ACEP News - June 2008 - (Page 35)

JUNE 2008 • ACEP NEWS PRACTICE TRENDS Emergency Medicine Residencies Exert Strong Appeal B Y M A RY E L L E N S C H N E I D E R Else vier Global Medical Ne ws mergency medicine residency programs have been filling nearly all of their positions over the last few years, and experts in the field don’t see any indication that the popularity of the specialty is likely to wane. “People like dealing with high-acuity life-and-death situations,” said Dr. Louis Binder, associate program director and director of education in the department of emergency medicine at MetroHealth Medical Center in Cleveland. “Medical students are also drawn to the meaningfulness of the work,” said Dr. Binder, adding that it’s an aspect of the practice that is unlikely to change. Figures from the National Residency Match Program show that the fill rate for emergency medicine positions remained steady overall and among U.S. medical graduates in 2008. This year, 1,399 emergency medicine residency positions were offered. Of those, 97.9% were filled, with spots and the open positions, he said. One of the reasons that interest has grown at the same pace as the expansion of residency programs is mentorship. As residency programs have been established, more medical students have been exposed to the specialty and inspired by its leaders, said Dr. Binder, past president of the Society for Academic Emergency Medicine. Emergency medicine residency positions have expanded rapidly in recent years. In 2001, 1,001 positions were offered, compared with 1,399 during the 2008 match process. But an even greater expansion may be necessary to keep up with demand for care, Dr. Binder said. There are several societal trends that are driving the demand for care in emergency departments. For example, the aging population and its associated illnesses such as cancer, stroke, and diabetes will require ongoing care in the emergency department. In addition, the trends toward increases in drug use, domestic violence, child abuse, and homelessness continue to drive the need for ex- panded access to emergency medicine. In addition, workforce studies in emergency medicine have highlighted the need to produce more emergency physicians, Dr. Binder said. For example, an analysis of workforce data from 1999 estimated that 27,067 physicians were practicing clinical emergency medicine in 1999—but about 31,797 physicians were needed to staff emergency departments around the country (Ann. Emerg. Med. 2002;40:3-15). “There’s a need for emergency medicine to open up its training base,” he said. ■ OVERALL, 7.5% OF U.S. MEDICAL GRADUATES WHO MATCHED TO A RESIDENCY PROGRAM CHOSE EMERGENCY MEDICINE IN 2008, UP FROM 6.6% IN 2004. 77.4% filled by U.S. medical graduates. In 2007, 99.5% of the 1,288 total positions were filled, with 79.7% going to U.S. medical graduates. Overall, 7.5% of all U.S. medical graduates who matched to a residency program chose emergency medicine in 2008, up from 6.6% in the 2004 match. Emergency medicine physicians are seen as sort of “global caretakers,” said Dr. Mary Jo Wagner, residency director of the emergency medicine program at Synergy Medical Education Alliance, of Michigan State University’s College of Human Medicine, Saginaw. In many ways, they have taken on some of the roles of family physicians but with a “bit more excitement.” That makes the specialty appealing to those students looking for a chance to help a large crosssection of individuals, she said. The diversity of cases and the quality of care make the work appealing, said Dr. Joshua Moskovitz, president-elect of the Emergency Medicine Residents Association and an intern at the University of Maryland in Baltimore. “There’s nothing you don’t see in the ED,” he said. The schedule is also a plus, he said. Because most emergency physicians have a set schedule, they have a chance to pursue projects in other areas of professional interest, such as public health or disaster medicine, adding to their job satisfaction, he said. Dr. Moskovitz predicts that as emergency medicine programs expand, so will interest among medical students. That is exactly the trend Dr. Binder has seen since he began reviewing match data in 1990. There has been a relative parity between the supply of medical students seeking emergency medicine residency BRIEF SUMMARY ACETADOTE® (acetylcysteine) Injection For Intravenous Use INDICATION Acetadote, administered intravenously within 8 to 10 hours after ingestion of a potentially hepatotoxic quantity of acetaminophen, is indicated to prevent or lessen hepatic injury. CONTRAINDICATIONS Acetadote is contraindicated in patients with hypersensitivity or previous anaphylactoid reactions to acetylcysteine or any components in the preparation. WARNINGS Serious anaphylactoid reactions, including death in a patient with asthma, have been reported in patients administered acetylcysteine intravenously. Acute flushing and erythema of the skin may occur in patients receiving acetylcysteine intravenously. These reactions usually occur 30 to 60 minutes after initiating the infusion and often resolve spontaneously despite continued infusion of acetylcysteine. Anaphylactoid reactions (defined as the occurrence of an acute hypersensitivity reaction during acetylcysteine administration including rash, hypotension, wheezing, and/or shortness of breath) have been observed in patients receiving I.V. acetylcysteine for acetaminophen overdose and occurred soon after initiation of the infusion (see Adverse Reactions section). If a reaction to acetylcysteine involves more than simply flushing and erythema of the skin, it should be treated as an anaphylactoid reaction. This usually entails administering antihistaminic drugs as well as epinephrine in severe cases. In addition, the acetylcysteine infusion may be interrupted until treatment of the anaphylactoid symptoms has been initiated and then carefully restarted. If the anaphylactoid reaction returns upon reinitiation of treatment or increases in severity, intravenous acetylcysteine should be discontinued and alternative patient management should be considered. For specific treatment information regarding the clinical management of acetaminophen overdose, please contact your regional poison center at 1-800-222-1222, or alternatively, a special health professional assistance line for acetaminophen overdose at 1-800-525-6115. PRECAUTIONS Acetadote should be used with caution in patients with asthma, or where there is a history of bronchospasm. The total volume administered should be adjusted for patients less than 40 kg and for those requiring fluid restriction. To avoid fluid overload, the volume of 5% dextrose should be reduced as needed. If volume is not adjusted fluid overload can occur, potentially resulting in hyponatremia, seizure, and death. Carcinogenesis, Mutagenesis, and Impairment of Fertility Long-term studies in animals have not been performed to evaluate the carcinogenic potential of acetylcysteine. Acetylcysteine was not genotoxic in the Ames test or the in vivo mouse micronucleus test. It was, however, positive in the in vitro mouse lymphoma cell (L5178Y/TK+/-) forward mutation test. Treatment of male rats with acetylcysteine at an oral dose of 250 mg/kg/day for 15 weeks (compared to the recommended total human intravenous dose of 300 mg/kg) did not affect the fertility or general reproductive performance. Pregnancy: Teratogenic Effects: Pregnancy Category B Teratology studies were performed in rats at oral doses up to 2000 mg/kg/day and in rabbits at oral doses up to 1000 mg/kg/day (compared to the recommended total human intravenous dose of 300 mg/kg) and revealed no evidence of impaired fertility or harm to the fetus due to acetylcysteine. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies may not always be predictive of human response, this drug should be used during pregnancy only if clearly needed. Pregnant Women In four pregnant women with acetaminophen toxicity, oral or I.V. acetylcysteine was administered at the time of delivery. Acetylcysteine crossed the placenta and was measurable in newborn circulation and cord blood of three viable infants following delivery and in cardiac blood of a fourth infant at autopsy (22 weeks gestational age who died 3 hours after birth). No adverse sequelae developed in the three viable infants. All mothers recovered and none of the infants had evidence of acetaminophen poisoning. Nursing Mothers It is not known whether this drug is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when acetylcysteine is administered to a nursing woman. Pediatric Patients No adverse effects were noted during I.V. infusion with acetylcysteine at a mean rate of 4.2 mg/kg/h for 24 hours to 10 preterm newborns ranging in gestational age from 25 to 31 weeks and in weight from 500 to 1380 grams in one study or in 6 newborns ranging in gestational age from 26 to 30 weeks and in weight from 520 to 1335 grams infused with acetylcysteine at 0.1 to 1.3 mg/kg/h for 6 days. Elimination of acetylcysteine was slower in these infants than in adults; mean elimination half-life was 11 hours.1 There are no adequate and wellcontrolled studies in pediatric patients. Geriatric Patients The clinical studies do not provide a sufficient number of geriatric subjects to determine whether the elderly respond differently. Drug Interactions Drug stability and safety of acetylcysteine when mixed with other drugs have not been established. ADVERSE REACTIONS2,3 In the literature the most frequently reported adverse events attributed to I.V. acetylcysteine administration were rash, urticaria, and pruritus. The frequency of adverse events has been reported to be between 0.2% and 20.8%, and they most commonly occur during the initial loading dose of acetylcysteine. In a randomized study (Infusion Rate Study) in patients with acetaminophen poiso

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ACEP News - June 2008

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