How many emergency physicians does Korea need?

Purpose: This research used mathematical modeling to project the supply and demand of emergency physicians over the next decade in Korea. Methods: A model was used to project the annual emergency physicians (EP) workforce supply and demand through the year 2015. The mathematical equations used were as follows: Supply = number of emergency physicians at the beginning of the year plus annual residency graduates minus annual attrition; Demand formula I = 5.29 fulltime equivalent positions/emergency department (ED) x the number of hospital EDs, Demand formula II = annual ED visits/(4,700visits/EP/year), Demand formula III = (11 to 16 EP per major referral ED) + (6 to 8 EP per urban district/ regional hospital ED). Results: While the most conservative demand projection was 1,505 EPs in the year 2015, the most aggressive supply estimate with a yearly supply of 120 new EPs and a 1% attrition rate was 1,362 EPs in that year. Conclusion: In Korea, emergency physicians will remain in short supply for the next ten years, even at the present levels of EM residency output.ope

Lower Extremity Weakness and Back Pain from a Ruptured Iliac Artery Aneurysm - A Case Report -

An isolated iliac artery aneurysm is a rare condition. Its prevalence is less than 0.01% of the general population and less than 1% of all vascular aneurysms. Metachronous occurrence of an iliac artery aneurysm is very rare, and its prevalence is unknown. Most iliac artery aneurysms do not have any clinical symptoms. If there are symptoms, they are due either to compression of adjacent organs, which depends on the anatomical position of the aneurysm, or to rupture. Aneurysmal rupture can present very variable clinical symptoms, which originate from the anatomical position, so diagnosis is often delayed. We report a case of a common iliac artery and an internal iliac artery aneurysm presenting as temporary lower extremity weakness and back pain, and we present a review of related literature.ope

Comparison of lactated Ringer’s solution and 0.9% saline in the treatment of rhabdomyolysis induced by doxylamine intoxication

Objective: To compare the effectiveness and side effects of lactated Ringer’s solution (LR) and 0.9% saline (NS) in the treatment of rhabdomyolysis induced by doxylamine intoxication. Methods: In this 15-month-long prospective randomised single-blind study, after excluding 8 patients among 97 doxylamine-intoxicated patients, 28 (31%) patients were found to have developed rhabdomyolysis and were randomly allocated to NS group (n = 15) or LR group (n = 13). Results: After 12 h of aggressive hydration (400 ml/h), urine/serum pH was found to be significantly higher in the LR group, and serum Na+/Cl− levels to be significantly higher in the NS group. There were no significant differences in serum K+ level and in the time taken for creatine kinase normalisation. The amount of sodium bicarbonate administered and the frequency administration of diuretics was significantly higher in the NS group. Unlike the NS group, the LR group needed little supplemental sodium bicarbonate and did not develop metabolic acidosis. Conclusion: LR is more useful than NS in the treatment of rhabdomyolysis induced by doxylamine intoxication.ope

Effect of Cyclophosphamide and High Dose Methylprednisolone on Paraquat Poisoned Rats

BACKGROUND: Paraquat(PQ) is used widely all over the world for its excellent effect as a herbicide. But its mortality rate is known to be very high, because there is no effective therapeutic modality. Recently, surprising improvement in survival rate was reported using the cyclophosphamide & methylprednisolone pulse therapy in paraquat poisoning. However, this report was not based upon animal study, we designed this experiment to confirm the therapeutic effect. METHODS: Under the halothane anesthesia, paraquat dichloride 40 mg/kg was injected intraperitoneally to 18 Sprague-Dawley rats. Two hours later, cyclophsphamide 40 mg/kg IP and methylprednisolone 62.5 mg/kg IM were injected in the treatment group(n=9). After 24 hours, we examined serum creatinine levels and pathologic findings of lung stained with hematoxylin-eosin and Masson's trichrome. And 72 hour mortality was compared between 2 groups(5 rats respectively). RESULTS: There were no statistical differences between the treatment group and control group in serum creatinine level, degree of lung injury, and survival rates. CONCLUSION: Cyclophosphamide and high dose methylprednisolone combination therapy did not decrease pulmonary toxicity and mortality of paraquat poisoned rats. Further animal studies using various doses and administrative methods of above medications are necessary to demonstrate their effects.ope

Cardiac rupture due to Blunt Injury

Blunt injury to the heart ranges from a contusion to a cardiac rupture. Cardiac rupture, however, is uncommon and is associated with a very high mortality rate. We experienced a case of right atrial rupture caused by a compression to the chest wall. The patient was a 19-year-old male who suffered injury by being crushed under an elevator. We suspected cardiac tamponade caused by cardiac rupture with profound shock, elevated central venous pressure, and anterior chest wall bruise. Rapid diagnosis was done by using emergency sonography. Percutaneous pericardiocentesis was done. The patient was sent to O.R., and the right atrial rupture was repaired with a simple suture.ope

Cervicofacial Subcutaneous Emphysema and Pneumomediastinum after a Dental Procedure

The occurrences of subcutaneous emphysema or pneumomediastinum after a dental procedure are rare, but they are potentially life-threatening complications. These complications are reported to occur mainly in patients after dental procedures on the third molar, in particular during mandibular extractions and treatment on the right side. A 22-yearold woman visited the emergency department with neck swelling and chest pain after a right lower third molar extraction. She had a subcutaneous emphysema on the face and neck. Her chest x-ray and computed tomography of the chest showed a pneumomediastinum. She was discharged 6 days later without serious complications. Many cases of subcutaneous emphysema are of limited severity, resulting in minor, localized swelling, and require nothing more than observation and reassurance. However, early recognition of these problems is essential in preventing lifethreatening complications such as airway obstruction, mediastinitis, deep neck infection, and cardiac failure. We review the pathophysiology and clinical course of this disease.ope

Three Cases of an Eshophageal Foreign Body Caused by Coin-shaped Rock Called Maeksum-seok

Generally, the occurrence of an esophageal foreign body due to a coin-like material is rare in adults. The Maeksumseok is a kind of rock that is believed to be good for health in Korean folk medicine. Thus, people use a Maeksumseok in various ways, one of which is keeping coin-shaped Maeksum-seok in the mouth. Because of this use, it is easy to swallow a Maeksum-seok coin by accident, and a swallowed Maeksum-seok coin will easily lodge in esophagus. We experienced three cases of an esophageal foreign body caused by a Maeksum-seok coin. The patients swallowed the Maeksum-seok coin accidentally while sleeping with the Maeksum-seok coin in their mouth for health reasons. The problem is that it was hard to detect the Maeksum-seok coin by using a simple radiologic study. However, the patients in these cases complained of a sustained foreign body sensation, so we used endoscopy. The foreign bodies were easily detected and removed by endoscopy in both cases.ope

Distribution of Time to Death in Trauma Patients : A Review of 11 years' Experience at a Tertiary Care Teaching Hospital

BACKGROUND: Traumatic death occupies a high ranking in the annual national report on causes of death and causes a significant burden to society. To reduce traumatic death, an area-wide trauma care system is urgently needed, and basic mortality data will be an essential component in designing such a system. The purpose of this study was to review the experience of trauma death in a hospital to determine the pattern of time to death and the effect of the emergency medical services(EMS) system in traumatic death.0aMETHODS: A retrospective analysis of 495 traumatic deaths experienced from 1990 to 2000 was performed. Time to death, mechanism of injury, injury severity, and cause of death were reviewed. The influence of the EMS system before 1995 was compared with its influence after 1995.0aRESULTS: The mean age of the 495 patients was 41.1en the 2nd and 7th days in 9.9%, and later than the 7th day in 12.7%. The majority of early deaths occurred within 4 hr of injury, but a minor increase was noted during the 2nd week. After 1995, the ambulance transportation rate increased significantly without any difference in prehospital interventions.0aCONCLUSION: Our results showed a bimodal distribution of time to death, which reflected geographic, mechanism of injury, and trauma care system differences. We also noted deficiencies in prehospital trauma care in our EMS system. We recommend nationwide trauma registry initiatives to provide basic trauma data and to implement a quality trauma care system.ope

Inter-rater Reliability of the Modified Emergency Severity Index as a Triage Tool

Purpose: Triage in the emergency departmen (ED) is the preliminary clinical sorting process before full disclosure of patients' problems so that patients with the highest acuity are treated first in the setting of resource constraints. To overcome the inter-rater variability of existing triage tools, the Emergency Severity Index (ESI) was developed and was shown to be both valid and reliable in practice. Because of the disparity in practice patterns and some inappropriate criteria in the original ESI, the authors have modified the ESI and determined its inter-rater reliability. Methods: We applied the modified ESI to a convenient sample of adults who visited an urban academic ED between July 24, 2001, and August 5, 2001. After completion of a short, 4-hour training course on the modified ESI, an intern and emergency medicine resident pair triaged the patients independently. The inter-rater reliability was measured using a weighted kappa analysis and was categorized as excellent (?0.8), good (0.60-0.79), or fair (?0.59). Results: Five hundred forty-two patients were enrolled. The overall weighted kappa between the intern and the resident was 0.82 (95% CI : 0.78-0.86). Among the 542 patients, 469/542 (87%) pairs agreed exactly, 67 (12%) pairs disagreed by 1 level, and 6 (1%) pairs by 2 levels. Conclusion: In this study, the modified ESI demonstrated excellent inter-rater reliability when used by residents and interns for our ED patients.ope

Contrast Nephrotoxicity Associated with Emergency CT scans

Purpose: In the last 30 years, there has been a markedly increased use of iodinated contrast agents in diagnostic and interventional radiological procedures. Due to the possible side effect of nephrotoxicity of these radiocontrast agents, we investigated the incidence of nephrotoxicity and attempted to identify the patient groups at higher risk for contrast nephrotoxicity among the patients who underwent emergency computerized tomography. Methods: We reviewed the medical records of 1,572 patients who had undergone contrast computerized tomography at the Emergency Center, Yonsei Medical Center, from January to May 2002. We defined contrast nephrotoxicity as any increase in the creatinine value of more than 0.5 mg/dL (44mol/L) or 25% compared to the vaseline value. Results: We found 21 patients (1.3%) who met the criterion for contrast nephrotoxicity: 13 patients with normal renal function, and 8 patients with a higher than normal creatinine value before contrast-enhanced computerized tomography. The incidence of contrast nephrotoxicity in the patient group with normal renal function was 0.8% (13/1551), compared to 38.1% (8/21) in the pre-existing renal insufficiency group. There were no statistical differences on the amounts of dye used and the frequencies of risk factors for contrast nephrotoxicity between the patients in pre-existing renal insufficiency group who developed nephrotoxicity and who did not. The renal function of all patients returned to the baseline value without dialysis or renal replacement therapy. Conclusion: Pre-existing renal insufficiency is the most important risk factor for contrast nephrotoxicity. We need to take precautions and to have a proper protocol for the prevention of contrast nephrotoxicity in emergency care.ope