Purpose: A comparison of current standard emergency treatment facilities and the treatment system between North American type Emergency Rooms (ERs) and Japan emergency medical facilities was performed to better understand Japan's present emergency medical service.
Methods: An interview survey was conducted with 10 doctors working in 10 emergency facilities in the Kanto region. The 11 questions covered in the interview inquired about the emergency treatment system at each facility, the problems facing the healthcare system at each facility, and Japan's entire emergency medical system.
Results:
1. The following differences and common points were found among several emergency facilities.
(a) In 8 facilities, regardless of the seriousness of patients or whether patients were transported by ambulance or visited on their own, the initial examination of all emergency patients was the responsibility of the emergency department.
(b) In only 4 facilities, the staff members performing the initial examination were all primarily full-time emergency doctors.
(c) A shift-work schedule is set up for emergency department doctors in 3 facilities.
(d) Overnight beds were provided for monitoring progress in 3 facilities.
(e) A triage nurse is available and a corresponding system is established in 2 facilities.
(f) In all 10 facilities, There are admittance beds specifically for the emergency department, and post-admittance management is carried out by the emergency department when a medical condition cannot be designated into a specific department.
2. Problems faced at each facility: Insufficient staff, overcrowding, and difficulties in adjustment and contacting each specialty department when admitting patients.
3. Problems with the entire emergency healthcare system: Chronic shortage of personnel in the emergency department and each specialty department, financial pressures and decline in the number of personnel due to the changing of the mindset of patients.
Conclusion: Various points differed in the medical system at each facility in Japan, as would be expected with the diversified administration implemented contingent with the medical care district and circumstances of each facility. In Japan, it would be difficult to introduce and apply the exact medical system adopted in North America. Enhancing the partnership between the emergency department and each specialty department as well as developing and applying a suitable medical system for each district and facility are thus necessary to improve existing emergency medical service in Japan.

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A 56-year-old man had a sudden cardiac arrest when he was playing table tennis. A medical student administered bystander cardiopulmonary resuscitation to him and activated the emergency medical service system. When the ambulance officers arrived, the patient's cardiac rhythm registered ventricular fibrillation (VF) on the automated external defibrillator (AED) monitor. However, the first through third AED analysis was not recognized as VF. The cardiac rhythm was analyzed as VF during the fourth analysis and defibrillation was performed. After the shock, the patient's spontaneous circulation resumed. He was discharged without any complications. We found 99% stenosis in his right coronary artery caused the patient's VF. Because various companies make AED software, there is slight variance in AED analysis. However all AED software must meet compliance standards proposed by the American Heart Association as well as Association for the Advancement of Medical Instrumentation. Software sensitivity is not exactly 100% because some sacrifice in sensitivity is necessary to reach adequate specificity. Health care practitioners should be aware that AED software sensitivity is not 100% perfect. Therefore, in cases where the AED doesn't fix the problem, adequate cardiopulmonary resuscitation should be performed.

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A 48-year-old man presented with generalized fatigue and sudden bilateral blindness after continuous drinking without eating for about 3 weeks. He was transferred to our emergency center for suspected liver failure. He had an initial Glasgow Coma Scale of 11 and dilated pupil (7 mm) without light reflex. Laboratory data showed severe metabolic acidosis with elevated blood lactate. Although the acidosis and abnormal pupils were gradually improved by vitamin B administration and continuous hemodiafiltration treatment under mechanical ventilation, bleeding tendency became apparent, resulting in prolonged shock with progressing anemia. Abdominal CT (day 4) revealed an enlarged hematoma in the iliopsoas region. Hemorrhage continued despite platelet transfusion for thrombocytopenia. Menatetrenone (20 mg) administration immediately stopped the bleeding tendency and his prothrombin time increased from 56 to 99%. Subsequently, his circulatory dynamics stabilized and he was discharged on day 31 without complications. We speculated that the severe and rare iliopsoas hemorrhage was caused by coagulation disorder due to vitamin K deficiency from continuous drinking. When shock or progression of idiopathic anemia is observed in alcohol abusers, the possibility of bleeding from deep tissues (e.g., iliopsoas hemorrhage) should be considered keeping in mind the pathology associated with vitamin K deficiency.

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A 28-year-old male commercial diver lost consciousness during an underwater operation and suddenly surfaced. When the EMS (Emergency Medical Service) arrived at the scene, his consciousness was rated as Japan Coma Scale 300. He developed cardiopulmonary arrest (CPA) during transfer; however, immediate commencement of resuscitation led to recovery of spontaneous circulation after one minute. On transfer to a nearby hospital, chest X-ray showed bilateral severe pulmonary edema. He was intubated after the chest X-ray and was administered catecholamine for circulatory support. He was diagnosed with type II decompression sickness (DCS). As he required early hyperbaric oxygen therapy (HBO), he was transferred to our Emergency Center by a helicopter at an altitude below 300 meters for 19 minutes (a 40 km distance). HBO was performed on admission according to US Navy Table 6A. The pulmonary edema improved rapidly and he was extubated on day 3. Peripheral nervous system DCS was later diagnosed; however, sensory nerve function recovered almost fully with repeat HBO. The sequence of prompt resuscitation, transportation by helicopter, early HBO according to US Navy Table 6A, and concurrent systemic management in a multiplace chamber was considered to have saved the life of this young diver with severe decompression illness.

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Diffuse axonal injury (DAI) commonly causes immediate loss of consciousness after head injury. We report the case of a 20-year-old man who was involved in a motor vehicle accident, which his estate car ran into a truck from behind. Although he was alert on arrival at the hospital, his conscious level deteriorated approximately 7 hours after the accident. At this time point, he had a generalized tonic seizure and decorticate posturing of his arms with a Glasgow coma scale (GCS) score of 5. MRI revealed findings consistent with DAI. On the 14th day, his conscious level improved to a GCS of 9 and MRI showed chronic DAI. The patient recovered well with only mild memory deficit at discharge. There are few reports of delayed onset DAI, but in terms of its neuropathology, it is possible for it to occur after the time of injury. DAI is the result not only of direct injuries to the axon membrane and axonal sheath due to shearing force, but also of secondary injury by loss of axon transport. In the emergency department, a diagnosis of DAI should be considered in any patient who has suffered head injury by rotational forces even if there is no loss of consciousness on arrival at the hospital.

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Exposure to chlorine gas induces various respiratory insufficiencies, including upper respiratory tract irritation and acute lung injury (ALI). Previous reports suggested a latent period between exposure to chlorine gas and the development of ALI. Here we report 2 patients with ALI after exposure to chlorine gas. Patient #1 was a 26-year-old female who inhaled chlorine gas, produced by mixing 3 different chemical cleaners. She had no symptoms on arrival. However, hypoxia and pulmonary infiltration appeared 10 hours later, and she was diagnosed with ALI. Patient #2 was a 64-year-old male who inhaled mixtures of chlorine-containing chemicals. He complained of dyspnea, and mild hypoxia was observed on arrival. His symptoms and hypoxia deteriorated 35 hours later. He developed pulmonary infiltration and was diagnosed with ALI. On the basis of the present results and previous reports and the results of previous animal experiments, we speculated that there could be a latent period as long as 10 hours, and symptoms may worsen 48 hours after exposure to chlorine gas. Thus, we recommend observation for at least 10 hours, even though some patients may not show any symptoms on initial examination. Observation for at least 48 hours is necessary in patients with respiratory symptoms.

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It is no exaggeration to say that the appropriateness of “research hypotheses” governs the quality of clinical studies. However, few papers in the published literature describe how to set up research hypotheses and how to refine them, and many clinicians conduct clinical studies based on inadequate hypotheses. When setting up a research hypothesis, it is most important to properly define the subjects, exposure (intervention), controls, and results, and to repeatedly engage in discussions and debates based on counterfactual models. It is also important to establish a research plan and analysis plan based on direct acyclic graphs (DAGs), which in recent years have come to be used in the field of epidemiology, and to assess confounding factors that require adjustment. If several simple rules are thoroughly understood, DAGs are very useful tools, and they are useful both when conducting clinical studies and when reading papers.

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