There is a much higher rate of admission for prepubertal males than females. However, there is a higher incidence of asthma admissions for adult females than adult male asthmatic patients, and female asthmatic patients experience longer hospital stays per admission as well. These data indicate that adult females are more severely affected by asthma and raise the possibility that hormonal or biochemical differences related to sex may play a role in the pathophysiology of asthma.

Objective: T o determine how often trainees in emergency medicine (EM) are observed while performing a history. a physical examination. or specific procedures.Methods: The 26 members of the National Consensus Group on Clinical Skills in Emergency Medicine affiliated with an EM residency program were asked to circulate a survey to their residents during February and March 1994. Twentyone programs participated. surveying a total of 514 residents. The residents were asked how many times they had been observed by an attending physician while they performed a history, a physical examination. endotracheal intubation. or central vein catheterization during training. The residents also were asked about observation of specific components of the physical examination. such as the heart. lung, and genitourinary systems.Results: Three hundred nineteen residents (62%) responded to the survey. Thirteen percent of the residents reported that they had never been observed taking a history during training. During their PGY 1 training, 19% of the residents reported that they had never been observed taking a history, 42%' had been observed one to three times, 255% had been observed four to 12 times. and 13% had been observed >12 times. Six percent of the residents reported that they had never been observed doing a physical examination during training. During their PGYl training, 10% of the residents had never been observed performing a physical examination, 38% had been observed one to three times. 34% had been observed four to 12 times, and 18% had been observed > I 2 times. Conclusions:Many residents report that they are infrequently observed performing histories and physical examinations during their EM training. with a significant number of residents reporting that they were never observed performing hasic bedside clinical skills. More direct observation with trained faculty observers may provide an opportunity for better evaluation and remediation of bedside clinical skills. training using certification examinations. Because of t h e acknowledged limitations of board examinations t o fully assess clinical c o m p e t e n c e , ' t h e ABEM requires program directors t o certify t h a t applicants t o their examination have achieved a satisfactory level of clinical skill before they t a k e t h e examination.Program directors m a k e this assessment using a variety of methods. One c o m m o n m e t h o d is listening t o residents' case presentations during their training, with an attempt t o identify deficiencies in d a t a gathering skills by corroboration o f p a r t s of t h e history a n d physical examination at t h e bedside. In addition, case discussion addressing clinical reasoning a n d problem solving skills is used. Assessment of clinical skills also m a y occur at a case m a n a g e m e n t conference in a m a n n e r similar t o the oral portion of t h e certifying examination.

Abstract. Objective: To determine whether patients with retained lead shrapnel who present to the ED have elevated whole blood lead levels (BLLs) compared with matched control patients. Methods: Test subjects were patients with x-ray evidence of retained lead shrapnel who presented to any of three urban EDs, and consented to inclusion in the study. BLLs were obtained from 15 ED patients, and data regarding time since injury and symptoms of plumbism were collected. Control subjects consisted of 15 ED patients, without similar lead exposure, matched for age, sex, race, and place of dwelling as determined by zip code, who also presented to any of the same three EDs. Results: The mean (ϮSD) BLL in the test subjects was 17 Ϯ 9.78 g/dL (range 7 -50 g/dL). Time since impalement ranged from 1 to 45 years.The mean BLL in the control subjects was 7 Ϯ 3.77 g/dL (0 -16 g/dL). This difference was statistically significant (two-tailed t-test p = 0.002). Conclusions: In this preliminary study, the patients with retained lead shrapnel who presented to the ED had significantly elevated BLLs, compared with the matched control subjects. Chronic plumbism may be considered in patients with retained lead shrapnel, and a history should be taken to assess the presence of symptoms referable to plumbism. These patients may require long-term follow-up to assess the development of elevated blood lead level and lead toxicity.

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