Objective: To mathematically model the supply of and demand for emergency physicians (EPs) under different workforce conditions. Methods: A computer spreadsheet model was used to project annual EP workforce supply and demand through the year 2035. The mathematical equations used were: supply = number of EPs at the beginning of the year plus annual residency graduates minus annual attrition; demand = 5 full-time equivalent positions/ED X the number of hospital EDs. The demand was empirically varied to account for ED census variation, administrative and teaching responsibilities, and the availability of physician extenders. A variety of possible scenarios were tested. These projections make the assumption that emergency medicine (EM) residency graduates will preferentially fill clinical positions currently filled by EPs without EM board certification. Results:Under most of the scenarios tested, there will be a large deficit of EM board-certified EPs well into the next century. Even in scenarios involving a decreasing "demand" for EPs (e.g., in the setting of hospital closures or the training of physician extenders), a significant deficit will remain for at least several decades. Conclusions:The number of EM residency positions should not be decreased during any restructuring of the U.S. health care system. EM is likely to remain a specialty in which the supply of board-certified EPs will not meet the demand, even at present levels of EM residency output, for the next several decades.
workforce and to estimate effects of proposed changes in the U.S. health care system on the EM workforce. Methods: Relevant data were extracted from the American College of Emergency Physicians (ACEP) I995 Membership Activity Report, the American Medical Association (AMA) publication " 199996 Physician Characteristics and Distribution in the U.S.,' ' the American Hospital Association (AHA) 1994 hospital directory, a written survey of each state's medical licensing board and state medical society, and the American Board of Emergency Medicine (ABEM) annual activity report for 1995. These data were used to project workforce supply and demand estimates applicable to workforce models. Results: None of the available information sources had complete data on the number and distribution of emergency physicians (EPs) currently practicing in the United States. Extrapolating the limited reliable statewide EP numbers to make nationwide projections reveals a shortage of EPs needed to fully staff the nation's existing EDs. At least 22 states had an average ratio of c5 EPs per existing ED. Additional national projections incorporating a decreasing number of U.S. EDs indicate that the current annual number of EM residency graduates will not eliminate the deficit of EPs for at least several decades, given that projected numbers of retiring EPs annually will soon equal the total annual EM residency graduate production. Conclusions: Although the current data on EPs in practice in the United States are incomplete, the authors project a relative shortage of EPs. More accurate and complete information on the numbers and distribution of EPs in America is needed to improve workforce projections.
This study demonstrated that with an intensive training program using selected highly motivated providers and close monitoring, a program of EMT-Basic ETT placement in a rural setting can achieve acceptable success rates in patients in cardiac or respiratory arrest.
Summary. Thaw subsidence during the production life of wells drilled through the permafrost can transfer very high axial compressive loads to the surface casing. Improved techniques were required to define the compressive strain capacity of surface casing for North Slope operations. These techniques were used to identify cost-effective surface-casing designs capable of withstanding the axial compressive strains imposed by permafrost thaw. Plans to drill North Slope development wells on closer surface spacing resulted in predicted permafrost thaw loads on the surface casing that exceed current operating practices. In addition, development of lower-productivity wells has resulted in completions with smaller-diameter tubulars. Both of these considerations have led to a reassessment of the surface-casing programs for these new wells. The results presented are based on two parallel and complementary investigations: full-scale physical testing and nonlinear finite- clement analysis. The physical tests provided information about the performance of the casing and connections under high compressive loads. Data were used to verify the accuracy of corresponding finite-element models with three different criteria: strain-gauge data from the coupling and pin surfaces, failure mode comparison, and failure load comparison. An excellent match was achieved between the strain-gauge data and the analytical strain results, the actual vs. modeled failure mode (i.e., compressive bulging in the pipe body), and the actual vs. modeled failure load. Once verified, the models were used to investigate the effects of field-related parameters that were not tested. These included variations in makeup condition, pipe-wall thickness, thread taper angle, and casing length. Finally, these results enabled the selection of suitable surface-casing materials and connections for arctic operations. Introduction Surface casing is set through the permafrost for Alaskan North Slope wells (as deep as 2,000 ft [610 m] in some areas) to establish an adequate "foundation" for the wellhead and tree assembly, to provide backup pressure containment, and to isolate the inner strings from permafrost loads. Permafrost thawing caused by the long-term production of high-rate oil wells can lead to pore-pressure reduction, resulting in sediment compaction. The magnitude of strain that these effects induce on the surface casing depends on several factors, including the mechanical properties and lithology of the permafrost and the proximity of nearby wellbores that contribute to the overall thaw area. The incentives to reduce the wellhead spacings of arctic wells include limiting gravel requirements for both offshore islands and onshore well pads on the tundra and reducing the length of pipe- line required to manifold the wells. Proposed wellhead spacings (as close as 15 ft [4.6 m] for offshore islands) were expected to produce higher soil strains than those predicted for original Prudhoe Bay wells spaced roughly 120 ft [37 m] apart. Therefore, a full performance study was conducted to quantify the axial strain limits of 13 3/8-in. [34-cm] -diameter, 72-lbm/ft [107-kg/m], L-80 butress-threaded casing (common surface casing in North Slope use). The performance was compared with that predicted for normalized N-80 grade casing used on some early Prudhoe Bay wells. Description of Analysis Methods The casing performance was analyzed with the finite-element method and verified by well-instrumented, full-scale testing. Non- linear finite-element analysis techniques have been developed for the analysis of threaded connections with a development version of the ABAQUS general-purpose finite-element program. Additionally, processing hardware and software were used to allow efficient analysis of large finite-element models on the Cray X/MP supercomputer. This processing and analysis system allows efficient and accurate creation of large finite-element models and aids greatly in the interpretation of the results. Finite-Element-Model Generation. Three initial assumptions used in creating the models wereaxisymmetry,symmetry about the plane through the center of the coupling, anddisplacement-controlled axial loading at the ends only. The two symmetry assumptions greatly reduce the size of the model and the associated computing cost. The third assumption allows no shear loading on the outside of the casing, only displacement-controlled end loading. This loading constraint corresponded to the physical test con-ditions. Permafrost thaw subsidence causes displacement-controlle loading on the casing in the field, although the loading is applied by shear forces on the outside of the casing. Several finite-element meshes were created and tested during the course of the casing analysis. First, test meshes were developed for the buttress threadform itself. Next, test meshes were developed for the pipe and coupling walls. For a given model, or model subset, a finer mesh with smaller elements will give a more accurate solution. Computer costs associated with a given model increase approximately with the square of the number of elements in the model. The final finite-element mesh selection is a tradeoff between cost and accuracy that was resolved by examining strain jump and radial stress contour plots and considering the need to retain fidelity in the threadform geometry. A typical finite-element mesh for the buttress connection is shown in Fig. 1. This mesh contains about 4,500 nodes and 2,500 quadrilateral constitutive elements (both second-order, reduced-integration and first-order, full-integration). Nonlinear Analysis Techniques. Three major areas of nonlinear behavior must be modeled accurately to analyze the performance of the casing with buttress-threaded connections:material properties,deformation geometry, andsurface interaction between the pipe and coupling in the thread region. These nonlinearities must be handled with an iterative solution procedure. For a solution to satisfy the convergence criterion. equilibrium must be satisfied within a specified tolerance at every degree of freedom. To model the history dependence of the final solution accurately, equilibrium convergence must be achieved for each incremental solution during loading. This process required more than 500 iterations for each model. SPEDE P. 289^
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