When serious emergency patients come to a 3rd-level emergency hospital, they are able to obtain optimal medical treatment for their condition. However, the emergency room of general hospitals are extremely crowded with many kinds of patients, ranging from 1st-to 3rd-level emergencies. Thus, a good training program in triage is necessary for emergency medicine doctors because of the risk of inappropriate management of patients.
In this study, we examined the number of 2nd-and 3rd-level emergency patients who came to our emergency room initially as walk-in 1st-level emergency patients in 1991 and 1992. Our results indicate that the education for emergency medicine doctors needs to cover a wide range of medical fields dealing with 1st-to 3rd-level emergency patients, and that ideal training in emergency medicine must be organized in hospitals that accept 1st-to 3rd-level emergency patients.

Cardiovascular surgery in situs inversus totalis (SIT) is unusual. We report a case of coronary artery bypass grafting (CABG) in SIT. A 67-year-old man with unstable angina pectoris was admitted to our hospital. Coronary arteriography demonstrated three-vessel disease in the mirror-image heart. CABG with 4 distal anastomosis was carried out with conventional methods. Careful observation based on complete understanding for preoperative images could minimize operative difficulties caused by mirror-image heart.

We report a case of graft infection long after femorofemoral crossover bypas grafting (FFBG), first presenting as septic distal emboli without any infective signs in the groin. A 71-year-old man who had undergone FFBG visited our hospital because of sudden pain in his right foot. No infective signs were found in the graft route from physical examination. However, computed tomography demonstrated perigraft fluid and graft thrombi. Graft excision and extra-anatomic revascularization were successfully done. Light micrography showed Staphylococcus aureus extensively infiltrating in the expanded polytetrafluoroethylene graft wall.

A university hospital plays roles as a specific functional hospital and as a teaching hospital in primary care because most medical school graduates receive basic clinical training in this area. An important objective of primary care education for all residents is the initial treatment of patients with first-to third-level emergencies. We examined the number of patients, the level of emergency (first, second, and third level) and the diagnoses that each resident encountered. Subjects included 29 residents (3 in the first year, 4 in the second year, and 2 in the third year) who had undergone clinical training for 3 months in the department of emergency medicine at the Saga Medical School Hospital which treats 7, 000 to 8, 000 patients per year with first-to third-level emergencies. Residents were involved with 214.6 emergency cases, which included approximately 59 types of first-level emergency, 31 types of second-level emergency, and 15 types of third-level emergencies. These results were largely compatible with the Objectives of Postgraduate Basic Clinical Training proposed by the Japan Society for Medical Education. These results show that university hospitals as specific functional hospitals should accept numerous emergency patients and that residents must receive clinical training in emergency medicine to achieve the objectives of primary care education.