姑息医学中的循证医学证据

为了解姑息医学中的循证医学证据，我们检索了Cochrane图书馆（2005年第3期），对针对疾病终末期常见症状的系统评价证据进行了总结。结果发现，阿片类药物可以改善终末期病人的呼吸困难；口服吗啡和氢吗啡酮对癌痛有效；体内外放疗及二膦酸盐对肿瘤转移性骨痛有效；姑息性化疗能提高晚期或已发生转移的结肠癌病人的生存质量。     

International Emergency Medicine and the Role for Academic Emergency Medicine

International emergency medicine continues to grow and expand. There are now more than 30 countries that recognize emergency medicine as a specialty. As the field continues to develop, many physicians are reaching across borders and working with their colleagues to improve patient care, education, and research. The future growth and success of the specialty are based on several key components. These include faculty development (because this is the key driver of education), research, and curriculum development. Each country knows what resources it has and how best to utilize them. Countries that are developing the specialty can seek consultation from successful countries and develop their academic and community practice of emergency medicine. There are many resources available to these countries, including distance learning and access to medical journals via the Internet; international exchanges by faculty, residents, and medical students; and physicians who are in fellowship training programs. International research efforts require more support and effort to be successful. This report discusses some of the advantages and hurdles to such research efforts. Physicians have a responsibility to help one another succeed. It is the hope of the authors that many more emergency physicians will lend their skills to further global development of the specialty.     

Procedural Competency in Emergency Medicine: The Current Range of Resident Experience

OBJECTIVES: To evaluate the recorded range of procedures tracked by emergency medicine (EM) programs, and to determine whether differences in procedural experience occur in various types of residency or hospital settings. METHODS: The program directors of 112 approved EM programs were asked to send actual procedure logs. The requested information included the average total number of a given procedure per graduating resident, for all procedures that were tracked. Data were categorized by program format, hospital type, and ED volume. To assess the global procedural experience among programs, a set of 22 "index procedures" were identified; all procedures the EM residency review committee (RRC-EM) required to be tracked were included in this set. The means per graduating resident for each index procedure were added together to generate a "mean index procedure sum" (MIPS) per graduating resident for each residency program. These MIPSs for a residency were then compared by program format, hospital type, and ED volume. A similar analysis was performed for all resuscitations, and a "mean index resuscitation sum" (MIRS) per graduating resident was generated. RESULTS: An overall response rate of 82% was achieved; a number of programs had not graduated a residency class and were not included. Sixty-five of 85 eligible programs (76%) provided procedural data. The average number of a given procedure per graduating resident (95% CI in parentheses) for selected procedures is as follows: oral intubation 65 (46 to 85), intubation unspecified 75 (62 to 87), nasal intubation 6 (4 to 9), cricothyroidotomy 2 (1 to 2), subclavian catheter 23 (16 to 30), chest tubes 17 (14 to 20), intraosseous line 2 (1 to 3), thoracotomy 3 (2 to 5), and vaginal deliveries 17 (13 to 21). The only statistically significant differences in subgroup comparisons were in diagnostic peritoneal lavage, trauma resuscitations, and pediatric medical resuscitations when compared by postgraduate year format, and intubation-unspecified and cricothyroidotomy when compared by hospital type. There was no statistically significant difference when MIPSs were compared by format, hospital type, or ED volume. CONCLUSIONS: To the authors' knowledge, this is the first study of the range of EM resident procedure experience across the spectrum of EM residency types and settings. Overall, there are few statistically significant differences in procedure experience among different program formats. Similar experiences are recorded in a variety of different hospital types or ED volumes. However, some programs report very limited EM resident experience with selected critical procedures. There is a large variation in the types and numbers of procedures recorded by EM programs.     

Components of the Model of the Clinical Practice of Emergency Medicine: A Survey of American Board of Emergency Medicine Diplomates

Background

The Model of the Clinical Practice of Emergency Medicine is the basis for the content specifications of all American Board of Emergency Medicine (ABEM) examinations. This study describes the frequency with which ABEM diplomates diagnose and manage the conditions and components listed in the Model of the Clinical Practice of Emergency Medicine.

Objectives

The objectives of this study were to determine the frequency with which ABEM diplomates diagnose and manage the conditions and components described in the Model of the Clinical Practice of Emergency Medicine.

Methods

The listing of conditions and components of the Model of the Clinical Practice of Emergency Medicine were sent to 16,230 randomly selected ABEM diplomates. One of five surveys was sent to each diplomate. Each condition and component was assessed by participants for the frequency that emergency physicians diagnose (D) and manage (M) that condition, as seen in their practice of Emergency Medicine.

Results

Of the 16,230 surveys sent, 5006 were returned (30.8% response rate). The genders of the respondents were 75% male and 24% female. The ages of the respondents were primarily in the age 40–49 years, and 30–39 years age groups. All categories of the listing of conditions and components of the Model of the Clinical Practice of Emergency Medicine were encountered frequently in the practice of Emergency Medicine, as indicated by study participants.

Conclusions

A survey of practicing ABEM diplomates was useful in defining the frequency with which specific conditions and components are diagnosed and managed in the practice of Emergency Medicine.     

Emergency medicine in Poland

The article describes the feature of Poland's emergency medicine services system. Pre-hospital emergency medical service (EMS) access, regional differences and the main features of the system are described. EMS personal education and skill level are discussed. The authors offer a critical analysis of the current situation and proposal for the future development of emergency medicine in Poland based on changes in law, organization and education.     

Procedural skills quality assurance among Australasian College for Emergency Medicine fellows and trainees

Objective: Presently, no objective quality control mechanism exists for monitoring procedural skills among Australasian College for Emergency Medicine trainees. The present study examined trainee and fellow procedural experience and perceived competency, participation in accredited training courses and support for a procedural logbook. Methods: A cross‐sectional mail survey of Australasian College for Emergency Medicine advanced trainees and fellows was performed. Experience and perceived competency in 23 common and important ED procedures were examined. Results: In total, 202 fellows and 264 trainees responded (overall response rate 39.0%). Overall, fellow procedural experience and perceived competency were reasonable. However, some fellows had never performed a number of procedures including some common procedures (e.g. nasal packing, fracture reduction) and there were reports of ‘very poor’ competency for 17 (73.9%) procedures. Trainee experience and perceived competency were less than the fellows but showed similar patterns. Perceived numbers of each procedure required to achieve competency varied considerably between the procedures and among the respondents. However, there were no significant differences in the perceived numbers reported by the trainees and the fellows (P > 0.05). Variable proportions of trainees and fellows had undertaken courses that incorporated procedural skills training. More fellows (75.7%, 95% confidence interval 69.1–81.4) than trainees (59.9%, 95% confidence interval 53.6–65.8) supported the use of a procedural logbook (P = 0.003). Conclusions: Lack of experience in some procedures among some fellows, especially commonly performed procedures, might represent a deficiency in existing quality assurance mechanisms for procedural skills training. Greater participation in skills courses, to improve experience in difficult and uncommonly encountered procedures, is recommended. Improved quality assurance mechanisms, including a procedural logbook, should be considered.     

Pediatric Emergency Medicine Education in Emergency Medicine Training Programs

BACKGROUND: The educational goal of emergency medicine (EM) programs has been to prepare its graduates to provide care for a diverse range of patients and presentations, including pediatric patients. OBJECTIVE: To evaluate the methods used to teach pediatric emergency medicine (PEM) to EM residents. METHODS: A written questionnaire was distributed to 118 EM programs. Demographic data were requested concerning the type of residency program, number of residents, required pediatric rotations, elective pediatric rotations, type of hospital and settings in which pediatric patients are seen, and procedures performed. Information was also requested on the educational methods used, proctoring EM received, and any formal curriculum used. RESULTS: Ninety-four percent (111/118) of the programs responded, with 80% of surveys completed by the residency director. Proctoring was primarily performed by PEM attendings and general EM attendings. Formal means of PEM education most often included the EM core curriculum (94%), journal club (95%), EM grand rounds (94%), and EM morbidity and mortality (M&M) conference (91%). Rotations and electives most often included the pediatric intensive care unit (PICU) and the emergency department (ED) (general and pediatric). CONCLUSIONS: Emergency medicine residents are exposed to PEM primarily by rotating through a general ED, the PED, and the PICU, being proctored by PEM and EM attendings and attending EM lectures and EM M&M conferences. Areas that may merit further attention for pediatric emergency training include experience in areas of neonatal resuscitation, pediatric M&M, and specific pediatric electives. This survey highlights the need to describe current educational strategies as a first step to assess perceived effectiveness.     

急诊医学的发展与发展中的急诊医学

自1979年起,急诊医学正式成为医学专业领域的第23个专科。1983年,我国第一个急诊科在北京协和医院成立。目前我国急诊医学目前还处在发展中阶段。急诊医学服务体系（EMSS）涵盖了院前急救、灾害医学、院内急诊及加强治疗等领域。急诊医学在发展中体现出与其他二级学科不同的时间重要性、特殊的临床决策思路、与突发公共卫生事件的密切关系等特点。将来,急诊医生的工作任务应扩展到急诊医学教学和预防、急诊医学基础和临床研究、损伤预防、医学继续教育、灾害医学和（群体伤亡事件MCI）管理、中毒处理和中毒咨询、危险化学品和生物恐怖事件的处理、医院和EMS管理等。急诊科将来的发展需要政府及医院充分认识急诊医学在临床医学中的位置,从政策上给予支持,制定相关的准入制度、专科医师培养制度、福利待遇制度、风险分摊制度等,促进急诊医学在我国的发展。     

Emergency Medicine Leadership in Industry-sponsored Clinical Trials

OBJECTIVE: To identify and characterize emergency medicine (EM) researchers who, since 1990, have served on a steering committee (SC) or as overall principal investigator (PI) of an industry-sponsored, multicenter clinical trial involving a pharmaceutical or device. METHODS: North American EM research directors (RDs) and other prominent EM investigators (for those hospitals without a RD) were identified from eight sources, including the Society for Academic Emergency Medicine RD Interest Group and the Multicenter Airway Research Collaboration (MARC) database. The identified investigators were sent a screening survey requesting information regarding industry-sponsored clinical research at their site. The individual EM investigators identified by this screening survey were then interviewed by telephone (validation survey) to further explore their leadership experience in industry-sponsored clinical trials. RESULTS: Of 153 identified RDs and prominent EM researchers, 138 responded to the screening survey (90% response rate). Eighty-five EM investigators reportedly had served on a SC or as overall PI for an industry-sponsored clinical trial. Of these 85 North American EM investigators, 77 were available for a structured telephone interview (91% response rate). Although 41 (53%) of the investigators confirmed their leadership role, 36 (47%) had not served in either role. Among the 41 confirmed investigators, 19 (25%) had served as a SC member, 10 (13%) had served as overall PI, and 12 (16%) had experience in both roles. Individual responses provided suggestions for pursuing such leadership positions. CONCLUSIONS: These data suggest the opportunity to expand EM leadership in industry-sponsored clinical trials and demonstrate the need for validation of reports obtained by a departmental research contact. The suggestions from EM researchers who have attained these leadership roles may provide strategies for investigators interested in pursuing these positions.     

Physician Medical Direction andClinical Performance at an Established Emergency Medical Services System

Objective. Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop andimplement medical direction andquality assurance programs. We report subsequent changes to system performance over time. Methods. Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, andskills maintenance andeducation programs were implemented. Credentialing, physician chart auditing, clinical remediation, andonline medical command/hospital notification systems were introduced. Results. Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- andpost-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20–0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9–9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004–1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices andsecuring devices (0.7% compliance to 98%, OR 714 [95% CI 64–29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09–1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35–1,604], p < 0.001). Conclusions. We suggest that implementation of a physician medical direction is associated with improved clinical indicators andoverall quality of care at an established EMS system