To study emergency medical education in Japan, questionnaires were sent to the Faculty of Medicine of 80 institutions, including 51 public universities and 29 private universities, in autumn 2000, with the following results: (1) Emergency medicine was considered an important subject by 80% of the institutions. The number of authorized emergency medical courses increased to 39 in 80 institutions, with 29 new courses appearing in the last 10 years. Of institutions, 85% used their own emergency medical curriculum, and most regarded emergency medicine to be a required subject. In most institutions, full-time emergency room (ER) physicians participated in lectures and bedside learning. These results indicate that a strong foundation for emergency medical education has been established in the last 10 years. (2) The average number of ER staff members employed by public and private institutions differed, with public institutions having 3 persons/institution and private 11 persons/institution. (3) Bedside learning was conducted in outpatient clinics of emergency units or centers in 80% of institutions; 94% of institutions agreed that bedside learning programs were a key for resolving dialogue problems between teachers and the small number of students visiting the ER. Clinical clerkship was available only at 42% of the institutions. (4) Even though 66% of institutions agreed that medical students should be allowed to practice a wider range of procedures, the type of procedures to which more than 80% of the institutions actually agreed was very limited, e.g., basic life support, venous puncture, electrocardiogram (ECG) diagnosis, blood gas analysis, blood typing, and radiographic diagnosis. (5) Of institutions, 46% had evaluation programs for faculty development and 60% used reciprocal assessments for teachers and students. The above results suggest that guidelines for emergency medical education should be established by the Japanese Society for Acute Medicine in close cooperation with the Japanese Society for Acute Medicine and postgraduate training programs to be required for all postgraduates in 2004.

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A quality-assurance program for hospital care has been well accepted in Japan, but clinical indicators for evaluating the quality of care in tertiary emergency medical centers have not been identified. The Committee of Clinical Indicators for Quality Assurance of the Japanese Association for Acute Medicine therefore developed ten such indicators, including two indicators for head injuries, three for abdominal injuries, two for cardiopulmonary resuscitation, two for acute myocardial infarctions, and one for asthmatic attacks. Assessments were prospectively made using a questionnaire over a 3-month period, from April 1 to June 30, 1999, during which 4, 860 cases were collected from 80 out of 159 Japanese emergency and critical care centers. Suitable clinical indicators appeared to include the time from admission until computed tomography examination for isolated head traumas, time from admission until laparotomy in hemodynamically unstable abdominal traumas, blood gas analysis in the emergency room (ER) for endogenic cardiopulomonary arrest on arrival (CPAOA), return of spontaneous circulation in endogenic CPAOA, time from admission until thrombolytic therapy in acute myocardial infarction, and the mortality rate for acute myocardial infarction. A cross-analysis on the characteristics of hospitals showed an association between a larger number of treated patients and better procedures and outcomes. In conclusion, certain clinical indicators were determined to be useful for evaluating the quality of care in tertiary emergency medical centers. The development of new clinical indicators and the consolidation of disease-specific registry systems are the next anticipated tasks of the committee.

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We retrospectively analyzed 315 patients with aneurysmal subarachnoid hemorrhage (SAH) treated with direct clipping surgery. Their ages ranged from 19 to 89 (mean±SD: 61.0±13.1) years. The preoperative grade was evaluated by WFNS grade, with 112 patients were in grade I, 80 in grade II or III, 72 in grade IV, and 51 in grade V. We surgically treated all patients whose preoperative Glasgow Coma Scale (GCS) score was ≥6. In the patients whose GCS score was <6, patients who exhibited improvement in neurological symptoms were selected as candidates for direct surgery. We conducted clipping surgery in the acute stage to avoid further bleeding. We then surgically removed the subarachnoid clot and any intracerebral or intraventricular hematoma. Surgical outcome of patients was evaluated using the Glasgow Outcome Score (GOS) 3 months after onset. Rebleeding after surgery occurred in only 1 patient (0.3%). The percentage of patients achieving a favorable outcome (good recovery or moderately disabled) was 98% in grade I, 84% in grade II or III, 61% in grade IV, and 18% in grade V. The main factor responsible for an unfavorable outcome was cerebral vasospasm in grade II or III and initial brain damage in grade IV and V. The incidence of surgical complications related to a less favorable outcome was 2.9%. Patients over 80 years of age had a less favorable outcome than those younger than 80 (p<0.05). In conclusion, direct surgery is safe and secure for patients with aneurysmal SAH in WFNS grade I. Outcomes from direct clipping surgery was not always satisfactory, however, in patients with a poor WFNS grade or who were too elderly. A combination of intravascular treatment with novel treatment strategies may improve overall outcome in patients with aneurysmal subarachnoid hemorrhage.

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Eleven years have passed since the Emergency Lifesaving Technician Law was enacted in Japan. Emergency lifesaving technicians are permitted to secure the airway by instrument insertion, secure intravenous access using Ringer's lactate, and conduct defibrillation in patients with out-of-hospital cardiac arrest, but the range of their authority has not been expanded during these 10 years. Debate has thus arisen on whether emergency lifesaving technicians should conduct tracheal intubation, but in Japan there has been very little comparison of tracheal intubation versus other methods to establish airways in patients with out-of-hospital cardiopulmonary arrest. From January 2001 to December 2001, we compared arterial blood gas analysis data and chest radiography at arrival at the Department of Emergency and Critical Care Medicine, Sapporo General Hospital, of patients with nontraumatic out-of-hospital cardiopulmonary arrest who received esophageal obturator airway (EOA) insertion by an emergency lifesaving technician versus those who received tracheal intubation (TI) by a physician in the ambulance. Mean arterial partial oxygen pressure was 150.0±120.9mmHg in 55 patients in the EOA group and 260.6±173.7mmHg in 71 patients in the TI group, ---- was significantly higher in the TI group (p<0.001). Although the mean arterial oxygen partial pressure of 150mmHg in the EOA group may be considered acceptable, partial pressure was less than 80mmHg in 21 patients (38%). Pulmonary congestion and pulmonary edema were frequently seen in the chest radiography on admission, and conversion to tracheal intubation improved oxygenation in two-thirds of these patients. These results suggest that tracheal intubation is better than EOA in establishing an airway in patients with out-of-hospital cardiopulmonary arrest, and may also serve as useful information in determining whether emergency lifesaving technicians should be permitted to conduct tracheal intubation.

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We report a case of a pontomedullary tear presenting as locked-in syndrome. A 38-year-old man injured in a traffic accident while driving a motorcycle was unconscious upon arrival and computed tomography (CT) showed only a small interhemispheric subdural hematoma. He became alert 6 hours later and was found to have locked-in syndrome. His neurologic deficits pointed to a lesion involving the lower pons and magnetic resonance imaging (MR) clarified that the pontomedullary junction was partially torn, leading to a determination of locked-in syndrome resulting from a pontomedullary tear. Pontomedullary lesions may be found in cases of hyperextension injury of the head.

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