muscle paralysis caused by Neuromuscular blockade, will provide adequate visualization of airway structures (a known difficult airway).

The patient in Jackson County, having been severely burned, was hypoxic and, because the burns involved the face, required protection against mechanical obstruction of the airway. The patient was awake and breathing spontane- ously. The CRNA, by bquick-lookQ laryngoscopy, recog- nized the presence of a difficult airway. Despite her preference for awake nasal intubation, RSI was performed on the recommendation of the ED physician. Subsequent complications resulted in the patient’s death.

Putting aside the critical importance in ensuring proper placement of the ET tube in the trachea, the degree of sophistication required in choosing between various meth- ods of airway management is highlighted by this case. Although RSI offers important advantages over other forms of airway management, primarily, in its improving laryngo- scopic view, it is not universally available (eg, to Emergency medical service providers), and its use does not guarantee success (as demonstrated in this case). Consequently, despite the widespread use of the RSI procedure, nasal intubation should remain an option for health care providers in the management of ED patients.

The legal conclusion to the case was unfortunate for the CRNA [3]. The emergency physician, employed by the hospital, was protected under the state (Florida) Good Samaritan Act. The CRNA, as an independent contractor, was not protected by the Act and was held to a mere negligence standard. The jury found that the physician, by failing to ensure appropriate ET tube place- ment, acted with reckless disregard, thus exempting him from the Act. However, an appellate court reversed these findings and found the physician immune from liability under the Act. Accordingly, the corporation employing the CNRA was wholly liable for the damages. This result was despite the reasoning (as articulated in a dissenting opinion) that it is billogical to infer the legislature intended application of a different standard to medical professionals working as part of the same team, affording greater protection to the person in charge than to those carrying out the orders.. .Q[4]

	Mechanism	35	30	.77
	(blunt, %)
Mark J. Greenwood, DO, JD	Location of injury	52	53	.98

1. Bay Anesthesia v. Aldrich, 863 So.2d 310 (Fla. 2003) (review improvidently allowed; appeal dismissed).
2. Jackson county hospital v. Aldrich, 835 So.2d 318 (Fla. App. 2002) at 332 (Miner, J., dissenting).

Predictors of inner-city recurrent violence-related injuries

Violence-related injury (VRI) is a major source of morbidity and mortality in inner-city populations. Nation- wide, there are roughly 1.6 million ED visits for assault- related injuries annually [1]. Violence is the second leading cause of death nationally for individuals between the ages of 10 and 24 years and the leading cause of death of African Americans in this age group. In Brooklyn/Kings County, the focal area for this study, there were 189.64 annual hospital- izations per 100000 because of Violent injury [2]. This number is higher than the average VRI hospital admissions rate for New York City (156.1) [3] and the United States (63.9) [3].

ED-based research on Violence prevention typically centers on victims of violence and how best to decrease the risk for recurrent VRI (RVRI) in these populations [4,5]. The approach seems valid, as individuals presenting to the ED with VRI have an increased risk of repeat injury, criminal prosecution, and 5-year mortality [6,7]. However,

Aero Med Spectrum Health Grand Rapids, MI 48875, USA

Table 1 Comparison of the demographic and social

characteristics of patients with RVRIs to those without RVRI

Mean age F SD (y) Male sex (%)

Ethnicity

(African American, %)

marital status (single, %)

Education (less than high school diploma, %)

Childhood (single parent, %)

Employment (unemployed, %)

RVRI

30 F 11

79

79

No RVRI

28 F 11

84

80

Pa

.37

.55

.66

89

77

.94

79

71

.39

55

51

.83

69

37

.004

(own neighborhood, %)

Weapon of assault (gun, %)

Perpetrator (known, %)

Drug abuse

(alcohol and/or drugs, %)

History of criminal arrest/conviction (%)

History of psychiatric disorder (%)

24

30

.69

45

55

58

53

.16

.69

69

30

.001

3

0.5

.15

^a Student t test for age, Fisher exact test for all other variables; level of significance, P b .05.

E-mail address: [email protected] doi: 10.1016/j.ajem.2005.05.005

References

1. Roppolo LP, Vilke GM, Chan TC, et al. Nasotracheal intubation in the emergency department, revisited. J Emerg Med 1999;17(5):791 – 9.
2. Jackson County Hospital v. Aldrich, 835 So.2d 318 (Fla. App. 2002).

few studies have been able to produce a quantifiable reduction in VRI through ED-based interventions [8].

This pilot study involved conducting a survey of patients who presented to Kings County Hospital Center with VRI. The design of this multidisciplinary project is the result of a collaborative effort among the Department of Emergency Medicine, Department of Preventive Medicine, and the Masters of Public Health program at SUNY Downstate Medical Center. This survey was designed to evaluate the demographic, social, and behavioral character- istics of VRI in central Brooklyn to identify the determi- nants with the potential to predict the likelihood of the outcome measure, RVRI. The study was approved by the institutional review boards of SUNY Downstate Medical Center and Kings County Hospital Center. The results of this study will be used to design an ED-based violence prevention program.

Patients aged between 13 and 60 years who present to the ED with VRI were enrolled in the study. Patients older than 60 years were excluded. Patients with change of mental status and victims of sexual assault were also excluded. The survey included demographic information, level of education, marital status, family unit during upbringing, place of injury, mechanism of assault, weapon of assault, history of drug/alcohol abuse, criminal arrest/conviction, previous VRI, and psychiatric disorders. Trained data abstractors administered the survey.

The outcome was a dichotomous variable for RVRI. VRIs are those injuries assessed as deliberately caused by another person. These injuries may result from assaults, fights, and family violence or abuse. RVRI was defined as occurrence of VRI in the past. A multivariable logistic regression model was generated to identify the variables that related to the dichotomous outcome of RVRI. Variables were selected based on univariate association with VRI and the statistical contribution of each variable to the model.

A total of 105 patients were enrolled (mean age F SD, 29 F 11 years; range, 15-60; 83% were men). Twenty-eight percent (n = 29) of patients reported prior VRI (RVRI). Characteristics of the study groups (with and without RVRI) are summarized in Table 1. Univariate analysis detected significant differences between the 2 groups only in Employment status ( P = .004) and history of prior criminal arrest/conviction ( P = .001). The logistic regression analysis revealed that risk for RVRI increases by unemployment (odds ratio, 5.5; 95% confidence interval, 1.7-18.4, P = .004) and by history of arrest/conviction (odds ratio, 8.2; 95% confidence interval, 2.4-28.3, P = .001).

The relationship between history of criminal arrest/ conviction and VRI is in agreement with the study performed by Rivara et al [6] in South Wales. According to this study, assault patients were more likely to be formally warned or convicted than other injured patients [6]. Conversely, our results differ from a case-control study conducted in New Haven by Moscovitz et al [9]. This study did not show higher rate of criminal conviction victims of

VRI. However, there was a higher rate of criminal activity in their control group compared with their general population. A strong relationship between low socioeconomic status and violence has been shown in previous studies [4]. Our study expands upon this idea by relating violence with a specific predictor related to poverty: unemployment. We showed that an unemployed state significantly increases the risk of RVRI. As more than 50% of all Central Brooklyn residents are unemployed [10], our results are very significant to understanding how one aspect of poverty relates to RVRI. Previous studies have predominately studied overall predictors of RVRI such as criminal activity, reinjury, and death, but none have addressed specific

predictors such as unemployment.

The demographic characteristics of our patients were not correlated with increased risk of RVRI. For example, both of our study groups consisted of predominately young African- American men. This is consistent with previous studies which showed that most victims of violence are African- American men [7,9].

More detailed surveys and larger scale studies are needed to validate these results and help designing an ED-based violence prevention program.

Kabir Yadav, MD Shahriar Zehtabchi, MD Nicole Johnson, MD Danielle Mailloux, MD Laurie Dubois, MD Reinaldo Austin, MD

Department of Emergency Medicine State University of New York Downstate Medical Center Brooklyn, NY, USA

E-mail address: [email protected].

Edmond S. Malka, MPH, AB Judith H. LaRosa, PhD, RN Department of Preventive Medicine State University of New York

Downstate Medical Center, Brooklyn, NY, USA

doi: 10.1016/j.ajem.2005.05.010

References

1. National Center for Health Statistics. Centers for Disease Control and Prevention TC. National Hospital Ambulatory Medical Care survey: 2002 emergency department summary. http://www.cdc.gov/ nchs/fastats/homicide.htm.
2. New York State Department of Health, Bureau of Injury Prevention. Mean annual frequency, hospitalizations due to assaults, 1990-1992 survey data. http://www.health.state.ny.us/nysdoh/research/injury/ injury.htm.
3. National Center for Injury Prevention and Control. Web-based injury statistics query and reporting system, 2000 survey data. http:// www.cdc.gov/ncipc/wisqars.
4. Abbott J. Assault-related injury: what do we know, and what should we do about it? Ann Emerg Med 1998;32(3 Pt 1):363 – 6.
5. Dahlberg LL. Youth violence in the United States. Major trends, risk factors, and prevention approaches. Am J Prev Med 1998;14(4):259 – 72.
6. Rivara FP, Shepherd JP, Farrington DP, Richmond PW, Cannon P. Victim as offender in youth violence. Ann Emerg Med 1995; 26(5):609 – 14.
7. Becker MG, Hall JS, Ursic CM, Jain S, Calhoun D. Caught in the crossfire: the effects of a peer-based intervention program for violently injured youth. J Adolesc Health 2004;34(3):177 – 83.
8. Zun LS, Downey L, Rosen J. An emergency department-based program to change attitudes of youth toward violence. J Emerg Med 2004;26(2):247 – 51.
9. Moscovitz H, Degutis L, Bruno GR, Schriver J. Emergency department patients with assault injuries: previous injury and assault convictions. Ann Emerg Med 1997;29(6):770 – 5.
10. New York City Department of City Planning. Census 2000 data. http://gis.nyc.gov/dcp/pa/address.jsp.