Emergency Medicine by Alexandros G. Sfakianakis: Ιανουαρίου 2017

Τρίτη 31 Ιανουαρίου 2017

Fever in the Emergency Department Predicts Survival of Patients With Severe Sepsis and Septic Shock Admitted to the ICU.

Objectives: To study the prognostic value of fever in the emergency department in septic patients subsequently admitted to the ICU. Design: Observational cohort study from the Swedish national quality register for sepsis. Setting: Thirty ICU's in Sweden. Patients: Two thousand two hundred twenty-five adults who were admitted to an ICU within 24 hours of hospital arrival with a diagnosis of severe sepsis or septic shock were included. Interventions: None. Measurements and Main Results: Body temperature was measured and classified according to four categories (= 39.5[degrees]C). The main outcome was in-hospital mortality. Odds ratios for mortality according to body temperature were estimated using multivariable logistic regression. Subgroup analyses were conducted according to age, sex, underlying comorbidity, and time to given antibiotics. Overall mortality was 25%. More than half of patients had a body temperature below 38.3[degrees]C. Mortality was inversely correlated with temperature and decreased, on average, more than 5% points per [degrees]C increase, from 50% in those with the lowest temperatures to 9% in those with the highest. Increased body temperature in survivors was also associated with shorter hospital stays. Patients with fever received better quality of care, but the inverse association between body temperature and mortality was robust and remained consistent after adjustment for quality of care measures and other factors that could have confounded the association. Among vital signs, body temperature was best at predicting mortality. Conclusions: Contrary to common perceptions and current guidelines for care of critically ill septic patients, increased body temperature in the emergency department was strongly associated with lower mortality and shorter hospital stays in patients with severe sepsis or septic shock subsequently admitted to the ICU. Copyright (C) by 2017 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

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LiquidSpring at EMS Today 2017

SALT LAKE CITY — LiquidSpring™ LLC is exhibiting at EMS Today, the JEMS Conference & Exposition in Booth #1519 from February 23 - 25. Held at the Calvin L. Rampton Salt Palace Convention Center in Salt Lake City, UT, EMS Today is the fastest growing EMS event in the United States, providing information and experience for EMS personnel through sessions and workshops. LiquidSpring will ...

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Video medicine platform swyMed announces formation of Scientific Advisory Board

LEXINGTON, Mass. — swyMed, a provider of exceptional-quality video telemedicine solutions, today announced the creation of its Scientific Advisory Board (SAB) with four key appointments: Lester Wold, M.D.; James McCarthy, M.D.; Ronald Merrell, M.D.; and Noah Rosen, M.D. The Scientific Advisory Board will advise swyMed on the highest value applications for swyMed’s truly mobile telemedicine ...

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Program Director, Emergency Medical Services (EMS) - Yavapai College

Directly responsible for the oversight and administration of all aspects of the Emergency Medical Services Program. Identifies needs and develops plans and projections for future programs and courses. Participates in building and maintaining community and agency partnerships by development of good working relationships and involvement with district committees on various issues related to program. - ...

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Paramedic - Wake County - EMS

Paramedics are the primary provider of prompt, compassionate, and clinically excellent emergency medical care to the sick and injured citizens of and visitors to Wake County. Paramedics are responsible for the operation of emergency vehicles, biomedical equipment and other equipment necessary to provide patient and situational assessment, treatment and transport in an emergency setting. Paramedics are ...

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EMS Deputy Director of Operations - Wake County EMS

The EMS Deputy Director of Operations (EMS Deputy Director of Operations ) will be primarily responsible for the oversight and management EMS System Operations. As one of five EMS Deputy Directors, the Deputy Director of Operations is directly responsible for making sure EMS system operations function at a high level of effectiveness and efficiency. The EMS Deputy Director of Operations directly supervises ...

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Emergency Communications Specialist Trainee - Fauquier County Government

ESSENTIAL FUNCTIONS/TYPICAL TASKS: Receiving, classifying, processing and dispatching emergency service calls; receiving, recording and forwarding non-emergency service calls; preparing and maintaining records and files; preparing reports. (These are intended only as illustrations of the various types of work performed. The omission of specific duties does not exclude them from the position if the work ...

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Man fires shot into Ariz. ambulance with 4 people onboard

Police said the man fired a single shot into an ambulance before fleeing and attempting to rob a convenience store

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South African medics seriously injured after ambulance crashes into hippo

Three EMS providers were returning from a call when a hippo crossed into the roadway

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Orlando Pulse nightclub shooting lessons for EMS response to MCIs

NEW ORLEANS — The Orlando Pulse nightclub shooting on June 12, 2016 was the deadliest mass shooting in U.S. history. It was also the worst attack on the LGBTQ community in documented history and the deadliest terror attack in the U.S. since 9/11.

Christopher Hunter, MD, Ph.D, the Associate Medical Director of the Orange County EMS System, presented on the EMS response to the shooting and aftermath at the 2017 National Association of EMS Physicians annual meeting.

Memorable quotes on Pulse patient triage and care

Here are some memorable quotes and key takeaways from his talk.

"When people say this can happen anywhere, this (Orlando) is about as anywhere as it gets."

"What we really ended up with over the course of the day was three different MCIs."

"The civilians that were involved did not run away, they stayed."

"One of the less sexy, but more important things that saved lives was throughput within the hospital."

"I’m still not sure triage tags are the answer."

"It’s difficult to coordinate when you have this many agencies responding to something."

"Family reunification is something we were not prepared for in any way, shape or form."

7 key takeaways on EMS response and transport

Here are seven key takeaways from the EMS response to Pulse, patient triage, patient transport and the challenges of media interest and family reunification.

1. Preparedness matters for performance

Drills may be one of the less flashy sides of preparedness, but they directly impact the cohesive performance of responding agencies when the big event happens.

2. Rogue responders

In a mass shooting like this, units are going to go "rouge." The first unit to arrive on scene was not initially dispatched there, but ended up transporting 11 patients in two hours.

3. Dispatch is going to be overwhelmed

During the Pulse incident, dispatchers received over 600 911 calls over the course of the early morning. If the system is reliant on dispatchers to do anything beyond answer calls, such as sending text alerts to employees, there must be a back-up plan.

4. Triage tags might not get used

Very few triage tags will be used in a large urban environment, likely more useful in scenarios significantly further from a trauma center. During this event, anyone still alive with a bullet wound to a non-extremity was transported immediately upon extrication from the nightclub.

6. Pre-plan for family reunification

The family reunification center was a very unanticipated and resource-heavy need. Have locations predetermined with a hotline and a script ready for collecting the right types of information. Orlando is developing a free computer system for any agency to use that will help collect information on unaccounted individuals

7. Overwhelming media interest

News coverage will be more than the agency has ever seen. The media will do anything they can to gain access to sensational audio, photos and video. Lawyers will need to get creative. In Orlando, they used a law that protects any information related to an autopsy to ensure that photos of the crime scene were not released.

Learn more

To learn more about MCI planning, response, triage and patient care, read these EMS1 articles.

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Protective effects of breastfeeding against acute respiratory tract infections and diarrhoea: Findings of a cohort study

Journal of Paediatrics and Child Health

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Republican lawmakers worry if 'Trumpcare' doesn't deliver

AP

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Basic educational needs of midwifery students for taking the role of an assistance in disaster situations: A cross-sectional study in Iran

Nurse Education Today

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Factors associated with adverse outcomes in patients with traumatic intracranial hemorrhage and Glasgow Coma Scale of 15

The American Journal of Emergency Medicine

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Effect of social deprivation on the admission rate and outcomes of adult respiratory emergency admissions

Respiratory Medicine

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Ohio teen zaps cop with stun gun to fulfill bucket-list wish

AP

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Effects of atorvastatin on biomarkers of acute kidney injury in amikacin recipients: A pilot, randomized, placebo-controlled, clinical trial

Journal of Research in Medical Sciences

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California looks to build $7 billion legal pot economy

AP

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Alternative models of disorders of traumatic stress based on the new ICD-11 proposals

Acta Psychiatrica Scandinavica

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Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis

British Journal of Surgery

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Clinical implications of DNMT3A mutations in a Southeast Asian cohort of acute myeloid leukaemia patients

Journal of Clinical Pathology

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Randomized comparison of three guidewire insertion depths on incidence of arrhythmia during central venous catheterization

The American Journal of Emergency Medicine

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Prognostic impact of disseminated intravascular coagulation score in acute heart failure patients referred to a cardiac intensive care unit: A retrospective cohort study

Heart and Vessels

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UPMC mold transplant lawsuits not targeting linen firm, too

AP

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Clinical profiles of young adults with juvenile-onset fibromyalgia with and without a history of trauma

Arthritis Care & Research

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Falls, risk factors and fear of falling among persons older than 65 years of age

Psychogeriatrics

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Efforts of a Unit Practice Council to implement practice change utilizing alcohol impregnated port protectors in a burn ICU

Burns

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More delays in executions as some states find lethal drugs

AP

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A decision-making algorithm for initiation and discontinuation of RRT in severe AKI

Clinical Journal of the American Society of Nephrology

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Acute kidney injury and in-hospital mortality after coronary artery bypass graft versus percutaneous coronary intervention: A nationwide study

American Journal of Nephrology

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Δευτέρα 30 Ιανουαρίου 2017

Pa. man reunited with responders who saved him

By EMS1 Staff

VALLEY VIEW, Pa. — After a near-death experience, a man had the opportunity to personally thank the first responders who saved his life.

Bill Malloy, 64, suffered a heart attack Jan. 3; doctors said the cardiac event is often known as the “widow-maker,” and is caused by a blockage in his left anterior descending artery.

“All I remember was that I had indigestion. The next thing I knew, it was Thursday or Friday. I got lucky,” Malloy told the Philadelphia Inquirer.

After Malloy’s wife, Ann Kreitz, called 911, responders quickly arrived. A dispatcher instructed Kreitz to perform CPR until EMS providers and EMT students arrived to the scene; the responders and students were in an EMT certification class nearby.

"I directed her [Ann] to start CPR because I heard him breathing ineffectively," dispatcher Steve Oravitz said. "We did three rounds, and they (EMTs) were there within a few minutes. She did very well, following my instructions to a 'T.'"

Malloy and Kreitz were able to visit and thank the EMS providers for their actions Jan. 26.

"It's weird because you don't know these people, but you love them," Kreitz said.

“I like to help people” Valley View man reunites with first responders who saved his life https://t.co/Rrl3pYIZOY #firstaid #cpr #responders http://pic.twitter.com/X6eqTu3FqB
— Mobilize (@MobilizeRescue) January 24, 2017

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Innovation Zone - Belluscura Evacuation Slyde

The Evacuation Slyde by Belluscura is a compact, wall mountable, patient evacuation sled for moving immobile patients by carrying or pulling up and down stairs or other uneven terrain in the case of fire, natural disasters, attacks or other emergencies.

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Wis. fire dept. mandates body armor for paramedics

Although the vests add an additional 20 to 30 pounds of weight, officials said paramedics don’t mind

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Innovation Zone - Belluscura Evacuation Slyde

Fla. ambulance transporting patient, car collide

Three paramedics and a patient were on board the ambulance when the crash occurred

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Patient steals, crashes Ohio ambulance

EMS crews had just unloaded the patient and were restocking medical supplies when he stole the ambulance

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What color uniform should paramedics wear?

Applying the lessons learned from research about uniform colors in other industries to EMS

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EMT-B/Paramedic - Kurtz Ambulance

The basic function of the EMT/Paramedic is to provide medical care and transportation for a patient within their scope of practice, as stipulated by EMS Commission of Indiana.

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Importance of situational awareness process for emergency responders

MILWAUKEE ― Firefighters and EMS personnel learned and reviewed the critical steps to situational awareness and action for a safe and effective incident response at the Wisconsin EMS Association Working Together conference. Rom Duckworth, a fire captain, delivered the presentation "Aware, Alert, Aggressive, Always: How to do your job effectively when things are trying to kill you" to an audience of EMS personnel, firefighters and officers.

Situational awareness (and action), according to Duckworth, follows six steps. The first step is to perceive by seeking and scanning for critical clues and cues. The second step is process to form a mental model from the critical clues and cues gathered during the seek and scan. The third step is to predict what will happen next if responders don’t intervene. The prediction is based on the mental model formed in the previous step. Use the prediction to decide in the fourth step and then in step five take action. The final step in Duckworth's situational awareness process is to communicate and coordinate.

Memorable quotes about situational awareness

Duckworth is a rapid-fire presenter with an engaging and entertaining presentation style. He mixed theory with quick group exercises and videos of actual incidents to inform the audience. Here are a few memorable quotes from the presentation.

"Situational awareness is knowing what's going on so you can figure out what to do. It involves perceiving, processing and predicting. Then doing something about it."

"For you to operate safely (as a firefighter), but effectively you need to understand what your role is in the incident."

"When you feel something isn't right, that's because something isn't right and you need to say something."

"People start doing unsafe things and they don't even realize it. Nobody wants to say anything to get anyone in trouble."

"Do not pick a strategy or tactic that is not going to change the outcome."

3 top takeaways on situational awareness for emergency responders

Duckworth delivered an information dense presentation on situational awareness. Here are my three top takeaways from his presentation.

1. Know and understand top causes of LODD

Duckworth opened the session by reminding participants of top contributors to LODD. Those contributors are:

1. Inadequate risk assessment
2. Lack of incident command
3. Lack of accountability
4. Inadequate communications
5. Lack of SOGs or failure to follow established SOGs

These contributors of LODD affirm the importance of knowing and practicing a situational awareness process.

2. Learn and practice situational awareness and action process

Duckworth gave attendees a six-step process, as well as other tools for communication, for situational awareness and action. Situational awareness and action, consistently applied, needs to be part of training, EMS responses, rescue incidents, fire alarms and working fires.

3. Failures to situational awareness are predictable

Duckworth guided the audience through a series of quick scenarios and on-screen experiments to identify predictable failures to situational awareness. Several photos and videos were used to show how peripheral vision, distraction and stress impact perception of change in an environment. Because of the limitations of cognition, especially when compromised by stress, failures in situational awareness are predictable. Knowing possible failures reinforces the importance of following and repeating a situational process.

Learn more about situational awareness

Duckworth's presentation is available on SlideShare or can be viewed in full below. Here are other articles to learn more about situational awareness.

Situational Awareness for Fire and EMS from Rommie Duckworth

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Emerging trends in EMS grants

The top three emerging trends in EMS grants reflect the shift in health care toward value amid political uncertainty. EMS organizations will need to adapt, innovate and build new programs. This is a different approach for EMS providers who are widely seen as transport for emergent and non-emergent patients to the hospital. Here are the top three trends that are expected to be widely funded by government, private and partnership agencies.

1. Substance abuse and mental illness

One in five adults in the United States experience mental illness, costing more than $440 billion each year, according to the National Alliance on Mental Illness [1]. All too often, these patients go to emergency departments via EMS — accounting for an estimated one in eight patients in the emergency department [2]. Emergency departments are not staffed to appropriately handle people with mental health issues that are often coupled with substance abuse issues.

Some health systems are partnering with EMS and local resources to address this problem. Alternative destinations for these patients, such as specialized psychiatric emergency departments or non-profit integrated behavioral health care clinics, can be a solution. In North Carolina, 11 EMS agencies are assisting the community with those in mental health and substance abuse crisis through grants provided by the Division of Mental Health/Developmental Disabilities/Substances Abuse Services in collaboration with the N.C. Office of Emergency Medical Services. There are similar programs in Georgia and Colorado.

Read full story on EMSGrantsHelp.com

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What color uniform should paramedics wear?

New Orleans EMS personnel wear navy blue shirts and pants with white lettering. Acadian Ambulance services a number of neighboring parishes; they wear light green tops and dark green pants. One thousand miles north of New Orleans and up-river, Hennepin EMS (Minn.) paramedics wear light brown shirts and dark brown pants. Bell Ambulance paramedics in Milwaukee wear a light blue shirt and navy pants while Gold Cross (Wis.) paramedics wear a white shirt over black pants.

Because of the variety in EMS uniforms, as well as some being very distinct and others being very similar from law enforcement, it is worth considering the impact of uniform color on patient interactions and EMS provider safety. Here is what we know about uniforms, the role uniform color plays in police-public interactions, and what, if anything, EMS can do with this knowledge.

Uniform power

That uniforms confer a power or status to the wearer is not an unknown concept [1]. In health care, physicians have been outwardly proclaiming their rank and stature via white coats for well over a century [2]. This use of white to convey authority also seems to have transferred to nursing. Regardless of age, patients judge a nurse as more professional when they are wearing all white [3].

Starting in the 1980s, hypotheses around the power of the police officers uniform began to be tested. Unsurprisingly, police officers in uniform were rated as more competent, intelligent, helpful and reliable [4].

A 2005 study showed that color matters. When compared to white/black, light blue/navy and khaki/khaki combinations, all black uniforms "evoke negative impressions from the citizen, producing negative attributions that the officer must overcome through behaviors" [5].

Although all navy uniforms were not tested in this experiment, many EMS organizations use a dark navy color scheme instead of white or light blue shirts. It would not be inappropriate to hypothesize that darker uniforms could force prehospital providers to overcome similar negative attributions faced by police officers wearing all black.

However, when comparing the actual level of aggression against police officers wearing different color uniforms, color does not matter. Specifically, officers wearing darker uniforms were not exposed to more violence compared to their light-uniform wearing counterparts when controlling for community contextual variables [6].

Uniform as a source of harm

Some EMS providers worry they look too much like other members of public safety. While EMS is just as dangerous as fire or police, the majority of line of duty deaths and long-term disability does not come at the hands of patients or bystanders.

EMS providers are at greatest risk of death from motor vehicle collisions [7]. The most common nonfatal injury diagnoses are sprains and strains, something that increasingly out of shape providers may be facilitating [7]. Although untested, mental health issues likely contribute heavilty to both death and disability within EMS.

Any decision to change uniforms for the safety of providers must consider these actual risks and must prioritize the types of changes that will increase protections such as reflective vests, enforcing seat belt adherence, stab vests and even ambulance redesign.

To argue that EMS is simply caught in the crossfire and would not have been harmed had they been wearing less "police-like" uniforms in Boston, Illinois, Maine and Detroit is a short-sighted argument that twists the reality of those events.

Those still concerned with the well-being of providers that may be mistaken for other arms of public safety should consider implementing, and enforcing, protocols such as ensuring police presence on potentially dangerous scenes or training providers in proven de-escalation techniques [8].

Patient safety and uniforms

While the primary purpose of this article was to discuss provider safety as it relates to uniform design, it would be careless to forgo any mention of the threat provider uniforms pose to patients. A 2016 Ohio study showed that EMS providers had a ten-fold increased risk of testing positive for methicillin-resistant Staphylococcus aureus (MRSA) colonies when they didn’t wash their hands after removing their gloves [9]. And while every provider knows they should wash their hands, according to a 2014 study, just over one-in-four in the prehospital setting manage to actually perform such a task [10].

So if providers are only washing their hands between 25 percent of patients, how often do they sanitize their boots, belt, stethoscope and radio between calls" Let alone between shifts" Per a 2011 study in Infection Control and Hospital Epidemiology, it takes water temperatures over 140F, or the "hot" setting on most domestic machines, for 10 minutes to decontaminate uniforms of MRSA [11].

Does every provider wash his or her uniform on the hot setting after each shift"

Applying systems thinking to uniform selection

If an EMS agency is making a change to their uniforms, they must apply the same systematic logic that is a standard practice for implementing new protocols or making a capital expenditure. Uniforms are part of the first impression the community will have on the responding crew. They must represent the importance of that role.

In some communities, simple changes like a new shirt color or reflective wording may provide more of a benefit than a complete overhaul. In other communities, the most value occurs in ensuring providers are appropriately labeled and that only providers which have received adequate training are put in situations where their attire could cause confusion over "which team" they are on.

Uniforms serve as not only a marker of rank and skill, but also act as method for communicating directly with the community [1]. As such, we must choose our words and colors wisely.

References
1. Hertz, C. (2007). The Uniform: As Material, As Symbol, As Negotiated Object. Midwestern Folklore, 32(1, 2): 43-56.

2. Hochberg M.S. (2007). The Doctor's White Coat — a Historical Perspective. AMA Journal of Ethics, 9(4): 310-314.

3. Albert, N.M., Wocial, L., Meyer, K.H., Na, J., Trochelman, K. (2008). Impact of nurses' uniforms on patient and family perceptions of nurse professionalism. Applied Nursing Research, 21(4): 181-190.

4. Singer, M.S., Singer, A.E. (1985). The Effect of Police Uniform on Interpersonal Perception. The Journal of Psychology: Interdisciplinary and Applied, 119(2): 157-161.

5. Johnson, R.R. (2005). Police uniform color and citizen impression formation. Journal of Police and Criminal Psychology, 20(2): 58-66.

6. Johnson, R.R. (2013). An Examination of Police Department Uniform Color and Police–Citizen Aggression. Criminal Justice and Behavior, 40(2): 228-244.

7. Reichard, A.A., Marsh, S.M., Moore, P.H. (2011). Fatal and nonfatal injuries among emergency medical technicians and paramedics. Prehospital Emergency Care, 15(4): 511-517.

8. Compton, M.T., Bakeman, R., Broussard, B., Hankerson-Dyson, D., Husbands, L., Krishan, S., …Watson, A.C. (2014). The Police-Based Crisis Intervention Team (CIT) Model: II. Effects on Level of Force and Resolution, Referral, and Arrest. Psychiatric Services, 65(4): 523-529.

9. Orellana, R.C., Hoet, A.E., Bell, C., Kelley, C., Lu, B., Anderson, S.E., Stevenson, K.B. (2016). Methicillin-resistant Staphylococcus aureus in Ohio EMS Providers: A Statewide Cross-sectional Study. Prehospital Emergency Care, 20(2): 184-190.

10. Bledsoe, B.E., Sweeney, R.J., Berkeley, R.P., Cole, K.T., Forred, W.J., Johnson, L.D. (2014). EMS provider compliance with infection control recommendations is suboptimal. Prehospital Emergency Care, 18(2): 290-294.

11. Lakdawala, N., Pham, J., Shah, M., & Holton, J. (2011). Effectiveness of Low-Temperature Domestic Laundry on the Decontamination of Healthcare Workers’ Uniforms. Infection Control and Hospital Epidemiology, 32(11): 1103-1108.

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PulmCrit- Six myths promoted by the new surviving sepsis guidelines

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Early Goal-Directed Therapy: A house collapsing in slow motion The original foundation of the Surviving Sepsis Campaign was the Rivers trial on early goal-directed therapy. This is basically the NINDS trial of the critical care world: a study with ~300 patients showing implausibly positive results, published in NEJM, and rapidly brainwashing an entire discipline. The […]

EMCrit by Josh Farkas.

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Work hard, sip often with Fire Dept. Coffee

Strong coffee pairs with strong values in this veteran-owned business

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PulmCrit- Six myths promoted by the new surviving sepsis guidelines

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EMCrit by Josh Farkas.

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The use of whole-body computed tomography in major trauma: Variations in practice in UK trauma hospitals

Emergency Medicine Journal

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Stenting after coiling using a single microcatheter for treatment of ruptured intracranial fusiform aneurysms with parent arteries less than 1.5 mm in diameter

World Neurosurgery

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Intramuscular midazolam versus intravenous diazepam for treatment of seizures in the pediatric emergency department: A randomized clinical trial

Pediatric Critical Care Medicine

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The effect of a short-stay unit on hospital admission and length of stay in acute heart failure: REDUCE-AHF study

European Journal of Internal Medicine

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The children with a diagnosis of meningitis in emergency department

Pediatric Critical Care Medicine

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Association of HIV and opportunistic infections with incident stroke: A nationwide population-based cohort study in Taiwan

Journal of Acquired Immune Deficiency Syndromes

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Risk factors of hyperglycemia in patients after a first episode of acute pancreatitis: A retrospective cohort

Pancreas

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Genetic variant rs3750625 in the 3'UTR of ADRA2A affects stress-dependent acute pain severity after trauma and alters a microRNA-34a regulatory site.

Pain

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The effect of sustained low efficient dialysis versus continuous renal replacement therapy on renal recovery after acute kidney injury in the intensive care unit: A systematic review and meta-analysis

Nephrology

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Profile and outcome of first 109 cases of pediatric acute liver failure at a specialized pediatric liver unit in India

Liver International

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Acute neuropsychiatric symptoms associated with antibiotic treatment of Helicobacter pylori infections: A review

Journal of Psychiatric Practice

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Effect of spinal needle characteristics on measurement of spinal canal opening pressure

The American Journal of Emergency Medicine

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Long-term functional outcome in patients with acquired infections after acute spinal cord injury

Neurology®

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Comparison of Medicaid payments relative to Medicaid using inpatient acute care claims from the medicaid program: Fiscal year 2010-fiscal year 2011

Health Services Research

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Long-term survival in adults treated with extracorporeal membrane oxygenation for respiratory failure and sepsis

Critical Care Medicine

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Chest compression fraction in ambulance while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan

Emergency Medicine Journal

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Impact of an emergency short stay unit on emergency department performance of poisoned patients

The American Journal of Emergency Medicine

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Vernal shield ulcers treated with frequently installed topical cyclosporine 0.05% eyedrops

International Ophthalmology

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Κυριακή 29 Ιανουαρίου 2017

White Shirts: The high cost of low morale

See all of Jessie Senini's comics.

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An Unlikely Cause of Hypokalemia

Publication date: Available online 28 January 2017
Source:The Journal of Emergency Medicine
Author(s): Jason Hine, Ari Schwell, Norah Kairys
BackgroundHypokalemia is a common clinical disorder caused by a variety of different mechanisms. Although the most common causes are diuretic use and gastrointestinal losses, elevated cortisol levels can also cause hypokalemia through its effects on the renin–angiotensin–aldosterone system. Cushing's syndrome refers to this general state of hypercortisolemia, which often manifests with symptoms of generalized weakness, high blood pressure, diabetes mellitus, menstrual disorders, and psychiatric changes. This syndrome is most commonly caused by exogenous steroid use, but other etiologies have also been reported in the literature. Ectopic adrenocorticotropic hormone production by small-cell lung cancer is one rare cause of Cushing's syndrome, and may be associated with significant hypokalemia.Case ReportWe describe the case of a 62-year-old man who presented to the emergency department with weakness and hypokalemia. The patient was initially misdiagnosed with furosemide toxicity. Despite having a 30-pack-year smoking history, this patient's lack of respiratory complaints allowed him to present for medical attention twice before being diagnosed with lung cancer. It was later determined that this patient's hypokalemia was due to Cushing's syndrome caused by ectopic adrenocorticotropic hormone production from small-cell lung cancer.Why Should an Emergency Physician Be Aware of This?This case reminds emergency physicians to consider a broad differential when treating patients with hypokalemia. More importantly, it prompts emergency physicians to recognize comorbid conditions and secondary, less common etiologies in patients with repeated visits for the same complaint.

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Σάββατο 28 Ιανουαρίου 2017

CC Nerd-The Case of the Elusive Mirage

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Tales are often told of an exhausted travel who has lost their way in the desert, and are drawn astray by the the sight of a lush oasis. But as they draw close, their salvation vanishes only to reappear on the distant horizon. This optical tormentor continues to lead the hapless travelers further and further […]

EMCrit by Rory Spiegel.

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CC Nerd-The Case of the Elusive Mirage

1-1.jpg?resize=750%2C375

EMCrit by Rory Spiegel.

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Calcium Pill Aspiration: A Case Report

Publication date: Available online 27 January 2017
Source:The Journal of Emergency Medicine
Author(s): David Clark Brewer, Mark Regala, Jamie Hess

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Παρασκευή 27 Ιανουαρίου 2017

Radiological evaluation of tube depth and complications of prehospital endotracheal intubation in pediatric trauma: a descriptive study

Abstract

Purpose

Pediatric prehospital endotracheal intubation (PHETI) is a difficult and rarely performed procedure that remains the gold standard for prehospital airway management when ventilation and/or anesthesia is required, but high complications rates, including malposition continue to concern. We reviewed the experience in our institution of pediatric intubations with particular emphasis on the position of the endotracheal tube (ETT) tip within the trachea and related complications.

Method

Intubated pediatric patients presenting directly from the scene to our level 1 trauma center, between 2006 and 2014, were included in our study. Patient records and radiographs were retrospectively reviewed to identify the ETT tip-to-carina distance and possible intubation-related complications. ETT tips identified beyond the carina on radiographs or by clinical diagnosis were defined as misplaced. Because head movement causes a significant ETT movement within the trachea, which is age related, we also defined ETT tip placement (1) less than 2 cm above the carina in children younger than 8 and (2) less than 3 cm above the carina in children 8 years or older as “near miss” intubations.

Results

From a total of 34 cases, ETT misplacement was identified in seven cases. Diagnosis was made radiologically in five cases and clinically in two cases. Four of these patients had left lung atelectasis due to tube misplacement. Tube thoracotomy was performed in two of these patients without concurrent evidence of chest injury. “Near miss” intubations accounted for 7/9 and 9/25 in children <8 years and ≥8 years old, respectively, totaling 16/34, with two of these leading to late displacements.

Conclusions

Pediatric endotracheal tube intubation carries a high rate of tube malposition and left lung atelectasis in our experience of pediatric trauma patients, with less than a third of ETTs placed in a safe position.

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Dr. Oz encourages viewers to learn hands-only CPR

Texas Two Step is a free 5-minute training session in hands-only CPR designed to teach participants how to potentially save a life: Step #1: Call 911. Step #2: Begin hands-only CPR by pushing hard and fast on the center of the chest.

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Dr. Oz encourages viewers to learn hands-only CPR

Identifying augmented renal clearance in trauma patients: Validation of the augmented renal clearance in trauma intensive care (ARCTIC) scoring system.

Background: Augmented renal clearance (ARC) is common in trauma patients and associated with subtherapeutic antimicrobial concentrations. This study reported the incidence of ARC, identified ARC risk factors and described a model to predict ARC (i.e.,ARCTIC) that is specific to trauma patients. Methods: Consecutive trauma patients who were admitted to the ICU between March 2015 and January 2016 and had a measured creatinine clearance (CrCl) were considered for inclusion. Patients were excluded if their serum creatinine (SCr) was >1.3 mg/dL. ARC was defined as a measured CrCl >=130ml/min. Demographic and trauma-specific variables were then compared and multivariate analysis was performed. Using these results, a weighted scoring system was constructed and evaluated using receiver operating characteristic (ROC) curve analysis. ARCTIC score cut-offs were chosen based on sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The derived scoring system was then compared to a previously published scoring system for accuracy. Results: There were 133 patients with a mean age of 48+/-19 years and SCr of 0.8+/-0.2 mg/dL. The mean measured CrCl was 168+/-65 ml/min and the incidence of ARC was 67%. Multivariate analysis revealed the following risk factors for ARC [odds ratios (95% CI)]: age = 6 had a sensitivity, specificity, PPV and NPV of 0.843, 0.682, 0.843 and 0.682, respectively. Conclusion: The incidence of ARC in trauma patients is high. The ARCTIC score represents a practical, pragmatic system that can be easily applied at the bedside. An ARCTIC score >=6 represents an appropriate cut-off to screen for ARC where antimicrobial adjustments should be considered. Level of Evidence: Prognostic and epidemiologic study, level III. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Trauma and psychiatric disorders, a systematic review.

Background: Suicide is currently a topic of high priority for policy-makers, researchers and clinicians. The World Health Organization estimated 804.000 suicide deaths worldwide in 2012. Some studies that focused on patients with self-inflicted injury revealed that mortality in this group is higher than for patients who sustain unintentional injury. However little is known about the impact of psychiatric disorders on health care resources including length of hospital stay. Objectives: To determine whether trauma patients with a psychiatric disorder or after attempting suicide are at higher risk of a complicated course than patients without a psychiatric disorder or accidental cause. The secondary objective was to provide an overview of the current literature on the same group of trauma patients with psychiatric comorbidity in regards to mortality rate, length of stay, hospital costs and quality of life. Our primary outcome measure, complicated course, was found to be most clinically relevant. Methods: We searched PubMed, Embase and PsycInfo electronic databases. All searches were updated to March 2016. The methodological quality was assessed using the QUIPS tool. Results: Our search identified 9284 articles (PubMed 3660, Embase 2590, PsycInfo 3034). Of these, 18 articles were included. Four studies investigated the association between psychiatric disorders and a complicated course after trauma, three found a significant higher risk of complications. Mortality was reviewed in fourteen studies, of which seven showed significant higher risk of in-hospital mortality for trauma patients with psychiatric disorder. Eight out of nine studies found significant prolonged length of stay for these patients. Conclusion: Patients who have a psychiatric disorder or who have attempted suicide are at higher risk of increased in-hospital mortality and prolonged length of stay after sustaining injuries. These patients also tend to be at higher risk of complications after severe trauma, however future research is needed to confirm these potentially important implications. Level of Evidence: Level III Systematic Review. Key words: psychiatric disorders, psychiatric comorbidity, trauma patients. (C) 2017 Lippincott Williams & Wilkins, Inc.

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Tissue injury suppresses fibrinolysis following hemorrhagic shock in non-human primates (rhesus macaque).

Background: Hypoperfusion is associated with hyperfibrinolysis and early death from exsanguination, while tissue trauma is associated with hypofibrinolysis and delayed death from organ failure. We sought to elucidate the effects of injury patterns on fibrinolysis phenotypes using a non-human primate (NHP) model. Methods: NHPs were randomized to three injury groups (n=8/group): 60 min severe pressure-targeted controlled hemorrhagic shock (HS); HS + soft tissue injury (HS+); or HS + soft tissue injury + femur fracture (HS++). Animals were resuscitated and monitored for 360 min. Blood samples were collected at baseline (BSLN), end-of-shock (EOS), end-of-resuscitation (EOR), and T=360 min for assessments of: severity of shock (lactate) and coagulation via prothrombin time (PT), partial thromboplastin time (PTT), D-dimer, fibrinogen, anti-thrombin-III (AT-III), von Willebrand factor (vWF); and viscoelastic testing (ROTEM(R)). Results are reported as mean+/-SEM; statistics: two-way ANOVA and t-tests; significance: p

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Management of pericardial fluid in blunt trauma: variability in practice and predictors of operative outcome in patients with computed tomography evidence of pericardial fluid.

Background: The objectives of this study were to assess current variability in management preferences for blunt trauma patients with pericardial fluid, and to identify characteristics associated with operative intervention for patients with pericardial fluid on admission computed tomography (CT) scan. Methods: This was a mixed-methods study of blunt trauma patients with pericardial fluid. The first portion was a research survey of members of the Eastern Association for the Surgery of Trauma conducted in 2016, in which surgeons were presented with four clinical scenarios of blunt trauma patients with pericardial fluid. The second portion of the study was a retrospective evaluation of all blunt trauma patients >=14 years treated at our Level I trauma center between 1/1/2010 and 11/1/2015 with pericardial fluid on admission CT scan. Results: For the survey portion of our study, 393 surgeons responded (27% response rate). There was significant variability in management preferences for scenarios depicting trace pericardial fluid on CT with concerning hemodynamics, and for scenarios depicting hemopericardium intraoperatively. For the separate retrospective portion of our study, we identified 75 blunt trauma patients with pericardial fluid on admission CT scan. Seven underwent operative management; six of these had hypotension and/or electrocardiogram changes. In multivariable analysis, pericardial fluid amount was a significant predictor of receiving pericardial window (relative risk for one category increase in pericardial fluid amount: 3.99, 95% CI 1.47-10.81) but not of mortality. Conclusions: There is significant variability in management preferences for patients with pericardial fluid from blunt trauma, indicating a need for evidence-based research. Our institutional data suggest that patients with minimal to small amounts of pericardial fluid without concerning clinical findings may be observed. Patients with moderate to large amounts of pericardial fluid who are clinically stable with normal hemodynamics may also appear appropriate for observation, although confirmation in larger studies is needed. Patients with hemodynamic instability should undergo operative exploration. Level of Evidence: Level IV, Therapeutic/Care Management (C) 2017 Lippincott Williams & Wilkins, Inc.

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Parenteral and enteral nutrition in surgical critical-care: plasma metabolomics demonstrates divergent effects on nitrogen, fatty-acid, ribonucleotide and oxidative metabolism.

Background: Artificial nutrition support is central to the care of critically ill patients and is primarily provided enterally (EN). There are circumstances when parenteral nutrition (PN) is considered necessary. We are uncertain how each of these approaches confer clinical benefits beyond simply providing calories. We sought to better understand how each of these techniques influence metabolism in critically-ill patients using a broad-based metabolomics approach. Metabolic responses to EN and PN may differ in ways that could help us understand how to optimize use of these therapies. Methods: We prospectively enrolled subjects over 7 months in 2015 at an urban, level-one trauma center. Subjects were included prior to starting either EN or PN during their inpatient admission. Plasma samples were obtained between 1-12 hours before initiation of artificial nutrition, and 3 and 7 days later. All samples were analyzed with liquid chromatography/mass-spectrometry-based metabolomics. Differences in metabolite concentrations were assessed via principal component analyses and multiple linear regression. Results: We enrolled 30 subjects. Among the critically-ill subjects, 10 received EN and 10 received PN. In subjects receiving EN, amino acid and urea cycle metabolites (citrulline, p=0.04; ornithine, p=0.05) increased, as did ribonucleic acid metabolites (uridine, p=0.04; cysteine, 0=0.05; oxypurinol, p=0.04). Oxidative stress decreased over time. (increased betaine, p=0.05; decreased 4-pyridoxic acid, p=0.04). In subjects receiving PN amino acid concentrations increased over time (taurine, p=0.04; phenylalanine, p=0.05); omega 6 and omega 3 fatty acid concentrations decreased over time (p=0.05 and 0.03, respectively). Conclusion: EN was associated with amino-acid repletion, urea cycle upregulation, restoration of antioxidants, and increasing RNA synthesis. Parenteral nutrition was associated with increased amino acid concentrations, but did not influence protein metabolism or antioxidant repletion. This suggests that parenteral amino acids are utilized less effectively than those given enterally. The biomarkers reported in this study may be useful in guiding nutrition therapy for critically-ill patients. Level of Evidence: III, Study Type: Diagnostic Tests or Criteria (C) 2017 Lippincott Williams & Wilkins, Inc.

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Traumatic transection of the posterior descending coronary artery.

No abstract available

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Long-term outcomes of thoracic endovascular aortic repair (TEVAR): A single institution's 11-year experience.

Introduction: TEVAR has largely replaced traditional open aortic repair for anatomically suitable lesions, however, long-term outcomes are unknown. Methods: All patients who underwent TEVAR from December 2004-October 2015 at a single tertiary care institution were included. Demographics, injury pattern, operative details, outcomes, and surveillance were reviewed. Follow-up ranged from 2-132 months, and was obtained from clinic notes and imaging reports. Results: A total of 88 patients underwent TEVAR; all suffered from blunt mechanisms, 72.7% were male. Median age, ISS, TRISS was 47(19.7), 38(13.5), 0.8(0.34). Injuries included 2% grade II, 90% grade III, 8% grade IV. Overall mortality was 6.8%, TEVAR-related mortality was 0%. Overall in-hospital complication rate was 57% while TEVAR-related complication rate was 9.1%: 4 type 1a endoleaks, 2 type 2, and 2 type 3. Of the type 1 endoleaks, all required re-operation, while all type 2 and 3 endoleaks resolved on subsequent imaging. The LSCA was intentionally covered at index operation in 19 patients (21.6%), and 7 patients (8%) had partial LSCA coverage. The rate of post-operative left upper extremity ischemia was 0%. Left carotid-subclavian bypasses were performed prophylactically in 2 patients prior to LSCA coverage at index operation. 87% of endograft access was by performed by open femoral artery exposure and one via retroperitoneal conduit. Percutaneous TEVAR (pTEVAR) was performed more recently in 11.4% of patients with no complications. Heparin was administered intra-operatively in 23 patients with TBI, and 12 patients were not heparinized; no adverse events or outcomes resulted from its use or lack thereof. First, second, and third surveillance imaging occurred at mean intervals of 14 days, 4 months, and 1 year, respectively. Percent of patients followed at 1, 3, 5 years from operation was 62.1%, 25%, 13.6%. Conclusion: TEVAR continues to be a feasible treatment modality for blunt traumatic aortic injury with minimal and early device and procedure-specific complications. Follow-up continues to be a significant challenge, and protocols for surveillance imaging are needed. This is the first study to describe access specific outcomes of pTEVAR in trauma patients. Long-term outcomes of TEVAR are still largely unknown, however, this data suggests it may be at least comparable to open repair. Level of evidence: IV (C) 2017 Lippincott Williams & Wilkins, Inc.

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COPD exacerbation: 5 things EMS providers need to know

Understand how monitoring tools can be used to guide treatment for COPD exacerbations

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Introduction to medication-assisted opioid dependence treatment for EMS

MILWAUKEE — An addiction treatment specialist shared important opioid dependence considerations for emergency response providers during the drug overdose and addiction summit at the Wisconsin EMS Association conference.

Jeffrey Junig, MD, PhD, shared historical and clinical information about opioid dependence as well as what he has learned working half-time at a methadone clinic in Wisconsin.

Junig compared types of treatment programs for opioid dependence. Traditional treatment follows the steps of detox, active treatment and maintenance. In abstinence-based programs, patients go through an environment change, learn coping strategies and make plans to maintain sobriety. Abstinence programs usually include group and individual therapy and don't include any medications.

The harm reduction approach recognizes that people die in the quest for abstinence. This approach doesn't require total sobriety and uses a variety of interventions, including medication-assisted treatments.

Medication-assisted treatments, like methadone, try to find an area of comfort without illicit opioid use for the patient between withdrawal symptoms and overmedication. A methadone treatment regime at Junig's clinic includes an initial phase of 90 days, regular drug tests and successful promotion into a take home program allowing patients to receive two or more daily doses when they visit the clinic.

Memorable quotes

Junig began his medical career as an anesthesiologist before completing a psychiatry residency. His professional knowledge and experience was complemented by his own experience as an opioid addict. Here are memorable quotes from Junig.

"It takes two months to feel better after stopping opioids."

"I want them (patients) on something to keep them alive."

"There may be combinations of treatment that work, but there isn't crossing over."

"Medication-assisted treatment. It’s never just the medication."

Key takeaways on opioid dependence

Here are three takeaways from Junig's presentation.

1. Problem caused by health care, but not always

Opioid dependence is most often an iatrogenic problem that begins with a prescription for a painful condition, like a back injury. Explosive increases in opioid demand parallels increasing emphasis on pain assessment and pain management since the early 1990s. However, Junig increasingly encounters patients who report heroin as their first opioid.

2. Opioid addiction has a high relapse rate

The reason that people have a high relapse rate after opioid addiction treatment is not totally clear. Junig offered several reasons for a high relapse rate. Opioids give a user a feeling of comfort, which along with withdrawal syndrome makes it especially difficult to recover from addiction and leads to relapse.

3. Medication-assisted treatment for opioid dependence

This treatment acknowledges that illnesses are managed, not cured, and that medications are available for opioid dependence. Medication-assisted treatment has the goal of reducing injury and death.

Methadone is used in a highly-regulated program. Methadone reduces cravings and removes the benefit of IV use of opioids. A patient who relapses while on methadone is given immediate counseling. The daily regime of methadone is believed to encourage compliance and stability.

Buprenorphine (Suboxone) is a partial agonist that activates and blocks opioid receptors. It eliminates the opioid high. Junig treats patients with buprenorphine for as long as the patient is at risk for overdose.

Junig acknowledged that treating a drug with a drug is a controversial practice, but a compelling option because it prevents death from opioid overdose. He also emphasized several times that medication-assisted treatment should also include counseling to address the underlying cause of addiction.

Learn more

Check out these articles to learn more about addiction.

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Effectiveness of low-molecular-weight heparin versus unfractionated heparin to prevent pulmonary embolism following major trauma: A propensity-matched analysis

The Journal of Trauma and Acute Care Surgery

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Initial therapeutic strategy of invasive candidiasis for intensive care unit patients: A retrospective analysis from the China-SCAN study

BMC Infectious Diseases

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Palliative care needs in patients with heart failure presenting to the emergency department: A patient-centered evaluation of health status and quality of life approach

Journal of Pain and Symptom Management

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How safe is that driver next to you? A trucker’s poor health could increase crash risk

University of Utah Health Care

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Epidemiology of intravenous fluid use for headache treatment: Findings from the National Hospital Ambulatory Medical Care Survey

The American Journal of Emergency Medicine

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A prospective study of the use of antibiotics in the Emergency Department of a Chinese University Hospital

International Journal of Pharmacy Practice

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Physiotherapy interventions for people with dementia and a hip fracture - A scoping review of the literature

Physiotherapy

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A novel way of linen management in an acute care surgical center

Indian Journal of Surgery

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Simulation training program for midwives to manage postpartum hemorrhage: A randomized controlled trial

Nurse Education Today

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Heart failure with preserved ejection fraction has a better long-term prognosis than heart failure with reduced ejection fraction in old patients in a 5-year follow-up retrospective study

International Journal of Cardiology

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Risk of acute kidney injury after intravenous contrast media administration

Annals of Emergency Medicine

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Performance of International Classification of Diseasesbased injury severity measures used to predict in-hospital mortality and intensive care admission among traumatic brain-injured patients

The Journal of Trauma and Acute Care Surgery

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How is chronic pain related to sympathetic dysfunction and autonomic dysreflexia following spinal cord injury?

Autonomic Neuroscience: Basic and Clinical

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Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: Analysis of 1,030 consecutive trauma laparotomies

The Journal of Trauma and Acute Care Surgery

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Gastrointestinal bleeding in patients with renal failure under hemodialysis treatment: A single-center experience

International Urology and Nephrology

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Uniqueness of the anterior dentition three-dimensionally assessed for forensic bitemark analysis

Journal of Forensic and Legal Medicine

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The impact of body composition parameters on ipilimumab toxicity and survival in patients with metastatic melanoma

British Journal of Cancer

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Study finds premature death rates diverge in the United States by race and ethnicity

NIH News

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Persistent pain after motor vehicle collision: Comparative effectiveness of opioids vs nonsteroidal antiinflammatory drugs prescribed from the emergency department-A propensity matched analysis

Pain

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UV light can aid hospitals' fight to wipe out drug-resistant superbugs

UNC Health Care System

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Which indicators to include in a crowding scale in an emergency department? A national French Delphi study.

Background: Emergency department (ED) crowding is a serious international public health issue with a negative impact on quality of care. Despite two decades of research, there is no consensus on the indicators used to quantify crowding. The aim of our study was to select the most valid ED crowding indicators. Materials and methods: The Delphi method was used. Selected indicators originated from a literature review and propositions from FEDORU (National Emergency Department Observatory Network) workgroup. Selected national experts were emergency physicians with a special interest in ED crowding. They had to assess each indicator in terms of validity out of a Likert scale from 1 to 9. Indicators withdrawal criteria after each round (consensus) were over 70% of answers of at least 7 with interquartile range less than 3 (positive consensus) or over 70% of answers of at least 4 and interquartile range less than 3 (negative consensus). The decision to stop the delphi procedure was based on the stability of answers between the rounds. Results: 41 (89.13%) experts answered the first round and 37 (80.43%) answered the second round. Among the 57 indicators included, 15 reached consensus: four input indicators, six throughput and five output ones. For those three categories of at least 7 answers rates were, respectively, 80.9, 76.9 and 75.0%. Five indicators were deducible from the mandatory Emergency Department Discharge Summary. They obtained 80.2% of at least 7 answers. Conclusion: Our study results enable the construction and validation of a crowding measuring tool from indicators approved by experts. It is necessary to further reflect about ED crowding as a concept and what is expected from a complex score. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Πέμπτη 26 Ιανουαρίου 2017

Paramedic - Holden Mine (WA) - Beacon Occupational Health and Safety Services

The Paramedic will assess, treat and coordinate transport for patients to higher-level medical providers, commonly in the form of a clinic or hospital. Invasive care may include advanced airways, IV therapy, medications and defibrillation. This is a short term rotational position, 14/14, but flexible and would be camp based on-site living while on rotation.

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Finding Diagnostic Errors in Children Admitted to the PICU.

Objectives: To determine whether the Safer Dx Instrument, a structured tool for finding diagnostic errors in primary care, can be used to reliably detect diagnostic errors in patients admitted to a PICU. Design and Setting: The Safer Dx Instrument consists of 11 questions to evaluate the diagnostic process and a final question to determine if diagnostic error occurred. We used the instrument to analyze four "high-risk" patient cohorts admitted to the PICU between June 2013 and December 2013. Patients: High-risk cohorts were defined as cohort 1: patients who were autopsied; cohort 2: patients seen as outpatients within 2 weeks prior to PICU admission; cohort 3: patients transferred to PICU unexpectedly from an acute care floor after a rapid response and requiring vasoactive medications and/or endotracheal intubation due to decompensation within 24 hours; and cohort 4: patients transferred to PICU unexpectedly from an acute care floor after a rapid response without subsequent decompensation in 24 hours. Interventions: Two clinicians used the instrument to independently review records in each cohort for diagnostic errors, defined as missed opportunities to make a correct or timely diagnosis. Errors were confirmed by senior expert clinicians. Measurements and Main Results: Diagnostic errors were present in 26 of 214 high-risk patient records (12.1%; 95% CI, 8.2-17.5%) with the following frequency distribution: cohort 1: two of 16 (12.5%); cohort 2: one of 41 (2.4%); cohort 3: 13 of 44 (29.5%); and cohort 4: 10 of 113 (8.8%). Overall initial reviewer agreement was 93.6% ([kappa], 0.72). Infections and neurologic conditions were the most commonly missed diagnoses across all high-risk cohorts (16/26). Conclusions: The Safer Dx Instrument has high reliability and validity for diagnostic error detection when used in high-risk pediatric care settings. With further validation in additional clinical settings, it could be useful to enhance learning and feedback about diagnostic safety in children. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Epidemiology of Pediatric Critical Illness in a Population-Based Birth Cohort in Olmsted County, MN.

Objectives: Investigations of pediatric critical illness typically focus on inpatient cohorts drawn from wide referral areas and diverse healthcare systems. Cohorts amenable to investigating the full spectrum of critical illness as it develops within a community have yet to be studied in the United States. Our objective was to provide the first epidemiologic report of the incidence and presentation of pediatric critical illness within a U.S. population-based birth cohort. Design: Retrospective cohort study. Setting: A geographically defined community (Olmsted, MN) with medical record linkage across all health systems. All ICU services are provided within a single children's hospital. Patients: A birth cohort of children (n =9,441) born 2003-2007 in Olmsted County, MN. Measurements and Main Results: During the study period, there were a total of 15,277 ICU admissions to Mayo Clinic Children's Hospital. A total of 577 birth cohort children accounted for 824 of these admissions during the 61,770 person-years of follow-up accumulated. Incidence of first-time ICU admission was 9.3 admits per 1,000 person-years. Admission rates were highest in the first year of life and then declined steadily. Respiratory problems were among the most common reasons for admission at any age and diagnoses reflect changes in health risk factors as children grow and develop over time. After 1 year old, a majority of children admitted have preexisting chronic comorbidities and/or prior ICU stays. In-hospital mortality occurred exclusively in children admitted prior to 5 days of age (n = 4). Seven children died after hospital discharge. Conclusions: This is the first report characterizing critical illness within a population-based birth cohort of U.S. children. The results demonstrate the changing incidence, presentation, and healthcare requirements associated with critical illness across the developmental spectrum as a population of children ages. (C)2017The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies

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Inside EMS Podcast: Advice for new EMTs working 24-hour shifts

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In this Inside EMS Podcast episode, co-hosts Chris Cebollero and Kelly Grayson answer a question from an EMT seeking advice on how to best react and respond to EMS calls after being woken up in the middle of the night.

Do you have additional advice or tips to offer for new EMTs that are working 24-hour shifts" Join the discussion and share your thoughts in the comment section below.

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Why drug addiction is a brain disease

MILWAUKEE — A former EMT and a flight physician, both recovering addicts, put a face on the risks and reality of addiction by sharing their personal stories with EMS providers. The opioid overdose epidemic and addiction were the focus of a full-day pre-conference session at the Wisconsin EMS Association Working Together Conference.

Addiction has impacted nearly every person attending the session. Only 10 of the 140 attendees raised their hands that they had not been touched by addiction. Rick Barney, MD, became addicted to narcotics after back surgery. He discussed the pressures that led him to continuing to use Percocet, including self-prescribing medications. Barney received treatment and was able to keep his medical license. He has now been sober for four years and continues to help others receive treatment and bring attention to addiction, a disease of the brain.

Don Hunjadi, the former executive director of the Wisconsin EMS Association, shared his personal story of addiction. "I guarantee you I injected morphine," before an opening session of the Wisconsin EMS Association conference many years ago.

Hunjadi became addicted to narcotics after a tonsillectomy as an adult. He described his path from occasional use to addiction to diverting narcotics. Hunjadi continued to use narcotics until a car accident, while suffering from withdrawal symptoms, that led to the discovery of his addiction. He has been in recovery since October 2009.

Barney and Hunjadi briefly described their treatment and recovery. They also encouraged any attendee battling the disease of addiction to seek treatment, including personally speaking with either of them.

Memorable quotes on becoming an addict

Barney and Hunjadi, two long-time and prominent figures in Wisconsin prehospital care, opened a window into their personal lives that was unknown to the many EMS professionals that knew them from statewide conferences, committees and events. Here are memorable quotes from their presentation.

"Becoming addicted was not a choice of mine."

"Once you have an addiction disease you have it for life."

"We are not getting anywhere. Addictions rates are climbing. Overdoses are increasing. What we are doing is not working."

- Rick Barney, MD

"I dabbled for 12 years which reinforced the notion I got this. It didn't do much for me as a high, but gave me energy."

"In withdrawals, I made a real fateful decision to borrow fentanyl from the fire department. That went on for almost 20 years."

"If this can happen to us, then it can happen to everyone."

- Don Hunjadi

Key takeaways on drug addiction, a brain disease

Barney delivered an additional presentation to attendees explaining why addiction is a brain disease. Here are the key takeaways from Barney's presentation.

1. Addiction is a disease of the brain

An addict's brain drives profound behaviors to seek out the substance or activity. The brain's reward center activates strongly for anything that is enjoyable, even though it might be dangerous or have negative consequences, and seeks to repeat that as soon as possible. Genetics, social experiences and past experiences can all play a role in this dysfunctional brain mechanism.

Barney encouraged attendees to think beyond alcohol and opioids as causes of addiction. A portion of his presentation was about the addictive similarities between high-fructose corn syrup and illegal substances like cocaine. He also described pathological behaviors observed in social networking and smartphone use.

2. Continuing use of drugs

The feeling of well-being, the severity of withdrawal symptoms and the fear of negative consequences drive continuing use of addictive substances. When the feeling of well-being is triggered, addiction can follow a behavior pathway from like to want to need to crave. Hunjadi described his need for continuing opioid use to stave off the symptoms of withdrawal or being dope sick.

Addicts will break the law, and often do when diverting drugs from their EMS service or hospital, if needed to fulfill the brain's craving for the reward. Laws can encourage good behavior but can't stop the intensifying necessity to fulfill the brain's craving for more of the drug.

3. Treatment is possible

Addicts need to replace the abnormal or dangerous behavior with something else. Survival for an addict depends on fulfilling the craving. Punishment does not fix the addiction cravings and addicts will continue the behavior despite negative consequences.

Legal action, what Barney feared most, is exactly what happened when he finally sought help. Messaging that tells addicts to ask for help is counterproductive if the ask for help is met with arrest and other legislated punishments.

Barney explained that abstinence is part of recovery, but abstinence doesn't equal recovery. In early abstinence, the brain is still driving the addict to repeat the use of drugs. Specific recovery skills are necessary through counseling, meetings and understanding the root cause of addiction.

The session concluded with a discussion about the work involved in recovery and possible predictors to successful recovery. Barney believes that the more an addict has to lose, when the stakes are still high, recovery is more likely. A support network of concerned family, friends and co-workers are also important to recovery. Barney, because of his status as a physician, had a lot more to lose and thus greater motivation than the homeless, lifelong addicts he now works with at a shelter.

How to get help and learn more

Help and treatment is available for the brain disease of addiction. Starting options include talking to a trusted friend or family member, pastor or religious advisor or a physician. Many EMS providers also have access to an employee assistance program. Anyone can call the Substance Abuse and Mental Health Services Administration national helpline, 1-800-662-HELP (4357), which is a confidential, free, 24-hour-a-day, 365-day-a-year, information service in English and Spanish for individuals and family members facing mental and/or substance use disorders. This service provides referrals to local treatment facilities, support groups and community-based organizations.

Check out these articles to learn more about addiction.

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Paramedic - Medcor Inc.

http://bit.ly/Brandywine-Paramedic to apply! Medcor is looking for talented and experienced Paramedics to fill openings as Occupational Health Technicians at our client’s construction site in Brandywine, MD. This is a PRN (as needed) position. This clinic operates Monday – Saturday. The 1st shift hours are 7am – 530pm and the 2nd shift hours are 630pm – 530am and in a few weeks ...

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Construction Site EMT in East Boston, MA - Medcor Inc.

Medcor is looking for a talented Paramedic or EMT to work Full Time on 1st shift, as a Medical Administrator at our client's construction site clinic located in East Boston, MA. TO BE CONSIDERED FOR THIS POSITION YOU MUST BE AVAILABLE TO WORK WEEKENDS, NO EXCEPTIONS! HAZWOPER 40 and Asbestos 16 hour Operations and Maintenance is a plus, but will train. Starting base salary is between $43k - $50k per ...

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Paramedic - Medcor Inc.

Medcor is looking for a talented Paramedic to work Per Diem on 1st shift, as a Medical Administrator at our construction site clinic located in Council Bluffs, IA. The clinic is open 7:00AM - 5PM Monday - Friday. Applicants should have availability to pick up shifts as needed during the week and feel comfortable navigating a construction site. Visit http://bit.ly/Council-Bluffs-Paramedic to apply. Sick ...

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Construction Site Paramedic in Ponca City, OK - Medcor Inc.

Medcor is looking for a talented Paramedic, or EMT to fill a temporary full time position as a Medical Administrator at our construction site clinic located in Ponca City, OK. The will be a 40 hour per week, Monday - Friday, plus you must have availability to be on call. If called out for an injury after hours you are compensated for your time. Visit http://bit.ly/Paramedic-Ponca-City to apply Duties ...

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Part Time EMT in Brooklyn, NY - Medcor Inc.

Medcor is looking for a talented and experienced EMT to help us fill an opening as an Occupational Health Technician at our client's construction site in Brooklyn, NY. The primary function of this position will be administering drug tests and recording the results. Successful candidates will also need to be able to effectively and efficiently treat any workplace injuries that may occur. Also, applicants ...

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Construction Site EMT - Medcor Inc

Medcor is looking to hire a talented and experienced EMT to help us fill an opening as a Medical Administrator at our client's construction site in Frisco, TX. Candidates will need to be able to effectively and efficiently treat any workplace injuries that may occur. Also, applicants should feel comfortable working in a construction environment, should be able to climb up and down stairs while carrying ...

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PWW Media, Inc. announce Spring 2017 conference dates

MECHANICSBURG, Pa. — PWW Media, Inc, the National provider of innovative compliance solutions and education for the EMS Industry, has announced its conference dates for Spring 2017. Among this year's planned events for EMS leaders, the abc360 conference series will take an integrated approach to ambulance revenue cycle management and compliance. This conference will explore how early problems ...

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What EMS providers can learn from Greek Coast Guard documentary

"4.1 Miles," an Oscar-nominated documentary short film, shows the magnitude of the Syrian refugee crisis through the at sea rescues made by a Greek Coast Guard captain and his crew. The film, named for the four-mile span of the Greek sea between Turkey and the small Greek island of Lesbos, shows rescues of dozens of Syrian migrants who have risked their lives and likely all of their treasure to attempt the dangerous open water crossing.

Daphne Matziaraki, who created the film for the New York Times Op-Docs, wrote, "I followed a coast guard captain for three weeks as he pulled family after family, child after child, from the ocean and saved their lives. All the ones in this film were shot on a single day, October 28, 2015. Two additional rescues happened that same day but were not included."

Watch the 20-minute film while waiting for your next call or in an EMT class or company training activity. Daphne Matziaraki concludes the film with the grim statistic that 600,000 migrants are believed to have attempted crossing this span in 2015 and 2016. After watching, read my takeaways for EMS providers and add your own in the comments.

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Rescuers do what they know, believe to work

Trained EMS providers will quickly critique and share Matziaraki's surprise that the Greek Coast Guard personnel seemed to lack basic life support skills. Look past rescuers and laypeople providing improper or inadequate care to drowning and hypothermia patients. Instead, consider your role to better inform laypeople in your neighborhood or community in drowning prevention, airway management, hypothermia treatment, rescue breathing and hands-only CPR.

Train for MCI response with an all-hazards approach

MCI preparedness requires an all-hazards approach. In "4.1 Miles," the mechanism of injury for dozens and hundreds of patients is immersion, hypothermia and submersion. Patients don't need pressure dressings or tourniquets, they need removal from a hazardous environment and triage — rapid sorting to identify drowning symptoms like airway compromise and absent or inadequate ventilation.

The film also provides a stark reminder about the importance of not letting patients deteriorate. Once rescued from the scene, rapid evacuation to shore and additional resources is an important task. Just as important, though, is preventing patients from further heat loss while finding and caring for the most severely ill and injured patients.

Keep parents and children together

There is no doubt that allowing mom to ride in the ambulance complicates assessment and care for EMS providers. There is also tremendous opportunity for mom, dad or another caregiver to console an ill child or share important history information during the ride to the hospital.

The frantic screams from parents and children on the deck of the coast guard boat is the rawest animal emotion — a parent separated from its offspring. Think carefully about any formal policy or informal practice that makes it OK for EMS providers to not transport a child with their parent in the same vehicle, especially when that parent or caregiver doesn’t have a method for self-transport to the hospital.

Never underestimate the pull of something better

People who are suffering will take, and have taken for centuries, extraordinary risks for the pull of freedom and from the push of suffering. Before risking everything to cross the Greek Sea, the migrants in "4.1 Miles" escaped Syria and traveled across Turkey. There is not an ocean wide enough, a chasm deep enough or a wall high enough to keep out people who are desperate for something better.

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What EMS providers can learn from Greek Coast Guard documentary

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Rescuers do what they know, believe to work

Train for MCI response with an all-hazards approach

Keep parents and children together

Never underestimate the pull of something better

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Kentucky paramedic nears 50 years in EMS

One night in the early '90s, paramedic John Hultgren was nearing the end of his shift at Louisville (Ky.) EMS when his supervisor told him someone was waiting for him.

"It was this really big guy — 200 pounds at least," Hultgren recalls. "We went outside and started walking down the tracks near the building. He said, 'When I was a kid, you came to my house.' As he talked about that call, I started remembering it.

"We'd been dispatched to an alley in Louisville in '82 or '83. There was this boy, maybe eight years old, jumping up and down in front of the house, waving his arms and yelling, 'It's my mama! It's my mama!' So we grabbed the equipment, went upstairs and there was his mother lying on the floor. The father was standing there saying, 'I think she's gone.'

"We did a quick look; she was in vfib, so we started working her. We got a pulse back pretty quickly, transported her and found out about a month later she was doing fine. She'd even come to the office to thank us.

"So now it's eight or nine years later and that same kid looks at me and says, 'Y'know, all my friends have been in trouble. They flunked out of school or went to jail or both. The only reason I'm not in the same boat is because I had my mama around.'

"That's when I knew EMS is what I'm supposed to be doing."

Pre-EMS perseverance

Hultgren's destiny was anything but clear to him when he was growing up in New Jersey. He lost his own mother in 1964.

"It was rough; I was only 11," he says. "The hospital had sent an ambulance for her, but she died en route. They turned off the lights and sirens and went to a funeral home. I'd ride my bike over to the hospital and look at the ambulance because that was the last place she'd been alive.

"I started thinking about helping out on the ambulance. I tried to volunteer, but I got no encouragement whatsoever."

It wasn't until Hultgren was in high school that he had a better chance to pursue his interest in the brand-new field of EMS.

"I was going to a boarding school in New Lebanon, New York," the 63-year-old says. "They had a fire department with a first-aid squad where I got my initial training. That carried over to college."

From volunteer to career caregiver

Hultgren attended Ohio University, where he majored in photojournalism until the school cancelled that curriculum in the early '70s.

"I managed to get a job with The Boston Globe as a freelance photographer," he says. "While I was there, I started volunteering for an ambulance service run by the local crisis hotline. It was an alternative for people who needed transport but didn't want the city responding — ODs, for example. I liked it enough to get my EMT, but EMS still wasn't something I thought of as a career.

"One day I took a picture for the paper at some accident scene and started thinking maybe I should be on the other side of the camera. 'Emergency!' was on TV by then and we'd all been exposed to this new occupation called paramedic, so I started looking for a place to get that training. I ended up in Florida, working as an EMT and going to medic school at Miami Dade College."

A new Kentucky home

By 1977, Hultgren had his paramedic card. He missed the change in seasons, though, and started looking for jobs up north.

"I wanted to work in Maine, but they weren't paying enough. Then I saw an ad in EMS Magazine for Louisville EMS. They were transitioning from nurses and EMTs to medics and EMTs and were trying to recruit people from other states. I went for an interview and got hired in '79."

Hultgren was promoted to operations supervisor, then left Louisville in 1988 to run Frankfort Fire and EMS. He became a flight medic and joined Air Evac Lifeteam, where he's now a manager for the Missouri-based aeromedical service. He still calls Louisville home.

"Our company is in 15 states and I get to visit most of them," Hultgren says. "Wherever I go, I see a strong dedication to taking care of patients. Our people are always trying to improve their skills. To me, that's very encouraging."

Caring about caregivers

Hultgren feels patients shouldn't be the only beneficiaries of well-run EMS systems. He believes in mentoring colleagues, and illustrates the advantages with a story from his years at Louisville.

"There was a construction guy at our building who asked if he could bring his son to our explorer program. I was active with that group, so I said, sure.

"Well, I didn't know it at the time, but his son was totally deaf. I wasn't sure what to do with him at first. He wanted to be on the ambulance. Unfortunately, the city wasn't real keen about that, so I talked them into letting him ride with me in the supervisor's car. Whenever we got to a scene, I made a point of watching him closely. Even without being able to hear, he was a contributor — the kind of kid you root for.

"He went on to graduate high school and college, then wanted to go to med school. I helped him with his application. Today he's a cardiologist who specializes in handicapped patients — primarily the hearing impaired.

"There are unlimited opportunities to make a difference; you just need to find them. Sometimes it's helping patients, sometimes their families, sometimes your own people. You have to reach out and make it happen."

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Kentucky paramedic nears 50 years in EMS

One night in the early '90s, paramedic John Hultgren was nearing the end of his shift at Louisville (Ky.) EMS when his supervisor told him someone was waiting for him.

"That's when I knew EMS is what I'm supposed to be doing."

Pre-EMS perseverance

Hultgren's destiny was anything but clear to him when he was growing up in New Jersey. He lost his own mother in 1964.

"I started thinking about helping out on the ambulance. I tried to volunteer, but I got no encouragement whatsoever."

It wasn't until Hultgren was in high school that he had a better chance to pursue his interest in the brand-new field of EMS.

"I was going to a boarding school in New Lebanon, New York," the 63-year-old says. "They had a fire department with a first-aid squad where I got my initial training. That carried over to college."

From volunteer to career caregiver

Hultgren attended Ohio University, where he majored in photojournalism until the school cancelled that curriculum in the early '70s.

A new Kentucky home

By 1977, Hultgren had his paramedic card. He missed the change in seasons, though, and started looking for jobs up north.

Caring about caregivers

Hultgren feels patients shouldn't be the only beneficiaries of well-run EMS systems. He believes in mentoring colleagues, and illustrates the advantages with a story from his years at Louisville.

"There was a construction guy at our building who asked if he could bring his son to our explorer program. I was active with that group, so I said, sure.

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Πληροφορίες

Τρίτη 31 Ιανουαρίου 2017

Memorable quotes on Pulse patient triage and care

7 key takeaways on EMS response and transport

1. Preparedness matters for performance

2. Rogue responders

3. Dispatch is going to be overwhelmed

4. Triage tags might not get used

6. Pre-plan for family reunification

7. Overwhelming media interest

Learn more

Δευτέρα 30 Ιανουαρίου 2017

Memorable quotes about situational awareness

3 top takeaways on situational awareness for emergency responders

1. Know and understand top causes of LODD

2. Learn and practice situational awareness and action process

3. Failures to situational awareness are predictable

Learn more about situational awareness

1. Substance abuse and mental illness

Uniform power

Uniform as a source of harm

Patient safety and uniforms

Applying systems thinking to uniform selection

Κυριακή 29 Ιανουαρίου 2017

Σάββατο 28 Ιανουαρίου 2017

Παρασκευή 27 Ιανουαρίου 2017

Abstract

Purpose

Method

Results

Conclusions

Memorable quotes

Key takeaways on opioid dependence

1. Problem caused by health care, but not always

2. Opioid addiction has a high relapse rate

3. Medication-assisted treatment for opioid dependence

Learn more

Πέμπτη 26 Ιανουαρίου 2017

Memorable quotes on becoming an addict

Key takeaways on drug addiction, a brain disease