- Email: [email protected]
Moonlighting Revisited
CORRESPONDENCE
Moonlighting Revisited To the Editor. As practicing emergency physicians in the Pacific Northwest, we read with interest the recent editorial by Kellermann (July 1995;26:83-84). Those of us involved in teaching emergency medicine in the state of Washington applaud Dr Kellermann's comments. Moonlighting in emergency medicine demeans those of us who have sacrificed time and energy to train in the specialty and demoralizes those of us who help train physicians in the specialty of emergency medicine. Most important, we consider it unethical to place patients in the care of physicians with training in other specialties (or with no specialty training) when the patients expect to receive specialty care in emergency medicine. The statement, "in Seattle, the University of Washington,.. does not support an emergency medicine residency training program," however, is incorrect. In July 1995, two University of Washington residents joined the Madigan Army Medical Center (MAMC) emergency medicine residents in an affiliated training program. Four University of Washington residents will join the program in July 1996. The University of Washington Academic Medical Center (UWAMC) is a joint venture comprising the University of Washington Medical Center, Harborview Medical and Trauma Center, and Children's Medical Center. The MAMC/UWAMC affiliation is a first step toward the eventual development of a joint program training military and civilian emergency physicians in Washington state. The combined support of the MAMC military medical command, the dean of the University of Washington Medical Center, and the Washington chapter of the American College of Emergency Physicians has been instrumental in the evolution of this program. The lack of properly trained emergency physicians can result in the substandard care often provided by moonlighters. The University of Washington, through the MAMC/UWAMC affiliation, now supports an emergency medicine residency program. We are confident that in the near future this program will bring the same high-quality emergency medical care enjoyed in the greater
102
Seattle/Tacoma area to other regions of the state and, yes, even to Moses Lake.
LawrenceA Wilson, MD, MAJ, USAMC Departmentof EmergencyMedicine Madigan Army Medical Center Tacoma, Washington Richard 0 Cummins,MD, MPH UWAMC EmergencyMedicine Service Seattle, Washington [Editor's note: The views statedin this letter are those of the authors and do not necessarily reflect the opinion of the US Army.] i
Computed Tomography and Basilar Skull Fracture To the Editor. I read with enthusiasm the recent article by Kadish and Schunk [July 1995;26:37-41). The authors retrospectively reviewed 239 patients with basilar skull fractures (BSFs) and subcategerized a group of patients as having "simple BSFs" who met the following criteria: normal neurelogic examination findings, Glasgow Coma Scale (GCS) score of 15, and computed tomography (CT) of the head negative for intracranial pathology. The authors suggested that this group is at low risk for complications and that hospitalization may not be necessary. I have many questions for the authors about their data analysis. Beyond the authors' immediate objectives, their study raises many questions for emergency physicians caring for head-injured patients in general. I had hoped that this study would aid me in my daily practice; however, I found no clinical applicability to the practicing community emergency specialist. The authors note that of the 239 patients found to have BSFs, 51 (21%) had no clinical findings of BSF and their BSFs were diagnosed solely on the basis of CT findings, whereas 188 (79%) had clinical signs of BSF. The following were considered clinical signs of BSF: hemotympanum, cerebrospinal fluid rhinerrhea, blood in the ear not associated with local trauma, cranial nerve palsy, raccoon eyes, or Battle's sign. Later, the authors analyze their data comparing GCS score or abnormal neurologic
findings and indicate that 30 of the 144 patients with normal neurologic findings and GCS score of 15 had CT scans demonstrating intracranial pathology. My question for the authors is, what percent of these patients are a part of the 51 patients (21%) with no clinical findings of BSF and with CT findings as the sole indicator of BSF? This is an extremely important analysis point that has been overlooked; most clinicians would not have ordered CT of the head in a patient with normal neurologic findings, a GCS score of 15, and no clinical findings. Even though CT is now widely available and our hospital has 24-hour CT capability, not every patient with a head strike can undergo CT. The authors list many limitations to their study, and aside from the inherent problems with retrospective studies, the reasons the CT scan of the head was obtained would be of the most interest in these patients. None of the 30 patients with intracranial injury required neurosurgery. Although this study does not address this question, it would be most clinically relevant to determine which patients with head strikes (minor head injury without loss of consciousness or amnesia) had intracranial injury (intracerebral, subdural, epidural, subarachnoid hemorrhages) requiring emergency craniotomy. A study evaluating clinical predictors in head-injured pediatric patients found that no single characteristic consistently identified intracranial injury. 1 This study gives outcomes in patients who underwent CT and the associated historical and clinical findings but does not give clear selection criteria of patients with head trauma requiring CT or reveal the outcomes of patients with head trauma in whom CT was not performed. Similarly, on evaluation of the ability to predict positive CT findings on the basis of patient complaints and examination findings, there was a high correlation of acute abnormalities; however, 29.2% of the acutely positive scans were in the remote or low prediction category. 2 Conversely, others have determined that excluding CT in patients with minor head injuries is safe. 3 In this study patients were admitted for observation, but no guidelines existed for determination of which patients would undergo CT.
ANNALS OF EMERGENCY MEDICINE
27:1 J A N U A R Y
1996
Moonlighting Revisited To the Editor. As practicing emergency physicians in the Pacific Northwest, we read with interest the recent editorial by Kellermann (July 1995;26:83-84). Those of us involved in teaching emergency medicine in the state of Washington applaud Dr Kellermann's comments. Moonlighting in emergency medicine demeans those of us who have sacrificed time and energy to train in the specialty and demoralizes those of us who help train physicians in the specialty of emergency medicine. Most important, we consider it unethical to place patients in the care of physicians with training in other specialties (or with no specialty training) when the patients expect to receive specialty care in emergency medicine. The statement, "in Seattle, the University of Washington,.. does not support an emergency medicine residency training program," however, is incorrect. In July 1995, two University of Washington residents joined the Madigan Army Medical Center (MAMC) emergency medicine residents in an affiliated training program. Four University of Washington residents will join the program in July 1996. The University of Washington Academic Medical Center (UWAMC) is a joint venture comprising the University of Washington Medical Center, Harborview Medical and Trauma Center, and Children's Medical Center. The MAMC/UWAMC affiliation is a first step toward the eventual development of a joint program training military and civilian emergency physicians in Washington state. The combined support of the MAMC military medical command, the dean of the University of Washington Medical Center, and the Washington chapter of the American College of Emergency Physicians has been instrumental in the evolution of this program. The lack of properly trained emergency physicians can result in the substandard care often provided by moonlighters. The University of Washington, through the MAMC/UWAMC affiliation, now supports an emergency medicine residency program. We are confident that in the near future this program will bring the same high-quality emergency medical care enjoyed in the greater
102
Seattle/Tacoma area to other regions of the state and, yes, even to Moses Lake.
LawrenceA Wilson, MD, MAJ, USAMC Departmentof EmergencyMedicine Madigan Army Medical Center Tacoma, Washington Richard 0 Cummins,MD, MPH UWAMC EmergencyMedicine Service Seattle, Washington [Editor's note: The views statedin this letter are those of the authors and do not necessarily reflect the opinion of the US Army.] i
Computed Tomography and Basilar Skull Fracture To the Editor. I read with enthusiasm the recent article by Kadish and Schunk [July 1995;26:37-41). The authors retrospectively reviewed 239 patients with basilar skull fractures (BSFs) and subcategerized a group of patients as having "simple BSFs" who met the following criteria: normal neurelogic examination findings, Glasgow Coma Scale (GCS) score of 15, and computed tomography (CT) of the head negative for intracranial pathology. The authors suggested that this group is at low risk for complications and that hospitalization may not be necessary. I have many questions for the authors about their data analysis. Beyond the authors' immediate objectives, their study raises many questions for emergency physicians caring for head-injured patients in general. I had hoped that this study would aid me in my daily practice; however, I found no clinical applicability to the practicing community emergency specialist. The authors note that of the 239 patients found to have BSFs, 51 (21%) had no clinical findings of BSF and their BSFs were diagnosed solely on the basis of CT findings, whereas 188 (79%) had clinical signs of BSF. The following were considered clinical signs of BSF: hemotympanum, cerebrospinal fluid rhinerrhea, blood in the ear not associated with local trauma, cranial nerve palsy, raccoon eyes, or Battle's sign. Later, the authors analyze their data comparing GCS score or abnormal neurologic
findings and indicate that 30 of the 144 patients with normal neurologic findings and GCS score of 15 had CT scans demonstrating intracranial pathology. My question for the authors is, what percent of these patients are a part of the 51 patients (21%) with no clinical findings of BSF and with CT findings as the sole indicator of BSF? This is an extremely important analysis point that has been overlooked; most clinicians would not have ordered CT of the head in a patient with normal neurologic findings, a GCS score of 15, and no clinical findings. Even though CT is now widely available and our hospital has 24-hour CT capability, not every patient with a head strike can undergo CT. The authors list many limitations to their study, and aside from the inherent problems with retrospective studies, the reasons the CT scan of the head was obtained would be of the most interest in these patients. None of the 30 patients with intracranial injury required neurosurgery. Although this study does not address this question, it would be most clinically relevant to determine which patients with head strikes (minor head injury without loss of consciousness or amnesia) had intracranial injury (intracerebral, subdural, epidural, subarachnoid hemorrhages) requiring emergency craniotomy. A study evaluating clinical predictors in head-injured pediatric patients found that no single characteristic consistently identified intracranial injury. 1 This study gives outcomes in patients who underwent CT and the associated historical and clinical findings but does not give clear selection criteria of patients with head trauma requiring CT or reveal the outcomes of patients with head trauma in whom CT was not performed. Similarly, on evaluation of the ability to predict positive CT findings on the basis of patient complaints and examination findings, there was a high correlation of acute abnormalities; however, 29.2% of the acutely positive scans were in the remote or low prediction category. 2 Conversely, others have determined that excluding CT in patients with minor head injuries is safe. 3 In this study patients were admitted for observation, but no guidelines existed for determination of which patients would undergo CT.
ANNALS OF EMERGENCY MEDICINE
27:1 J A N U A R Y
1996