to more serious disease or development of complications. Open table in a new tab Table 3Physician task definitions.Pre-hospital careParticipate actively in pre-hospital care; provide direct patient care or online or offline medical direction or interact with pre-hospital medical providers; assimilate information from pre-hospital care into the assessment and management of the patient.Emergency stabilizationConduct primary assessment and take appropriate steps to stabilize and treat patients.Performance of focused history and physical examinationCommunicate effectively to interpret and evaluate the patient's symptoms and history; identify pertinent risk factors in the patient's history; provide a focused evaluation; interpret the patient's appearance, vital signs and condition; recognize pertinent physical findings; perform techniques required for conducting the examination.Modifying factorsRecognize age, sex, ethnicity, barriers to communication, socioeconomic status, underlying disease, and other factors that may affect patient management.Professional and legal issuesUnderstand and apply principles of professionalism, ethics, and legal concepts pertinent to patient management.Diagnostic studiesSelect and perform the most appropriate diagnostic studies and interpret the results, eg, ECG, emergency ultrasonography, and laboratory tests.DiagnosisDevelop a differential diagnosis and establish the most likely diagnoses in light of the history, physical, interventions, and test results.Therapeutic interventionsPerform procedures and nonpharmacologic therapies, and counsel.PharmacotherapySelect appropriate pharmacotherapy, recognize pharmacokinetic properties, and anticipate drug interactions and adverse effects.Observation and reassessmentEvaluate and reevaluate the effectiveness of a patient's treatment or therapy, including addressing complications and potential errors; monitor, observe, manage, and maintain the stability of one or more patients who are at different stages in their evaluations.Consultation and dispositionCollaborate with physicians and other professionals to evaluate and treat patients, arrange appropriate placement and transfer if necessary, formulate a follow-up plan, and communicate effectively with patients, family, and involved health care members.Prevention and educationApply epidemiologic information to patients at risk; conduct patient education; select appropriate disease and injury prevention techniques.DocumentationCommunicate patient care information in a concise manner that facilitates quality care and coding.Multitasking and team managementPrioritize multiple patients in the emergency department to provide optimal patient care; interact, coordinate, educate, and supervise all members of the patient management team; utilize appropriate hospital resources; have familiarity with disaster management. Open table in a new tab Table 4Listing of conditions and components.1.0 Signs, Symptoms, and PresentationsCriticalEmergentLower Acuity1.1 General Altered mental statusXX AnxietyX ApneaX AtaxiaXX Back painXXX BleedingXXX ComaX ConfusionX Crying/fussinessXX CyanosisX Decreased level of consciousnessXX DehydrationXX DizzinessXX EdemaXX Failure to thriveXX FatigueXX Feeding problemsX FeverXXX HypotensionXX JaundiceX Joint pain/swellingXX LimpXX LymphadenopathyX MalaiseXX Multiple traumaXX Needle stickXX PainXXX ParalysisXX Paresthesia/dysesthesiaXX PoisoningXXX PruritusXX RashXXX ShockX SIDS (See 3.1)X Sleeping problemsX SyncopeXXX TremorXX WeaknessXX Weight lossXX1.2 Abdominal Abnormal vaginal bleedingXXX AnuriaX AscitesXX ColicXX ConstipationX CrampsXX DiarrheaXX DysmenorrheaX DysuriaX HematemesisXX HematocheziaXXX HematuriaXX Nausea/vomitingXX PainXXX Pelvic painXXX PeritonitisXX Rectal bleedingXXX Rectal painXX Urinary incontinenceX Urinary retentionX1.3 Chest Chest painXXX CoughXX DyspneaXX HemoptysisXX HiccupX PalpitationsXXX Shortness of breathXX TachycardiaXX WheezingXX1.4 Head and Neck CongestionX DiplopiaX DysphagiaXX Eye painXX Headache (See 12.3)XXX Loss of hearingX Loss of visionX RhinorrheaX Sore throatXX StridorXX TinnitusX VertigoXX2.0 Abdominal and Gastrointestinal DisordersCriticalEmergentLower Acuity2.1 Abdominal Wall HerniasXX2.2 Esophagus Infectious disorders Candida (See 4.4, 7.5)XX Inflammatory disorders EsophagitisXX Gastroesophageal reflux (GERD)X Toxic effects of caustic (See 17.1) AcidXX AlkaliXX Motor abnormalities SpasmsX Structural disorders Boerhaave's syndromeXX DiverticulaXX Foreign bodyX HerniasXX Mallory-Weiss syndromeXX Stricture and stenosisXX Tracheoesophageal fistulaXX VaricesXX TumorsXX2.3 Liver CirrhosisXX AlcoholicXX Biliary obstructiveX Drug-inducedXX Hepatorenal failureXX Infectious disordersXX AbscessX Hepatitis AcuteXX ChronicX TumorsXX2.4 Gall Bladder and Biliary Tract CholangitisXX CholecystitisX Cholelithiasis/choledocholithiasisXX TumorsXX2.5 Pancreas PancreatitisXX TumorsXX2.6 Peritoneum Spontaneous bacterial peritonitisXX2.7 Stomach Infectious disordersX Inflammatory disorders GastritisXX Peptic ulcer diseaseXX HemorrhageXX PerforationXX Structural disorders Congenital hypertrophic pyloric stenosisX Foreign bodyXX TumorsXX2.8 Small Bowel Infectious disordersXX Inflammatory disorders Regional enteritis/Crohn's diseaseXX Motor abnormalities ObstructionX Paralytic ileusX Structural disorders Aortoenteric fistulaX Congenital anomaliesXX Intestinal malabsorptionXX Meckel's diverticulumXX TumorsXX Vascular insufficiencyXX2.9 Large Bowel Infectious disorders Antibiotic associatedX BacterialXX ParasiticXX ViralXX Inflammatory disorders Acute appendicitisX Necrotizing enterocolitis (NEC)XX Radiation colitisX Ulcerative colitisXX Motor abnormalities Hirschsprung's diseaseXX Irritable bowelX ObstructionX Structural disorders Congenital anomaliesXX DiverticulaXX IntussusceptionXX VolvulusXX TumorsXX2.10 Rectum and Anus Infectious disorders Perianal/anal abscessXX Perirectal abscessX Pilonidal cyst and abscessXX Inflammatory disorders ProctitisX Structural disorders Anal fissureX Anal fistulaXX Congenital anomaliesX Foreign bodyXX HemorrhoidsX Rectal prolapseX TumorsXX2.11 SpleenXXX3.0 Cardiovascular DisordersCriticalEmergentLower Acuity3.1 Cardiopulmonary ArrestX SIDS (See 1.1)X3.2 Congenital Abnormalities of the Cardiovascular System Disorders due to anatomic anomaliesXXX Genetically transmitted disordersXXX3.3 Disorders of Circulation Arterial AneurysmXXX Aortic dissectionX ThromboembolismXX Venous Thromboembolism (See 16.6)XX3.4 Disturbances of Cardiac Rhythm Cardiac dysrhythmiasXXX VentricularXX SupraventricularXXX Conduction disordersXXX3.5 Diseases of the Myocardium, Acquired Cardiac failureXX Cor pulmonaleXX High outputXX Low outputXX CardiomyopathyXXX HypertrophicXXX Congestive heart failureXX Coronary syndromesXX Ischemic heart diseaseXX Myocardial infarctionXX MyocarditisXXX Ventricular aneurysmXXX3.6 Diseases of the Pericardium Pericardial tamponade (See 18.1)XX PericarditisXX3.7 EndocarditisXX3.8 HypertensionXXX3.9 TumorsXX3.10 Valvular DisordersXXX4.0 Cutaneous DisordersCriticalEmergentLower Acuity4.1 Cancers of the Skin Basal cellX Kaposi's sarcomaX MelanomaX Squamous cellX4.2 Decubitus UlcerXX4.3 Dermatitis AtopicX ContactX EczemaX PsoriasisX Sebaceous cystX SeborrheaX4.4 Infections Bacterial AbscessXX CellulitisXX ErysipelasX ImpetigoX Necrotizing infectionXX Fungal Candida (See 2.2, 7.5)X TineaX Parasitic Pediculosis infestationX ScabiesX Viral Aphthous ulcersX Erythema infectiosumX Herpes simplex (See 10.6, 13.1)X Herpes zoster (See 10.6)XX Human papillomavirus (HPV) (See 13.1)X Molluscum contagiosumX WartsX4.5 Maculopapular Lesions Erythema multiformeXX Erythema nodosumX Henoch-Schönlein purpura (HSP)X Pityriasis roseaX PurpuraXX UrticariaXX4.6 Papular/Nodular Lesions Hemangioma/lymphangiomaX LipomaX4.7 Vesicular/Bullous Lesions PemphigusX Staphylococcal scalded skin syndromeXX Stevens-Johnson syndromeXX Toxic epidermal necrolysisXX5.0 Endocrine, Metabolic, and Nutritional DisordersCriticalEmergentLower Acuity5.1 Acid-Base Disturbances Metabolic or respiratory AcidosisXX AlkalosisXXX Mixed acid-base balance disorderXX5.2 Adrenal Disease Corticoadrenal insufficiencyXX Cushing's syndromeXX5.3 Fluid and Electrolyte Disturbances Calcium metabolismXXX Fluid overload/volume depletionXX Hyperkalemia/hypokalemiaXXX Hypernatremia/hyponatremiaXXX Magnesium metabolismXX Phosphorus metabolismXX5.4 Glucose Metabolism Diabetes mellitus Type IXXX Type IIXX Complications in glucose metabolism Diabetic ketoacidosis (DKA)XX HyperglycemiaXX Hyperosmolar comaXX HypoglycemiaXX SystemicXX5.5 Nutritional Disorders Vitamin deficienciesX Vitamin excessX Wernicke-Korsakoff syndromeX5.6 Parathyroid DiseaseXX5.7 Pituitary DisordersXX PanhypopituitarismX5.8 Thyroid Disorders HyperthyroidismXXX HypothyroidismXXX ThyroiditisXX5.9 Tumors of Endocrine Glands AdrenalXX PituitaryXX ThyroidXX6.0 Environmental DisordersCriticalEmergentLower Acuity6.1 Bites and Envenomation (See 18.1) ArthropodsXX InsectsX SpidersXX MammalsXX Marine organisms (See 17.1)XXX SnakesXXX6.2 Dysbarism Air embolismXX BarotraumaXXX Decompression syndromeXX6.3 Electrical Injury (See 18.1)XXX LightningXX6.4 High-Altitude Illness Acute mountain sicknessXX Barotrauma of ascentXX High-altitude cerebral edemaXX High-altitude pulmonary edemaXX6.5 Submersion Incidents Cold water immersionXX Near drowningXX6.6 Temperature-Related Illness Heat Heat exhaustionXX Heat strokeX Cold FrostbiteXX HypothermiaXX6.7 Radiation EmergenciesXXX7.0 Head, Ear, Eye, Nose, Throat DisordersCriticalEmergentLower Acuity7.1 Ear Foreign bodyXX Impacted cerumenX LabyrinthitisX MastoiditisX Meniere's diseaseX Otitis externaX InfectiveX MalignantX Otitis mediaXX Perforated tympanic membrane (See 18.1)X7.2 Eye External eye BlepharitisX Burn confined to eye and adnexa (See 18.1)X ConjunctivitisX Corneal abrasions (See 18.1)XX DacryocystitisXX Disorders of lacrimal systemX Foreign bodyXX Inflammation of the eyelidsX ChalazionX HordeolumX KeratitisXX Anterior pole GlaucomaXX Hyphema (See 18.1)XX Iritis (See 18.1)XX Posterior pole Choroiditis/chorioretinitisX Optic neuritisX PapilledemaXX Retinal detachments and defects (See 18.1)X Retinal vascular occlusionX Orbit Cellulitis PreseptalX PostseptalX Purulent endophthalmitisX7.3 Cavernous Sinus ThrombosisXX7.4 Nose EpistaxisXXX Foreign bodyXX RhinitisX SinusitisX7.5 Oropharynx/Throat DentalgiaX Diseases of the oral soft tissue Ludwig's anginaXX StomatitisX Diseases of the salivary glands SialolithiasisXX Suppurative parotitisX Foreign bodyXX Gingival and periodontal disorders GingivostomatitisX Larynx/trachea Epiglottitis (See 16.1)XX LaryngitisX TracheitisXX Oral candidiasis (See 2.2, 4.4)X Periapical abscessXX Peritonsillar abscessX Pharyngitis/tonsillitisX Retropharyngeal abscessXX Temporomandibular joint disordersX7.6 TumorsXX8.0 Hematologic DisordersCriticalEmergentLower Acuity8.1 Blood Transfusion ComplicationsXX8.2 Hemostatic Disorders Coagulation defectsXXX AcquiredXXX HemophiliasXXX Disseminated intravascular coagulationX Platelet disordersXXX ThrombocytopeniaXX8.3 LymphomasXX8.4 PancytopeniaXX8.5 Red Blood Cell Disorders Anemias AplasticXX HemoglobinopathiesXX Sickle cell diseaseXX HemolyticX Hypochromic Iron deficiencyXX MegaloblasticXX PolycythemiaXX Methemoglobinemia (See 17.1)XX8.6 White Blood Cell Disorders LeukemiaXX Multiple myelomaXX LeukopeniaXX9.0 Immune System DisordersCriticalEmergentLower Acuity9.1 Collagen Vascular Disease Raynaud's diseaseX Reiter's syndromeXX Rheumatoid arthritis (See 11.3)XX SclerodermaXX Systemic lupus erythematosusXX VasculitisXX9.2 HIV and Manifestations (See 10.6)XXX9.3 Hypersensitivity Allergic reactionXX AnaphylaxisX AngioedemaXX Drug allergiesXXX9.4 Kawasaki SyndromeX9.5 SarcoidosisXX9.6 Transplant-related ProblemsXXX ImmunosuppressionXX RejectionXX9.7 Rheumatic FeverXX10.0 Systemic Infectious DisordersCriticalEmergentLower Acuity10.1 Bacterial Bacterial food poisoningXX BotulismXX ChlamydiaXX Gonococcal infectionsXX MeningococcemiaXX Mycobacterial infections Atypical mycobacteriaXX TuberculosisXX Other bacterial diseasesXX Gas gangrene (See 11.6)XX Sepsis/bacteremiaXX ShockX Systemic inflammatory response syndrome (SIRS)XX Toxic shock syndromeXX Spirochetes SyphilisXX TetanusXX10.2 Biologic WeaponsXX10.3 Fungal InfectionsXX10.4 Protozoan/Parasites MalariaX ToxoplasmosisXX10.5 Tick-borne EhrlichiosisX Lyme diseaseX Rocky Mountain spotted feverX10.6 ViralXX Infectious mononucleosisXX Influenza/parainfluenzaXX HantavirusXX Herpes simplex (See 4.4, 13.1)XX Herpes zoster/varicella (See 4.4)XX HIV (See 9.2)XXX RabiesX RoseolaX RubellaX10.7 Emerging Infections/PandemicsXX11.0 Musculoskeletal Disorders (Nontraumatic)CriticalEmergentLower Acuity11.1 Bony Abnormalities Aseptic necrosis of hipXX OsteomyelitisX TumorsXX11.2 Disorders of the Spine Disc disordersXX Inflammatory spondylopathiesXX Low back pain Cauda equina syndrome (See 18.1)XX SacroiliitisX Sprains/strainsX11.3 Joint Abnormalities Arthritis SepticX GoutXX Rheumatoid (See 9.1)X JuvenileX OsteoarthrosisX Congenital dislocation of the hipXX Slipped capital femoral epiphysisX11.4 Muscle Abnormalities Myalgia/MyositisX RhabdomyolysisXX11.5 Overuse Syndromes BursitisX Muscle strainsX Peripheral nerve syndromeX Carpal tunnel syndromeX TendonitisX11.6 Soft Tissue Infections FasciitisX FelonX Gangrene (See 10.1)XX ParonychiaXX Synovitis/tenosynovitisXX12.0 Nervous System DisordersCriticalEmergentLower Acuity12.1 Cranial Nerve DisordersX Idiopathic facial nerve paralysis (Bell's palsy)X Trigeminal neuralgiaX12.2 Demyelinating DisordersXX Multiple sclerosisXX12.3 Headache (See 1.4)XXX Muscle contractionX VascularXX12.4 HydrocephalusXX Normal pressureXX VP shuntX12.5 Infections/Inflammatory Disorders EncephalitisXX Intracranial and intraspinal abscessXX Meningitis BacterialXX ViralXX MyelitisX Neuralgia/neuritisX12.6 Movement DisordersXX Dystonic reactionXX12.7 Neuromuscular Disorders Guillain-Barré syndromeXX Myasthenia gravisXXX Peripheral neuropathyX12.8 Other Conditions of the Brain Dementia (See 14.5)X Parkinson's diseaseX Pseudotumor cerebriXX12.9 Seizure DisordersXXX FebrileXX NeonatalX Status epilepticusX12.10 Spinal Cord CompressionXX12.11 Stroke Hemorrhagic IntracerebralXX SubarachnoidXX Ischemic EmbolicXX ThromboticXX12.12 Transient Cerebral IschemiaXX12.13 TumorsXX13.0 Obstetrics and GynecologyCriticalEmergentLower Acuity13.1 Female Genital Tract Cervix Cervicitis and endocervicitisXX TumorsX Infectious disorders Pelvic inflammatory diseaseX Fitz-Hugh-Curtis syndromeX Tubo-ovarian abscessX Lesions Herpes simplex (See 4.4, 10.6)X Human papillomavirus (HPV) (See 4.4)X Ovary CystX TorsionX TumorsXX Uterus Dysfunctional bleedingXX EndometriosisX ProlapseX TumorsXX Gestational trophoblastic diseaseX LeiomyomaX Vagina and vulva Bartholin's abscessX Foreign bodyXX Vaginitis/vulvovaginitisX13.2 Normal PregnancyX13.3 Complications of Pregnancy AbortionX Ectopic pregnancyXX Hemolysis, elevated liver enzymes, low platelets (HELLP) syndromeXX Hemorrhage, antepartum Abruptio placentae (See 18.2)XX Placenta previaXX Hyperemesis gravidarumXX Hypertension complicating pregnancyXX EclampsiaXX PreeclampsiaX InfectionsX Rh isoimmunizationX13.4 High-risk PregnancyXX13.5 Normal Labor and DeliveryXX13.6 Complications of Labor Fetal distressX Premature labor (See 18.2)X Premature rupture of membranesX Rupture of uterus (See 18.2)X13.7 Complications of Delivery Malposition of fetusXX Nuchal cordX Prolapse of cordX13.8 Postpartum Complications EndometritisX HemorrhageXX MastitisXX14.0 Psychobehavioral DisordersCriticalEmergentLower Acuity14.1 Addictive Behavior Alcohol dependenceX Drug dependenceX Eating disordersXX Substance abuseX14.2 Mood Disorders and Thought Disorders Acute PsychosisXX Bipolar disorderXX DepressionXX Suicidal riskXX Grief reactionX SchizophreniaXX14.3 Factitious Disorders Drug-seeking behaviorX Munchausen syndrome/Munchausen by proxyXX14.4 Neurotic Disorders Anxiety/panicX Obsessive compulsiveX PhobicX Posttraumatic stressX14.5 Organic Psychoses Chronic organic psychotic conditionsX Alcoholic psychosesXX Drug psychosesXX DeliriumX Dementia (See 12.8)X Intoxication or withdrawal (See 17.1) AlcoholXXX HallucinogensXX OpioidsXXX PhencyclidineX Sedatives/hypnotics/anxiolyticsXXX Sympathomimetics and cocaineXXX14.6 Patterns of Violence/Abuse/Neglect Interpersonal violence Child, intimate partner, elderX Homicidal riskXX Sexual assaultX Staff/patient safetyX14.7 Personality DisordersX14.8 Psychosomatic Disorders HypochondriasisX Hysteria/conversionX15.0 Renal and Urogenital DisordersCriticalEmergentLower Acuity15.1 Acute and Chronic Renal FailureXXX15.2 Complications of Renal DialysisXX15.3 Glomerular Disorders GlomerulonephritisXX Nephrotic syndromeXX15.4 Infection CystitisX PyelonephritisX Urinary tract infection (UTI)X15.5 Male Genital Tract Genital lesionsX HerniasXX Inflammation/infection Balanitis/balanoposthitisXX Epididymitis/orchitisXX Gangrene of the scrotum (Fournier's gangrene)XX ProstatitisXX UrethritisX Structural Paraphimosis/phimosisX PriapismX Prostatic hypertrophy (BPH)X Torsion of testisX Testicular massesX Tumors ProstateX TestisX15.6 NephritisXX Hemolytic uremic syndromeX15.7 Structural Disorders Calculus of urinary tractXX Obstructive uropathyX Polycystic kidney diseaseX15.8 TumorsX16.0 Thoracic-Respiratory DisordersCriticalEmergentLower Acuity16.1 Acute Upper Airway Disorders Infections CroupX Epiglottitis (See 7.5)XX Pertussis/whooping coughXX Upper respiratory infectionX ObstructionX Tracheostomy/complicationsXX16.2 Disorders of Pleura, Mediastinum, and Chest Wall CostochondritisX MediastinitisXX Pleural effusionXX PleuritisX PneumomediastinumX Pneumothorax (See 18.1) SimpleX TensionX16.3 Noncardiogenic Pulmonary EdemaXX16.4 Obstructive/Restrictive Lung Disease Asthma/reactive airway diseaseXX Bronchitis and bronchiolitisXX Bronchopulmonary dysplasiaXX Chronic obstructive pulmonary diseaseXXX Cystic fibrosisXXX Environmental/industrial exposureXXX Foreign bodyXX16.5 Physical and Chemical Irritants/Insults PneumoconiosisXX Toxic effects of gases, fumes, vapors (See 18.1)XXX16.6 Pulmonary Embolism/Infarct Septic emboliXX Venous thromboembolism (See 3.3)XX16.7 Pulmonary Infections Lung abscessX Pneumonia AspirationXX AtypicalX BacterialXX ChlamydiaX FungalXX MycoplasmalXX ViralXXX Pulmonary tuberculosisX16.8 Tumors BreastX Chest wallX PulmonaryXX17.0 Toxicologic DisordersCriticalEmergentLower Acuity17.1 Drug and Chemical Classes Analgesics AcetaminophenX Nonsteroidal anti-inflammatories (NSAIDS)XX Opiates and related narcoticsXX SalicylatesXX Alcohol EthanolXXX GlycolXX IsopropylXXX MethanolXX AnestheticsXX Anticholinergics/cholinergicsXX AnticoagulantsXX AnticonvulsantsXX AntidepressantsXX Antiparkinsonism drugsX Antihistamines and antiemeticsX AntipsychoticsXX BronchodilatorsX Carbon monoxideXX Cardiovascular drugs AntiarrhythmicsXX DigitalisXX AntihypertensivesXX Beta-BlockersXX Calcium-channel blockersXX Caustic agents AcidXX AlkaliXX CocaineXXX Cyanides, hydrogen sulfideXX HallucinogensXX Hazardous materialsXX Heavy metalsXX Herbicides, insecticides, and rodenticidesXX Household/industrial chemicalsXXX Hormones/steroidsXX HydrocarbonsXX Hypoglycemics/insulinXX Inhaled toxinsXX IronXX IsoniazidXX Marine toxins (See 6.1)XXX Methemoglobinemia (See 8.5)XX Mushrooms/poisonous plantsXX NeurolepticsXX Nonprescription drugsXX OrganophosphatesXX Recreational drugsXXX Sedatives/hypnoticsXX Stimulants/sympathomimeticsXX StrychnineXX LithiumXXX18.0 Traumatic DisordersCriticalEmergentLower Acuity18.1 Trauma Abdominal trauma DiaphragmXX Hollow viscusXX PenetratingXX RetroperitoneumXX Solid organXX VascularXX Chest trauma Aortic dissection/disruptionX Contusion CardiacXXX PulmonaryXX Fracture ClavicleXX Ribs/flail chestXXX SternumXX HemothoraxXX Penetrating chest traumaXX Pericardial tamponade (See 3.6)X Pneumothorax (See 16.2) SimpleX TensionX Cutaneous injuries AvulsionsXX Bite wounds (See 6.1)XX Burns Electrical (See 6.3)XXX Chemical (See 16.5)XXX ThermalXXX LacerationsXX Puncture woundsXX Facial fracturesX DentalXX Le FortXXX MandibularXX OrbitalXX Genitourinary trauma BladderX External genitaliaX RenalXX UreteralX Head trauma Intracranial injuryXX Scalp lacerations/avulsionsXX Skull fracturesXX Injuries of the spine Dislocations/subluxationsXX FracturesXXX Sprains/strainsX Lower extremity bony trauma Dislocations/subluxationsX Fractures (open and closed)XX Neck trauma Laryngotracheal injuriesXX Penetrating neck traumaXX Vascular injuries Carotid arteryXX Jugular veinXX Ophthalmologic trauma Corneal abrasions/lacerations (See 7.2)XX Corneal burns AcidX AlkaliX UltravioletXX Eyelid lacerationsX Foreign bodyX Hyphema (See 7.2)X Lacrimal duct injuriesX Penetrating globe injuriesX Retinal detachments (See 7.2)X Traumatic iritis (See 7.2)XX Retrobulbar hematomaX Otologic trauma HematomaXX Perforated tympanic membrane (See 7.1)X Pediatric fractures EpiphysealXX GreenstickX TorusX Pelvic fractureXX Soft-tissue extremity injuries Amputations/replantationX Compartment syndromesX High-pressure injectionX Injuries to jointsXX KneeXX PenetratingX Penetrating soft-tissueXX PeriarticularX Sprains and strainsX Tendon injuries Lacerations/transectionsX RupturesX Achilles tendonX Patellar tendonX Vascular injuriesXX Spinal cord and nervous system trauma Cauda equina syndrome (See 11.2)XX Injury to nerve rootsXX Peripheral nerve injuryXX Spinal cord injuryXX Spinal cord injury without radiologic abnormality (SCIWORA)X Upper extremity bony trauma Dislocations/subluxationsX Fractures (open and closed)XX18.2 Trauma in PregnancyAbruptio placentae (See 13.3)XX Perimortem C-sectionX Premature labor (See 13.6)X Rupture of uterus (See 13.6)X18.3 Multisystem TraumaXX Blast injuryXX Open table in a new tab The Accreditation Council for Graduate Medical Education (ACGME) is implementing the ACGME Outcome Project to ensure that physicians are appropriately trained in the knowledge and skills of their specialties. The ACGME has identified 6 general (core) competencies thought to be essential for any practicing physician: patient care, medical knowledge, practice-based learning and improvement, interpersonal skills, professionalism, and systems-based practice. The 6 general competencies are an integral part of the practice of emergency medicine and are embedded in the EM Model.10Chapman D.M. Hayden S. Sanders A.B. et al.Integrating the Accreditation Council for Graduate Medical Education core competencies into the model of the clinical practice of emergency medicine.Ann Emerg Med. 2004; 43: 756-759Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar, 11Chapman D.M. Hayden S. Sanders A.B. et al.Integrating the Accreditation Council for Graduate Medical Education core competencies into the model of the clinical practice of emergency medicine.Acad Emerg Med. 2004; 11: 674-685 PubMed Google ScholarThe EM Model is designed for use as the core document for the specialty. It will provide the foundation for developing medical school and resi

Objective. The boarding of patients in Emergency Department (ED) hallways when no inpatient beds are available is a major cause of ED crowding. One solution is to board admitted patients in an inpatient rather than ED hallway. We surveyed patients to determine their preference and correlated their responses to real-time National Emergency Department Overcrowding Score (NEDOCS). Methods. This was a survey of admitted patients in the ED of an urban university level I trauma center serving a community of 5 million about their personal preferences regarding boarding. Real-time NEDOCS was calculated at the time each survey was conducted. Results. 99 total surveys were completed during October 2010, 42 (42%) patients preferred to be boarded in an inpatient hallway, 33 (33%) preferred the ED hallway, and 24 (24%) had no preference. Mean (±SD) NEDOCS (range 0–200) was 136 ± 46 for patients preferring inpatient boarding, 112 ± 39 for ED boarding, and 119 ± 43 without preference. Male patients preferred inpatient hallway boarding significantly more than females. Preference for inpatient boarding was associated with a significantly higher NEDOCS. Conclusions. In this survey study, patients prefer inpatient hallway boarding when the hospital is at or above capacity. Males prefer inpatient hallway boarding more than females. The preference for inpatient hallway boarding increases as the ED becomes more crowded.

Background: Ethics education is an essential component of graduate medical education in emergency medicine. A sound understanding of principles of bioethics and a rational approach to ethical decision-making are imperative. Objective: This article addresses ethics curriculum content, educational approaches, educational resources, and resident feedback and evaluation. Discussion: Ethics curriculum content should include elements suggested by the Liaison Committee on Medical Education, Accreditation Council for Graduate Medical Education, and the Model of the Clinical Practice of Emergency Medicine. Essential ethics content includes ethical principles, the physician-patient relationship, patient autonomy, clinical issues, end-of-life decisions, justice, education in emergency medicine, research ethics, and professionalism. Conclusion: The appropriate curriculum in ethics education in emergency medicine should include some of the content and educational approaches outlined in this article, although the optimal methods for meeting these educational goals may vary by institution. (C) 2011 Elsevier Inc.

A panel of physicians from the Society for Academic Emergency Medicine (SAEM) Graduate Medical Education (GME), Ethics, and Industry Relations Committees were asked by the SAEM Board of Directors to write a position paper on the relationship of emergency medicine (EM) GME with industry. Using multiple sources as references, the team derived a set of guidelines that all EM GME training programs can use when interacting with industry representatives. In addition, the team used a question-answer format to provide educators and residents with a practical approach to these interactions. The SAEM Board of Directors endorsed the guidelines in June 2009.

Although many residency programs mandate at least one rotation in emergency medicine (EM), to the best of our knowledge, a standardized curriculum for emergency department (ED) rotations for "off-service" residents has not been developed. As a result, the experiences of these residents in the ED tend to vary during their rotations. To design an off-service EM curriculum, we adopted Kern's six-step approach to curriculum development as a conceptual framework. The resulting program encompasses clinical experience and didactic sessions through which residents are trained in core topics and skills. This knowledge will be applicable in the clinical settings in which residents will continue to train and ultimately practice their specialty. It is flexible enough to be applicable and implementable without being limited by resource availability or faculty strengths.

Editor’s Introduction: The two commentaries that follow resulted from a vigorous debate among the members of this journal’s editorial board regarding whether or not paid commercial advertising from the pharmacy and medical device industries should be accepted and printed in our journal. The order in which they are presented was determined by a coin flip by the editor-in-chief. The two papers are attempts to clarify and provide background for further debate on this complex issue. This was a collaborative effort: there was continuous feedback between the two writing groups, and authors are listed alphabetically, but the participants held their view points with a significant degree of passion, appropriate for the importance of the topic. While the journal has no official practice banning advertisements by drug and device manufacturers, a combination of a very conservative posture toward the concept of such advertising and the general state of medical advertising in general (due to budgets being adversely affected by economic conditions) have resulted in no such industry advertising for the past several years. At issue is whether the journal should begin to more aggressively pursue advertising revenue or formalize a ban. The interested reader is also referred to the following article from the August issue of AEM: “A review of the federal guidelines that inform and influence relationships between physicians and industry.”1 A moderated online discussion board is available on the SAEM web site at http://www.saem.org/aemforum for those wishing to participate in further debate of the issues. David C. Cone, MD Editor-in-Chief, Academic Emergency Medicine The mission of the Society for Academic Emergency Medicine (SAEM) is “To improve patient care by advancing research and education in emergency medicine.” We, the undersigned members of the editorial board of SAEM’s journal, Academic Emergency Medicine (AEM), believe that accepting pharmaceutical and medical device advertising would directly conflict with this mission. AEM does not currently have such advertising; we believe that it should retain this status. Furthermore, we argue that no peer-reviewed or academic medical journal should accept advertisements for pharmaceuticals or medical devices. Candid and detailed discussions regarding this matter were held among members of the editorial board both online and at national meetings. We noted, not surprisingly, that the sole impetus for altering our journal’s “no advertising” practice was financial. Historically, AEM has had sufficient funding to maintain its habitually high volume of quality manuscripts. Additional revenue is always welcome; we can all think of meritorious projects that SAEM and AEM could undertake if we had more income, but we think that incorporating medical advertisements into our funding stream would compromise our journal’s mission and high standards. AEM represents one of the most visible and widely distributed faces of SAEM. In this role, it should serve as both a standard and a leader for our specialty. We do not seek to debate the merits of the pharmaceutical or medical device industries. Clearly, these industries have provided or facilitated significant advances in our collective ability to treat illness, which for the most part, have benefited our patients. We instead focus our arguments on the marketing arms of such industries, as they interface with emergency physicians in particular and the medical community at large. We contend that the delivery of health care is innately different from other products and services1 and that it is founded upon a trust formed between patient and physician. Such a trust implies that judgment will be applied objectively and with due diligence with the patient’s best interests as the sole focus. This unique relationship, which may be considered analogous to the relationship between a parishioner and confessor, a personal investor and broker, or a client and attorney must be conducted without conflict of interest, whether real or implied. We submit that the practice of employing advertisements for health care products by our publication, or indeed by any similar publication, interjects a conflict of interest both in the immediate sense of our journal’s relationship to its readers and, indirectly, between those readers and their patients. The only effective way of preventing this conflict is to proscribe such advertising. Health care consists of diagnostic and therapeutic interventions and the judgment required to apply them, with the intent to maximize the health of the individual patient. We acknowledge that this must be done in an environment of limited resources and often under circumstances where insufficient evidence exists to definitively recommend an intervention as being the best available. It is the physician’s professional duty to recommend and provide the best possible care within these constraints, without commercial bias. It is unethical for a physician to do anything less for his or her patient. Similarly, it is the responsibility of medical journals to maximize the health of patients. The journal’s job is to provide unbiased scientific research and commentary. This is what physicians need to make optimal therapeutic decisions. Medical journals have a similar responsibility to readers as physicians have to patients. Physicians come to AEM to read the latest emergency medicine research to make the most informed, evidence-based choices when caring for their patients. Here too, any bias is unethical. Prior to publication, reviewers and editors who are experts in content and study design carefully review each manuscript, spending considerable effort to identify and eliminate attempts to exaggerate, or “spin,” results. This methodical endeavor is directed toward one goal—getting as close to the “truth” as possible. In contrast, the purpose of advertising is not about conveying truth. Advertising is designed to successfully market a product. The merits of the product are of only secondary concern to the advertising industry. In fact, a successful advertising campaign often creates demand for a product that has few or no advantages over alternatives. We support robust pharmaceutical and medical device industries that successfully bring cutting-edge healthcare products to our patients. Indeed, to a large extent we read medical journals specifically to determine the relative merits of different treatments and products. Because of inherently conflicting purposes, however, we believe that it is incongruous and inappropriate to comingle purchased advertisements with carefully reviewed and selected manuscripts. To do so would be analogous to presenting 30-second paid advertisements between lectures at teaching conferences or to having physicians display the logos of favorite medications on their laboratory coats. Some would argue that medical advertising is just another potential source of knowledge translation. Unfortunately, pharmaceutical advertisements are not peer-reviewed and often contain inaccurate or misleading information. Villanueva et al.,2 after reviewing 287 medical ads, found that the promotional statements were not supported by their references 44% of the time. Drug advertising as a source of medical information represents an extreme form of publication bias. We have faith in our readers’ abilities to critically differentiate between medical fact and medical advertising. Yet, although not peer-reviewed, medical advertising is demonstrably effective at changing physicians’ prescribing patterns.3 The pharmaceutical industry clearly understands this fact, thereby justifying its $448 million medical advertising budget in 2003.4 The efficiency of pharmaceutical advertisements is enhanced by the multiplicative effect of physician-directed advertising.5 Compared to other targets of advertising, physicians are unique in that other consumers may be swayed to purchase only a single item from an ad, while a physician can be influenced to write multiple prescriptions for the same product. This high return on investment of advertising, while benefitting the pharmaceutical industry, has important implications for health care costs. There is another reason that advertisements aimed at physicians are ethically suspect. Physicians themselves are not the primary purchasers of pharmaceuticals and medical devices—their patients are. Thus, decisions by physicians with regard to these prescriptions possess the aforementioned inherently multiplicative effect, which we believe creates an unusual level of moral responsibility for physicians.5 Physicians may increase health care costs in general by writing for newer and more expensive medications or devices that offer no real advantages over their alternatives, but they may also shift the burden to the individual patient. This directly conflicts with their ethical responsibility to be good stewards of their patient’s well-being. Worse, increased out-of-pocket costs may cause some patients to allow their prescriptions to go unfilled, thereby resulting in a detriment to their health, as well as erosion of the quality of emergency care in general. This, then, is the basic conflict. Advertising is intended to sell product. It does so by biasing decision-making. For most products this is ethically neutral, but if health care is ethically special,1 then attempts to bias what kind of care is delivered for any reason other than to maximize benefit to the patient is unethical. This conflict is irresolvable because the objectives of medical advertising and medical practice are different. Medical practice is good when the provider delivers the best possible care to the patient, implying that it is scientifically based and unbiased. Advertising is good when it introduces a bias in favor of the targeted product. Arguments in favor of medical advertising that are based on individual physicians evaluating and censoring advertising set up an endless recursive battle between readers and the pharmaceutical/medical device advertising industry, not to mention an ethical dilemma in determining who is qualified to make these judgments on our collective behalf. Physicians may argue that they are not affected by advertising and that they are not susceptible to exaggerated or misleading claims, but the revenue from advertising does constitute a conflict of interest for journals and publishers. Some medical journals have been demonstrated to show bias in favor of advertisers,6,7 and major publishing houses have been caught publishing sham journals for pharmaceutical manufacturers.8 These scandals embarrass us and weaken our profession’s moral authority. We are quite convinced that AEM would never actually do these things, but claiming that we are above being influenced by a conflict of interest, even when this is true, is quite different from not having one. Patients and the public in general are not likely to believe that academia is immune to financial impropriety, and our journal’s reputation will be strengthened if we overtly refuse to accept advertising. There is no need to include pharmaceutical and medical device advertisements in academic medical journals. Readers, and by extension patients, are best served by ignoring the ads in journals and concentrating on the research. Journals do their job best when they do not publish material that is intended to undercut their ethical duty to present unbiased information. We believe that medical journals should not print advertisements whose goals are not linked inextricably to the goals of the journal—and that means all forms of medical product advertisement.

Academic Emergency MedicineVolume 16, Issue 1 p. 56-60 Free Access Overcrowding: Harming the Patients of Tomorrow? Jonathan Fisher MD, MPH, Jonathan Fisher MD, MPH From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this authorPeter E. Sokolove MD, Peter E. Sokolove MD From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this authorSean P. Kelly MD, Sean P. Kelly MD From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this authorfor the Society for Academic Emergency Medicine (SAEM) Crowding Taskforce Education Workgroup*, for the Society for Academic Emergency Medicine (SAEM) Crowding Taskforce Education Workgroup* From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this author Jonathan Fisher MD, MPH, Jonathan Fisher MD, MPH From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this authorPeter E. Sokolove MD, Peter E. Sokolove MD From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this authorSean P. Kelly MD, Sean P. Kelly MD From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this authorfor the Society for Academic Emergency Medicine (SAEM) Crowding Taskforce Education Workgroup*, for the Society for Academic Emergency Medicine (SAEM) Crowding Taskforce Education Workgroup* From the Departments of Emergency Medicine, Beth Israel Deaconess Medical Center (JF, SPK), Boston, MA; and the University of California, Davis (PES), Sacramento, CA.Search for more papers by this author First published: 29 December 2008 https://doi.org/10.1111/j.1553-2712.2008.00260.xCitations: 5 SAEM Crowding Taskforce Education Workgroup members are listed in Appendix A. A related article appears on page 76. AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL It is 3 am on August 1st, 2018, in a busy hospital when a 47-year-old male presents with chest pain. The emergency physician on duty, who is a new residency graduate, performs a history and physical, orders an ECG, chest x-ray, and blood work. After reviewing the data, the patient is given aspirin, nitroglycerin, and heparin and admitted to observation for a rule-out with serial enzymes. At 7 am, the patient's chest pain worsens and he suffers a cardiac arrest. An autopsy reveals cardiac tamponade and a large thoracic aortic dissection. As physicians and educators, we are products of our environment. In emergency departments (EDs) throughout the world, we were taught by our mentors to provide the most compassionate and best care possible, no matter what the circumstance. In turn, many of us try to repay our mentors by teaching the doctors of tomorrow. However, our "classroom" is changing. It is becoming increasingly overcrowded. As we spend more time discussing diversion with charge nurses, and less time teaching students and residents, we wonder if we are doing a disservice to the doctors (and patients) of tomorrow. Am I really supervising the residents adequately and giving the necessary feedback? When I barked in frustration at the family member who asked me for the fifth time when her mother would be admitted to the hospital, was I really modeling professional behavior? Could I really teach the student the subtleties of the abdominal exam on that fully clothed patient in the hallway? Who can be expected to teach under such difficult conditions? With so many competing interests and interruptions, who can possibly address the needs of students and residents? With constant pressure to perform clinically, despite limited resources, who has the time or energy to teach? Well . . . emergency physicians (EPs), that is who, it is what we do—adapt and overcome; create order from chaos. In fact, there are those among us that do it very well. Sometimes even the most clinically productive physicians somehow manage to be the best educators as well. How do they do it? What are the methods they use? What are the tricks of the trade that allow someone to manage an overcrowded ED and use all that extra learning substrate to their (and the learners') advantage rather than to their detriment? The ED is a high stakes environment, both clinically and educationally. It is ripe with risk, but also full of potential reward. The stakes have never been higher, for today's teachers and tomorrow's physicians. While overcrowding is an evil that most EPs would rather do without, it does present emergency medicine (EM) with a unique opportunity. From doctors and patients to administrators and politicians, the rest of the world is starting to take notice of overcrowding as a major issue in patient care and medical education. Now that people are paying attention, it is time for EPs to act. No one is more qualified to lead this charge than the EM community. We have grown up on the front lines of the overcrowding battle and know the issues intimately. Furthermore, we are well poised to take on the challenge of conducting research, formulating solutions, and testing results. Our specialty naturally selects physicians and educators who are flexible, adaptable, quick-thinking, team-oriented, multitasking, and pragmatic— the very qualities necessary to approach the task at hand. Brief background ED Crowding EDs across the country and the world are becoming increasingly crowded. The numbers and the complexity of patients presenting to the ED are increasing.1,2 At the same time, there has been a decrease in the number of EDs to care for these patients. ED crowding is not just an ED problem, but often a product of a lack of hospital capacity. As the patient population continues to grow and age, the demand for primary care outstrips the resources available in their communities. The inpatient bed capacity in most hospitals lags behind ED needs, so the problem of ED overcrowding is expected to worsen further. Size and Scope ED crowding is a public health crisis.3,4 It is becoming increasingly prevalent in all types of EDs in all locations: urban, suburban, rural, teaching hospitals, and community centers.5 It has been shown to be associated with increased patient mortality,6–8 decreased quality of care,9–12 and decreased patient satisfaction.13 It is associated with higher rates of patients leaving without being seen by a physician,14–17 ambulance diversion,18,19 and ED lengths of stay. Consensus of experts In response to the growing concern about the impact of ED crowding on education, the Society for Academic Emergency Medicine (SAEM) brought together a group of overcrowding and educational experts to study the issue. In this issue, an article is presented that is the product of these deliberations discusses the impact of overcrowding and education.20 Shayne et al.20 review the current literature and provide an excellent overview of the current state of EM education, particularly focusing on the Accreditation Council for Graduate Medical Education (ACGME) core competencies. While there is a growing body of literature on the negative impacts on ED overcrowding on patient care, there is a noticeable dearth of research on the effect of overcrowding on education. A truly novel conceptual model of ED crowding and education was proposed as a Starling-like curve, where initial increases in crowding may actually increase education, but as crowding increases, eventually education will peak and ultimately crash. Just as the real Starling curve can be shifted, this crowding–education curve provides a useful framework to conceptualize the fact that the impact on crowding may vary for different teachers, learners, skill sets, and educational settings. For example, senior residents may learn better in a busier high-acuity setting where they are learning to fine tune their skills. An intern in that same environment may become so overwhelmed that learning ceases to occur. Shayne et al. go on to review the unique opportunities and challenges that ED crowding provides to education. What we do not know How to Measure Crowding Despite the importance of the topic and the prevalence of overcrowding, it has been difficult to define and measure it properly. ED crowding is a complicated phenomenon with multifactorial causes and many varied effects. Some of these causes and effects are universal and some system- or site-specific. Multiple attempts have been made to measure crowding using various crowding scores.10,21–25 A recent study advocates using a simpler measure, ED occupancy rates, as a measure for overcrowding, because its reliability and validity are similar to the most accepted crowding score index.10 Some researchers advocate using the number of patients who left without being seen and ambulance diversion rates as surrogate measures of overcrowding. Work is ongoing to further define the most accurate tools and methods for measuring overcrowding, but it is a complicated problem, and some tools and methods that work well at one site may not be as accurate in others. How to Measure Education? Owing to the many confounding influences and variables involved in most teaching ventures, it is difficult to objectively measure the results of education and learning in any environment, especially that of a crowded ED. While there is no single perfect educational outcome measure, there are ways to evaluate educational interventions that involve triangulating data from several sources or methods to give the most valuable data possible. One could envision using Kirkpatrick's hierarchy of learning to explore the effects of overcrowding on education in the ED.20 Call to develop better teaching methods while we assess crowding and education While we consider the problem of studying the effects of crowding on education, we also need to figure out better ways to teach in the current environment. It is important to remember that the everyday business of patient care and bedside teaching goes on, regardless of our long-term plans to effect change. In fact, some of the early studies into the topic of crowding and education reinforce this point—that any research should be grounded in the real-life limitations of the environment, for these very qualities (the fast pace, the multitasking required, the constant interruptions, and less-than-ideal circumstances) are at the heart of the issue. Rather than ignore them, we must embrace them as the very qualities that make the environment unique, in both positive and negative ways, and accept that these conditions will dictate the best methods to use in researching the subject and teaching while we research. Several authors have used various parts of Kirkpatrick's hierarchy to evaluate the effects of overcrowding on education in the ED, but much more work needs to be done.26 Berger et al.27 and Kelly et al.28 used learner satisfaction tools (the first level of the hierarchy) to investigate the effect of overcrowding and clinical workload on learner satisfaction with ED faculty teaching. The study by Kelly et al. found that teacher attributes had a significant effect on learner reaction, independent of clinical volume. These findings reinforce the fact that ED learners value the teaching principles described by Thurgur et al.,29 Bandiera et al.,30 and Atzema et al.,31 which stress adaptability, practicality, and the ability to tailor teaching to the learner and situation. In short, it seems certain that teaching methods and characteristics may allow teachers and learners to adjust to a crowded environment. Along these lines, Aldeen and Gisondi32 proposed several practical strategies to improve bedside teaching in a crowded ED. More research is indicated to further evaluate the validity of these and other methods in crowded conditions. Call to develop better research methods to assess crowding and education Ongoing research into the effects of crowding on education is beginning to offer clues on what types of teaching ED learners (and teachers) prefer in busy learning environments. However, most of the existing studies have been predicated on the lower level of Kirkpatrick's hierarchy and depend on learner and teacher reaction tools. Much more work is needed, especially with regard to the higher levels of Kirkpatrick's hierarchy.26 It would be useful to investigate the effect of crowding on objective measures of teaching and learning (the second level of the hierarchy), such as scores on tests or objective structured clinical examinations, or actual time spent teaching, especially given the findings by Chisholm et al.,33 who demonstrated a paucity of actual time spent by faculty directly observing residents. Several authors have begun to investigate the validity of standardized bedside observation tools.34 While this work does not directly examine crowding effects, validated direct observation tools could be used to study the effects of overcrowding on learned behaviors at the bedside (Kirkpatrick's third level). Several authors have investigated the effects of teaching interventions on patient care outcomes (Kirkpatrick's fourth level), with mixed results.35–38 Again, these studies were not directly related to crowding, but one could envision an investigation along the same lines with a crowded and noncrowded control arm. More research is needed to develop a better understanding of crowding and its effect on education in the ED. Call for academic eps to advocate for relief of ed crowding In addition to developing better teaching and research methods, EPs who are involved with teaching health care providers need to stand up and advocate for our students. In addition to being the place where clinical care is delivered, EDs are our classrooms. None of us would accept having an inadequate number of desks or textbooks for our children, nor would we accept having our children trying to learn in a classroom with a leaking ceiling. When our ED beds are full, we have no desks. When our flow of patients is slowed, we have no textbooks. When we are trying to teach in crowded hallways, we have the equivalent of leaking ceilings. Academic EPs need to rally to the cause of our students in the same way that other teachers have done. We need to visit our legislators and share our insight regarding the effects of ED overcrowding on both patient care and education. We should also serve as role models to our students and involve them in advocacy efforts, so that they will add their voices to our common cause. Conclusions Emergency department crowding presents a challenge to EM, and for many, it has become a fact of life that is not likely to change. While there are some unique opportunities that ED crowding provides, there are many reasons to believe that ED crowding has a negative impact on both patient care and the education of future physicians. While ED crowding may lead to an increased number of patients and higher acuity, this educational "bonus" created by overcrowding is offset by compromised patient care and faculty teaching. In many cases, excessive ED crowding results from a lack of inpatient hospital capacity. In this gridlock situation when the ED is full but there is a decreased volume of new patient encounters, medical education is compromised as well. More discussion and research is needed to understand the true impact of crowding on education, and EPs are uniquely suited to the task. It is time we took a leadership position in the academic and research communities to determine what educational approaches are necessary to minimize damage and maximize learning in a crowded environment. SAEM, the Council of Emergency Medicine Residency Directors (CORD), and the Clerkship Directors in Emergency Medicine (CDEM) are ideally suited to foster the solutions to the education-crowding crisis. Just as we have adapted our clinical practice to maximize quality of care in the face of crowding, we need to change our teaching methods in a similar fashion. We cannot fail, for the true challenge of overcrowding in academic EDs is this: as we struggle in our busy EDs to avoid harming patients today, we cannot sacrifice teaching the doctors of tomorrow, for the effects of today's teaching will be felt for many years into the future, by teachers, students, and patients alike. Appendix Appendix A SAEM Crowding Taskforce Education Workgroup: Philip Shayne, MD, Department of Emergency Medicine, Emory University, Atlanta, GA Michelle Lin, MD, Division of Emergency Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA Jacob W. Ufberg, MD, Department of Emergency Medicine, Temple University, Philadelphia, PA Felix Ankel, MD, Department of Emergency Medicine, Regions Hospital, St. Paul, MN Kelly Barringer, MD, Department of Emergency Medicine, Regions Hospital, St. Paul, MN Sarah Morgan-Edwards, MD, Department of Emergency Medicine, University of New Mexico, Albuquerque, NM Nicole DeIorio, MD, Department of Emergency Medicine, Oregon Health and Science University, Portland, OR Brent Asplin, MPH, MD, Department of Emergency Medicine, Regions Hospital, St. Paul, MN Michelle Lin, MD, Division of Emergency Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA Susan E. Farrell, MD, Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA Jonathan Fisher, MD, MPH, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA Benjamin White, MD, Harvard Affiliated Emergency Medicine Residency Program, Boston, MA Louis Binder, MD, Department of Emergency Medicine, MetroHealth Medical Center, Cleveland, OH References 1 Burt CW, McCaig LF. Trends in hospital emergency department utilization: United States, 1992–99. Vital Health Stat. 2001; 13: 1– 34. 2 McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005; 358: 1– 38. 3 McCabe JB. Emergency department overcrowding: a national crisis. Acad Med. 2001; 76: 672– 4. 4 Derlet R, Richards J, Kravitz R. Frequent overcrowding in U.S. emergency departments. Acad Emerg Med. 2001; 8: 151– 5. 5 Institute of Medicine. The future of emergency care in the United States health system. 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Fam Med. 2003; 35: 489– 95. 38 Sox CM, Burstin HR, Orav EJ, et al. The effect of supervision of residents on quality of care in five university-affiliated emergency departments. Acad Med. 1998; 73: 776– 82. Citing Literature Volume16, Issue1January 2009Pages 56-60 ReferencesRelatedInformation

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