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Background: Patients who survive gunshot wounds often have retained missiles. Unlike intra-articular retained missiles, extra-articular retained missiles (EARMs) are not routinely removed. Cases of lead toxicity from EARMs have been described. This study seeks to determine whether blood lead levels are elevated in emergency department patients with EARMs compared with matched controls, whether clinical symptoms of lead toxicity are more prevalent in patients with EARMs than in controls, and whether longer missile retention times or recent hypermetabolic conditions are associated with higher blood lead levels., Methods: One hundred twenty adults with EARMs and 120 age- and gender-matched controls with no history of gunshot wound were prospectively enrolled on presentation to a large urban emergency department. Whole blood lead (WBL), zinc protoporphyrin, and hemoglobin levels were obtained. Patients completed a questionnaire regarding time since gunshot injury; symptoms of lead toxicity; and occurrence within 30 days of any surgery, alcohol abuse, illicit drug abuse, diabetic ketoacidosis, hyperthyroidism, infection, fracture, pregnancy, or lactation., Results: Five EARM patients (4%) and no control patients (0%) had WBL greater than our threshold for medical follow-up (20 microg/dL). Mean WBL was 6.71 microg/dL (95% confidence interval [CI], 5.68-7.74 microg/dL) in EARM patients and 3.16 mug/dL (95% CI, 2.79-3.53 microg/dL) in controls. This difference was statistically significant when analyzed by matched pairs t test (p = 0.0001). There was no difference in the number of symptoms associated with lead toxicity that were noted by EARM patients versus controls (p = 0.377). Longer duration of missile retention was not associated with higher blood lead levels (r = 0.125, p = 0.172). Of the five hypermetabolic conditions analyzed, only fractures were associated with elevated blood lead levels (9.95 microg/dL [95% CI, 5.77-14.13 microg/dL] in EARM patients with fractures vs. 6.23 microg/dL [95% CI, 5.23-7.23 microg/dL] in EARM patients without fractures)., Conclusion: Patients with EARMs have significantly elevated blood lead levels compared with matched controls. The occurrence of a bony fracture within the past 30 days is associated with a higher lead level. In 96% of patients with EARMs, elevated lead levels were not clinically significant and did not change patient management.

Context: Emergency department (ED) physicians often are uncertain about where in the hospital to triage patients with suspected acute cardiac ischemia. Many patients are triaged unnecessarily to intensive or intermediate cardiac care units., Objective: To determine whether use of a clinical decision rule improves physicians' hospital triage decisions for patients with suspected acute cardiac ischemia., Design and Setting: Prospective before-after impact analysis conducted at a large, urban, US public hospital., Participants: Consecutive patients admitted from the ED with suspected acute cardiac ischemia during 2 periods: preintervention group (n = 207 patients enrolled in March 1997) and intervention group (n = 1008 patients enrolled in August-November 1999)., Intervention: An adaptation of a previously validated clinical decision rule was adopted as the standard of care in the ED after a 3-month period of pilot testing and training. The rule predicts major cardiac complications within 72 hours after evaluation in the ED and stratifies patients' risk of major complications into 4 groups--high, moderate, low, and very low--according to electrocardiographic findings and presence or absence of 3 clinical predictors in the ED., Main Outcome Measures: Safety of physicians' triage decisions, defined as the proportion of patients with major cardiac complications who were admitted to inpatient cardiac care beds (coronary care unit or inpatient telemetry unit); efficiency of decisions, defined as the proportion of patients without major complications who were triaged to an ED observation unit or an unmonitored ward., Results: By intention-to-treat analysis, efficiency was higher in the intervention group (36%) than the preintervention group (21%) (difference, 15%; 95% confidence interval [CI], 8%-21%; P<.001). Safety was not significantly different (94% in the intervention group vs 89%; difference, 5%; 95% CI, -11% to 39%; P =.57). Subgroup analysis of intervention-group patients showed higher efficiency when physicians actually used the decision rule (38% vs 27%; difference, 11%; 95% CI, 3%-18%; P =.01). Improved efficiency was explained solely by different triage decisions for very low-risk patients. Most surveyed physicians (16/19 [84%]) believed that the decision rule improved patient care., Conclusions: Use of the clinical decision rule had a favorable impact on physicians' hospital triage decisions. Efficiency improved without compromising safety.

Purpose: Little is known about physicians' triage decisions for patients with chest pain in the emergency department. We sought to understand better the variability and accuracy of physicians' triage decisions., Subjects and Methods: We used 20 simulated cases to compare triage decisions by 147 physicians (46 emergency medicine, 87 internal medicine, and 14 cardiology physicians) with triage decisions recommended by a previously validated prediction rule. We calculated triage sensitivity and specificity using the prediction rule to estimate the likelihood that each of the simulated patients would suffer a major complication. Triage sensitivity was defined as the proportion of all patients expected to have major complications who were triaged to the coronary care or inpatient telemetry unit., Results: Triage specificity was defined as the proportion of all patients without complications who were triaged to sites other than the coronary care or inpatient telemetry unit.Physicians' triage decisions were less sensitive (85% vs. 96%, P <0.001) and less specific (38% vs. 41%, P = 0.02) than decisions recommended by the prediction rule. Physicians overestimated patients' risk of complications and triaged more patients to inpatient monitored beds. Despite their preference for inpatient monitored beds, physicians' decisions would have resulted in four times as many major complications in patients who were not triaged to inpatient monitored beds, compared with decisions recommended by the prediction rule (2.4% vs. 0.6%, P <0.001). Although physicians' decisions were best explained by their provisional diagnoses, interphysician agreement about triage decisions (kappa = 0.34) and diagnosis (kappa = 0.31) was only fair., Conclusions: In simulated cases, physicians' triage decisions varied widely and their predictions of patient outcomes differed markedly from that of the validated prediction rule, suggesting that use of the prediction rule in the emergency department could improve physicians' decisions and patients' outcomes.

Objective: To evaluate the predictive value of standard letters of recommendation (LORs) vs preprinted questionnaires (PPQs) for resident performance at one emergency medicine (EM) residency program., Methods: A retrospective association of LORs and PPQs with in-training residents performance ratings was done at one EM residency program. The residency application files of EM residents who completed the program were reviewed to locate files that had LORs and PPQs written by the same author. Seventeen resident files contained 32 LOR/PPQ pairs. These LORs and PPQs were submitted in a blinded fashion to 3 outside EM residency directors. Each LOR and PPQ was evaluated for the applicant's suitability for the specialty of EM, medical knowledge, procedural skills, interpersonal skills, motivation, and overall rank. The scores given by the outside reviewers were compared with resident performance ratings determined by 5 EM attending physicians who evaluated the residents along the same 6 dimensional ratings., Results: Statistically, no differences were found between the LORs and PPQs in predicting resident performance., Conclusions: PPQs may substitute for LORs in the evaluation of resident applicants.