- Email: [email protected]
Computer-assisted instruction in trauma
ABSTRACTS
Pediatric Curriculum for Emergency Medicine Training Program JV Weigand, SM Asch / Department of Emergency Medicine, Akron City Hospital; Division of Emergency/Trauma Services, Children's Hospital Medical Center of Akron, Akron, Ohio Reviews of current emergency medicine residency programs repeatedly document deficiencies in the teaching and clinical experience of emergency pediatrics. To remedy this, a group of experienced teachers of emergency medicine and emergency pediatrics have jointly designed and pilot tested an integrated curriculum designed to operate within a 3-year emergency medicine residency. This integrated pediatric curriculum identifies educational objectives for training in pediatric emergencies and provides a specific plan for meeting these objectives with coordinated readings, laboratories, demonstrations, and intensive clinical encounters. The format also demonstrates how these methods may be utilized flexibly to capitalize on the particular strengths of individual emergency medical residencies and their trainees.
Emergency Pediatric Tracheotomies: A Usable Technique and Model for Instruction JH McLaughlin. KV Iserson / Section of Emergency Medicine.
Arizona Health Sciences Center. Tucson We have developed a reliable technique for emergency pediatric tracheotomy and a model for practicing the procedure. Because such emergency surgical access is rarely demanded of emergency physicians or pediatricians, few have the opportunity to become p r o f i c i e n t with this d r a m a t i c life-saving maneuver. Cricothyrotomy is precluded by the small size of the cricothyroid space in infants and small children, and the conventional tracheotomy technique requires considerable experience and operative equipment. Our technique uses basic equipment found in any ED: syringe, needle, scalpel, and endotracheal tube: It may be used to manage complete a~rway obstruction from edema or foreigu bOdies, facial or laryngeal fractures, laryngospasm or apnea with possible cervical spine injury. A finder needle and a salinefilled syringe are used to locate the small and poorly defined trachea. When the saline flows freely of when air bubbles enter the syringe, indicating entrance into the lumen, the needle is stabilized and a stabbing incision is made lateral to and against the needle. Using the knife handle to open the stoma, the needle is removed and a standard pediatric endotracheal tube is inserted. We have found the anesthetized kitten weighing 1,000-1,500 g to be a useful model for teaching and rehearsing this technique. This size cat has a tracheal diameter of 5.5-6.0 mm, which is equivalent to that of a child under 1 year of age. Adult cats in the 4,000 g range simulate well the older child. Teaching sessions involving emergency medicine faculty, residents, and medical students indicate that this method helps nonsurgeons to secure an adequate airway. The participants in the teaching sessions had no prior formal training in tracheotomies and varied experience with cricothyrotomy. Practice with this model greatly enhanced their confidence and skill. Experience using this model can enable emergency practitioners to become confident w i t h this method for emergency pediatric traeheotomy and to perform successfully in the critical situations when conservative airway management will not suffice.
0
Computer Simulation of CPR: Computer Analysis of a Simple Electrical Model of the Circulation
SA Meador/Department of Medicine, Emergency Medicine
Division, The Milton S Hershey Medical Center, The Pennsylvania State University, Hershey There have been n u m e r o u s attempts to model the cardio172/492
vascular system. Most have been concerned with the hemodynamic properties of blood flow with a beating heart. Recently work using a simple electrical model of the circulation to simulate the hemodynamics of cardiopulmonary resuscitation (CPR) has been published. This hard-wired circuit consists of the heart and great vessels modeled as a resistive-capacitive network, pressure as voltage, blbod flow as current, blood inertia as inductance; and vascular valves as diodes. Such a model is useful for examining the physiology of various methods and techniques of CPR administration. In this investigation, a general purpose circuit simulation program, SPICE Version 2G.1, was used to analyze previously published CPR models. With minor modifications, the program was able to reproduce fully the hard-wired circuit results. The program is very flexible, allowing for easy model modification and a wide range Of parameter values. In addition, the program offers the advantages of increased accuracy and low cost. Suggested future applications are for rapid evaluation of new CPR concepts.
1
Application of Microcomputers in the Emergency Department: Experience with a Computerized Logbook
SJ Januzik / Department of Emergency Medicine, Butterworth
Hospital, Grand Rapids, Michigan The JCAH regulations stipulate that every ED maintain a control register or logbook of the patients seen. Typically, logbooks consist of a handwritten record maintained by the ED clerical staff. The retrieval of logbook data is characteristically a slow and tedious task prone to error commensurate with the fatigue of the searcher. In addition, the medical records department must be able to retrieve patient information to satisfy physician requests, admissions lists, ED deaths, and long-term recordkeeping. Furthermore, the effectiveness of the logbook is highly dependent on the legibility of the handwriting. A computerized logbook has been developed for use on personal microcomputers utilizing an econOmical database management system. Each patient record consists of 17 fields, including basic identifying data, chief complaint, diagnosis, physicians involved, and disposition. The daily log of patients seen is a computer-generated printout containing nearly 4 times the number of patients per printed page as our handwritten 10g system. Our ED utilizes this information to generate data listings which would be too time consuming to obtain by conventional manual methods. It is now possible t o obtain listings of admissions, mortalities, daily radiographs, laboratory cultures, and physician patient lists. The log also may be transported on magnetic disk tO other personal computers for medical record uses. The system is a valuable resource in an emergency medicine residency, and allows our program to generate interesting case and radiograph listings. Research data can be obtained in a fraction of the amount of time and effort usually required by manual methods. The database is capable of searching or Sorting any record field, making it useful for quality assurance purposes. The advantage of an easy-to-use database management system in the ED permits any physician or staff member to obtain information on a 24-h basis without depending on hospital computer personnel.
2
Computer-Assisted Instruction in Trauma
RD Evans, S Brotman / Department of Surgery, Geisinger Medical Center, Danville, Pennsylvania In an effort to improve education in trauma, a computer interactive program was developed for self-education and teaching. The program consists of Cases presented as patient management problems. Multiple choice answers are provided and a series of interactive loops is used to discuss both the correct and incorrect choices. Program branching is used to provide different outcomes
Annals of Emergency Medicine
14:5 May 1985
in certain cases. A case book containing radiographs, gram-stainS, and other visual aids is used with the program. This system also has the capability of record keeping for testing purposes. It provides a simple, cost-effective method of developing instructional programs for self-education.
3
5 Comparison of a Videotape Instructional Program with a Traditional Lecture Series for Medical Student Emergency Medicine Teaching
P Kline, R Shesser, M Smith, T Turbiak, R Rosenthal, H Chen,
R Wails / Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC A n e m e r g e n c y m e d i c i n e faculty has r e p o r t e d t h a t use of videotape for presenting curricular material to medical students is both cost-effective and well-suited to the educational milieu of the ED. In order to compare the effectiveness of videotape instruction w i t h that of a traditional lecture, groups of students received instruction in one topic by videotape and in another topic by lecture. The students' retention of material was tested by a multiple-choice examination administered 10 days later. The students scored 77% (430/550) on questions about material taught by lecture, and 73% (396/540} on questions about material taught by videotape (P > .10). Study participants surveyed indicated that t h e v i d e o t a p e f o r m a t was well received. We c o n c l u d e t h a t videotape instruction is well received by students and is as effective an educational tool as the traditional lecture for an emergency medicine course.
4
daily chart review for quality assurance purposes as described is effective in reducing physician charting and patient care errors in a setting of frequent resident physician turnover.
Emergency Department Daily Chart Review for Quality Assurance: One-Year Prospective Study in an Emergency Medicine Residency Program
ML Martin, FP Harchelroad, RM Kremen, KW Murray / Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh A prospective study utilizing a daily patient chart review of 11 categories of physician documentation and patient care was carried out over a 12-month period (September 1983 - - August 1984) for quality assurance purposes. T h e Joint C o m m i s s i o n on Accreditation of Hospitals requires an assessment of adequacy of e m e r g e n c y services r e n d e r e d and c h a r t d o c u m e n t a t i o n . T h e charts of 35,147 emergency patients at the authors' institution, a 3 6 - m o n t h e m e r g e n c y m e d i c i n e r e s i d e n c y program, were reviewed. The 11 categories surveyed included history and physical examinations; treatment; medication; disposition; consultation; ECGs; radiographs; laboratory data; diagnosis; physician signature; and time patient seen by a physician. All new physicians (those having 2 m o n t h s or less previous experience in t h e departm e n t - - all were PGY I or PGY II residents) rotated in convenient 2-month blocks and received orientation to patient care and chart d o c u m e n t a t i o n expectations prior to starting the service. T h e daily quality assurance chart review was done w i t h i n 24 hours of patient discharge and was approximately a 4-h0ur-a-day responsibility of 2 emergency-medicine certified, registered nurse practitioners w i t h attending physician supervision. Feedback on errors in all Categories was given to the physician(s) responsible. Necessary corrections were made as soon as possible. To test the hypothesis that the quality assurance system significantly reduced the percentage of errors, a one-sided paired t test was performed comparing the average of the percentage of errors for all the firstm o n t h s (A) w i t h the average of the percentage of errors for all the second m o n t h s (B) of the t w o - m o n t h block rotations. The m e a n percentage of errors in B was found to be significantly lower than in A (t = 2.35; P = .032). Third-year emergency medicine residents and attending physicians supervising the department were treated as relative constant factors. Their presence most likely influenced an observed trend of decreasing total m o n t h l y errors over the 12-month period. We concluded from this study t h a t a
14:5 May 1985
Effectiveness of an Organized Emergency Department Follow-up System
R Shesser, M Smith, S Garson, S Adams / Department of
Emergency Medicine, The George Washington University Medical Center, Washington, DC Hospitals and t h e i r emergency physician groups will benefit from m a n a g e m e n t strategies t h a t increase patien t satisfaction and improve the quality of care. An organized telephone followup system permits a second contact between the patient and the ED that may be useful for monitoring disease progression, for reinforcing aftercare and referral instructions, and for improving the patient's perception of the ED visi£ We randomly assigned half the patients discharged h o m e from the ED w i t h the diagnoses of acute infection, musculoskeletal strain, bronchospasm, allergic reaction, or undiagnosed chest/abdominal pain to receive a follow-up telephone call 2-3 days after their visit. Patients in the follow-up call (study) group were telephoned by an ED nurse, who questioned the patients about changes in their clinical status and clarified the aftercare and referral instructions received during the ED visit. Seven days after the visit, a questionnair e that rated patient satisfaction about 6 aspects of the ED visit was sent to those study group patients who had been contacted and to a diagnosis-matched (control) group of patients who did not receive a follow-up call. A nurse was able to reach 145 of the 297 patients assigned to the study group, making an average of 1.68 + .96 calls per p a t i e n t t h a t lasted an average of 6 m i n u t e s . One nurse was able to complete all the calls to one day's designated patients w i t h i n 4 hours. Significant referral and aftercare interventions were made in 54 cases (35%), including 2 patients who were i n s t r u c t e d to r e t u r n to the ED. Q u e s t i o n n a i r e s were returned by 82 of 145 (49%) in the study group and 93 of 262 (35%) in the control group. The average score in all 6 patient satisfaction categories was higher i n the study group t h a n in the control group of patients (P < .02). We conclude that a follow-up call system for defined patient subsets is feasible, effective in improving aspects of patient care, and will positively influence patients' perceptions of their ED visits.
6
Effect of a Treatment Protocol on the Efficiency of Care by Houseofficers to the Adult with Acute Asthma
SM Schneider / Medical Emergency Services, Montefiore Hospital;
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh A s t h m a t i c s present frequently to o u r adult ED. We b e c a m e concerned about the length of t i m e asthmatics spent in our dep a r t m e n t as well as frequent return visits and a high admission rate. We attempted to correct this situation by creating an aggressive treatment protocol based on the literature available in this area. The patient was first treated w i t h beta-agonists - - Epin e p h r i n e ( w i t h h e l d if age less t h a n 35), Isoetherine, and A1buterol. These were repeated every 30 minutes (Epinephrine limited to 3 total doses). If after any 30-minute period the patient failed to respond, a loading dose of aminophylline was given over a 30-minute period, and a m a i n t e n a n c e infusion was begum Betaagonists were continued throughout this time. Failure to respond over any 1-hour period while on m a i n t e n a n c e infusion led to admission. Steroids were initiated only on admitted patients. The patient's response was measured both subjectively by the houseofficer as well as objectively by spirometry. Each patient was to be assessed in this m a n n e r every 30 minutes. Response was defined as an improvement of 20% in their FeV1. A patient was a candidate for discharge w h e n the FeV1 reached 70% of predicted or 70% of normal baseline. A rebound visit was defined as a re-
Annals of Emergency Medicine
493/173
Pediatric Curriculum for Emergency Medicine Training Program JV Weigand, SM Asch / Department of Emergency Medicine, Akron City Hospital; Division of Emergency/Trauma Services, Children's Hospital Medical Center of Akron, Akron, Ohio Reviews of current emergency medicine residency programs repeatedly document deficiencies in the teaching and clinical experience of emergency pediatrics. To remedy this, a group of experienced teachers of emergency medicine and emergency pediatrics have jointly designed and pilot tested an integrated curriculum designed to operate within a 3-year emergency medicine residency. This integrated pediatric curriculum identifies educational objectives for training in pediatric emergencies and provides a specific plan for meeting these objectives with coordinated readings, laboratories, demonstrations, and intensive clinical encounters. The format also demonstrates how these methods may be utilized flexibly to capitalize on the particular strengths of individual emergency medical residencies and their trainees.
Emergency Pediatric Tracheotomies: A Usable Technique and Model for Instruction JH McLaughlin. KV Iserson / Section of Emergency Medicine.
Arizona Health Sciences Center. Tucson We have developed a reliable technique for emergency pediatric tracheotomy and a model for practicing the procedure. Because such emergency surgical access is rarely demanded of emergency physicians or pediatricians, few have the opportunity to become p r o f i c i e n t with this d r a m a t i c life-saving maneuver. Cricothyrotomy is precluded by the small size of the cricothyroid space in infants and small children, and the conventional tracheotomy technique requires considerable experience and operative equipment. Our technique uses basic equipment found in any ED: syringe, needle, scalpel, and endotracheal tube: It may be used to manage complete a~rway obstruction from edema or foreigu bOdies, facial or laryngeal fractures, laryngospasm or apnea with possible cervical spine injury. A finder needle and a salinefilled syringe are used to locate the small and poorly defined trachea. When the saline flows freely of when air bubbles enter the syringe, indicating entrance into the lumen, the needle is stabilized and a stabbing incision is made lateral to and against the needle. Using the knife handle to open the stoma, the needle is removed and a standard pediatric endotracheal tube is inserted. We have found the anesthetized kitten weighing 1,000-1,500 g to be a useful model for teaching and rehearsing this technique. This size cat has a tracheal diameter of 5.5-6.0 mm, which is equivalent to that of a child under 1 year of age. Adult cats in the 4,000 g range simulate well the older child. Teaching sessions involving emergency medicine faculty, residents, and medical students indicate that this method helps nonsurgeons to secure an adequate airway. The participants in the teaching sessions had no prior formal training in tracheotomies and varied experience with cricothyrotomy. Practice with this model greatly enhanced their confidence and skill. Experience using this model can enable emergency practitioners to become confident w i t h this method for emergency pediatric traeheotomy and to perform successfully in the critical situations when conservative airway management will not suffice.
0
Computer Simulation of CPR: Computer Analysis of a Simple Electrical Model of the Circulation
SA Meador/Department of Medicine, Emergency Medicine
Division, The Milton S Hershey Medical Center, The Pennsylvania State University, Hershey There have been n u m e r o u s attempts to model the cardio172/492
vascular system. Most have been concerned with the hemodynamic properties of blood flow with a beating heart. Recently work using a simple electrical model of the circulation to simulate the hemodynamics of cardiopulmonary resuscitation (CPR) has been published. This hard-wired circuit consists of the heart and great vessels modeled as a resistive-capacitive network, pressure as voltage, blbod flow as current, blood inertia as inductance; and vascular valves as diodes. Such a model is useful for examining the physiology of various methods and techniques of CPR administration. In this investigation, a general purpose circuit simulation program, SPICE Version 2G.1, was used to analyze previously published CPR models. With minor modifications, the program was able to reproduce fully the hard-wired circuit results. The program is very flexible, allowing for easy model modification and a wide range Of parameter values. In addition, the program offers the advantages of increased accuracy and low cost. Suggested future applications are for rapid evaluation of new CPR concepts.
1
Application of Microcomputers in the Emergency Department: Experience with a Computerized Logbook
SJ Januzik / Department of Emergency Medicine, Butterworth
Hospital, Grand Rapids, Michigan The JCAH regulations stipulate that every ED maintain a control register or logbook of the patients seen. Typically, logbooks consist of a handwritten record maintained by the ED clerical staff. The retrieval of logbook data is characteristically a slow and tedious task prone to error commensurate with the fatigue of the searcher. In addition, the medical records department must be able to retrieve patient information to satisfy physician requests, admissions lists, ED deaths, and long-term recordkeeping. Furthermore, the effectiveness of the logbook is highly dependent on the legibility of the handwriting. A computerized logbook has been developed for use on personal microcomputers utilizing an econOmical database management system. Each patient record consists of 17 fields, including basic identifying data, chief complaint, diagnosis, physicians involved, and disposition. The daily log of patients seen is a computer-generated printout containing nearly 4 times the number of patients per printed page as our handwritten 10g system. Our ED utilizes this information to generate data listings which would be too time consuming to obtain by conventional manual methods. It is now possible t o obtain listings of admissions, mortalities, daily radiographs, laboratory cultures, and physician patient lists. The log also may be transported on magnetic disk tO other personal computers for medical record uses. The system is a valuable resource in an emergency medicine residency, and allows our program to generate interesting case and radiograph listings. Research data can be obtained in a fraction of the amount of time and effort usually required by manual methods. The database is capable of searching or Sorting any record field, making it useful for quality assurance purposes. The advantage of an easy-to-use database management system in the ED permits any physician or staff member to obtain information on a 24-h basis without depending on hospital computer personnel.
2
Computer-Assisted Instruction in Trauma
RD Evans, S Brotman / Department of Surgery, Geisinger Medical Center, Danville, Pennsylvania In an effort to improve education in trauma, a computer interactive program was developed for self-education and teaching. The program consists of Cases presented as patient management problems. Multiple choice answers are provided and a series of interactive loops is used to discuss both the correct and incorrect choices. Program branching is used to provide different outcomes
Annals of Emergency Medicine
14:5 May 1985
in certain cases. A case book containing radiographs, gram-stainS, and other visual aids is used with the program. This system also has the capability of record keeping for testing purposes. It provides a simple, cost-effective method of developing instructional programs for self-education.
3
5 Comparison of a Videotape Instructional Program with a Traditional Lecture Series for Medical Student Emergency Medicine Teaching
P Kline, R Shesser, M Smith, T Turbiak, R Rosenthal, H Chen,
R Wails / Department of Emergency Medicine, The George Washington University Medical Center, Washington, DC A n e m e r g e n c y m e d i c i n e faculty has r e p o r t e d t h a t use of videotape for presenting curricular material to medical students is both cost-effective and well-suited to the educational milieu of the ED. In order to compare the effectiveness of videotape instruction w i t h that of a traditional lecture, groups of students received instruction in one topic by videotape and in another topic by lecture. The students' retention of material was tested by a multiple-choice examination administered 10 days later. The students scored 77% (430/550) on questions about material taught by lecture, and 73% (396/540} on questions about material taught by videotape (P > .10). Study participants surveyed indicated that t h e v i d e o t a p e f o r m a t was well received. We c o n c l u d e t h a t videotape instruction is well received by students and is as effective an educational tool as the traditional lecture for an emergency medicine course.
4
daily chart review for quality assurance purposes as described is effective in reducing physician charting and patient care errors in a setting of frequent resident physician turnover.
Emergency Department Daily Chart Review for Quality Assurance: One-Year Prospective Study in an Emergency Medicine Residency Program
ML Martin, FP Harchelroad, RM Kremen, KW Murray / Division of Emergency Medicine, Allegheny General Hospital, Pittsburgh A prospective study utilizing a daily patient chart review of 11 categories of physician documentation and patient care was carried out over a 12-month period (September 1983 - - August 1984) for quality assurance purposes. T h e Joint C o m m i s s i o n on Accreditation of Hospitals requires an assessment of adequacy of e m e r g e n c y services r e n d e r e d and c h a r t d o c u m e n t a t i o n . T h e charts of 35,147 emergency patients at the authors' institution, a 3 6 - m o n t h e m e r g e n c y m e d i c i n e r e s i d e n c y program, were reviewed. The 11 categories surveyed included history and physical examinations; treatment; medication; disposition; consultation; ECGs; radiographs; laboratory data; diagnosis; physician signature; and time patient seen by a physician. All new physicians (those having 2 m o n t h s or less previous experience in t h e departm e n t - - all were PGY I or PGY II residents) rotated in convenient 2-month blocks and received orientation to patient care and chart d o c u m e n t a t i o n expectations prior to starting the service. T h e daily quality assurance chart review was done w i t h i n 24 hours of patient discharge and was approximately a 4-h0ur-a-day responsibility of 2 emergency-medicine certified, registered nurse practitioners w i t h attending physician supervision. Feedback on errors in all Categories was given to the physician(s) responsible. Necessary corrections were made as soon as possible. To test the hypothesis that the quality assurance system significantly reduced the percentage of errors, a one-sided paired t test was performed comparing the average of the percentage of errors for all the firstm o n t h s (A) w i t h the average of the percentage of errors for all the second m o n t h s (B) of the t w o - m o n t h block rotations. The m e a n percentage of errors in B was found to be significantly lower than in A (t = 2.35; P = .032). Third-year emergency medicine residents and attending physicians supervising the department were treated as relative constant factors. Their presence most likely influenced an observed trend of decreasing total m o n t h l y errors over the 12-month period. We concluded from this study t h a t a
14:5 May 1985
Effectiveness of an Organized Emergency Department Follow-up System
R Shesser, M Smith, S Garson, S Adams / Department of
Emergency Medicine, The George Washington University Medical Center, Washington, DC Hospitals and t h e i r emergency physician groups will benefit from m a n a g e m e n t strategies t h a t increase patien t satisfaction and improve the quality of care. An organized telephone followup system permits a second contact between the patient and the ED that may be useful for monitoring disease progression, for reinforcing aftercare and referral instructions, and for improving the patient's perception of the ED visi£ We randomly assigned half the patients discharged h o m e from the ED w i t h the diagnoses of acute infection, musculoskeletal strain, bronchospasm, allergic reaction, or undiagnosed chest/abdominal pain to receive a follow-up telephone call 2-3 days after their visit. Patients in the follow-up call (study) group were telephoned by an ED nurse, who questioned the patients about changes in their clinical status and clarified the aftercare and referral instructions received during the ED visit. Seven days after the visit, a questionnair e that rated patient satisfaction about 6 aspects of the ED visit was sent to those study group patients who had been contacted and to a diagnosis-matched (control) group of patients who did not receive a follow-up call. A nurse was able to reach 145 of the 297 patients assigned to the study group, making an average of 1.68 + .96 calls per p a t i e n t t h a t lasted an average of 6 m i n u t e s . One nurse was able to complete all the calls to one day's designated patients w i t h i n 4 hours. Significant referral and aftercare interventions were made in 54 cases (35%), including 2 patients who were i n s t r u c t e d to r e t u r n to the ED. Q u e s t i o n n a i r e s were returned by 82 of 145 (49%) in the study group and 93 of 262 (35%) in the control group. The average score in all 6 patient satisfaction categories was higher i n the study group t h a n in the control group of patients (P < .02). We conclude that a follow-up call system for defined patient subsets is feasible, effective in improving aspects of patient care, and will positively influence patients' perceptions of their ED visits.
6
Effect of a Treatment Protocol on the Efficiency of Care by Houseofficers to the Adult with Acute Asthma
SM Schneider / Medical Emergency Services, Montefiore Hospital;
Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh A s t h m a t i c s present frequently to o u r adult ED. We b e c a m e concerned about the length of t i m e asthmatics spent in our dep a r t m e n t as well as frequent return visits and a high admission rate. We attempted to correct this situation by creating an aggressive treatment protocol based on the literature available in this area. The patient was first treated w i t h beta-agonists - - Epin e p h r i n e ( w i t h h e l d if age less t h a n 35), Isoetherine, and A1buterol. These were repeated every 30 minutes (Epinephrine limited to 3 total doses). If after any 30-minute period the patient failed to respond, a loading dose of aminophylline was given over a 30-minute period, and a m a i n t e n a n c e infusion was begum Betaagonists were continued throughout this time. Failure to respond over any 1-hour period while on m a i n t e n a n c e infusion led to admission. Steroids were initiated only on admitted patients. The patient's response was measured both subjectively by the houseofficer as well as objectively by spirometry. Each patient was to be assessed in this m a n n e r every 30 minutes. Response was defined as an improvement of 20% in their FeV1. A patient was a candidate for discharge w h e n the FeV1 reached 70% of predicted or 70% of normal baseline. A rebound visit was defined as a re-
Annals of Emergency Medicine
493/173