Impact of Chemical, Biological, Radiation, and Nuclear Personal Protective Equipment on the performance of low- and high-dexterity airway and vascular access skills

From Resuscitation:

Background

Following CBRN incidents health care professionals will be required to care for critically ill patients within the warm zone, prior to decontamination, whilst wearing CBRN-PPE. The loss of fine-motor skills may adversely affect delivery of medical care.

Methods

64 clinicians were recruited to perform, intubation, LMA placement, insertion of an IV cannula and IO needle whilst wearing CBRN-PPE. A fractional factorial design was employed, in which each of the 64 clinicians had two attempts at performing each skill whilst wearing CBRN-PPE and once unsuited according to a pre-specified sequence.

Analysis

The unsuited and suit data were analysed independently with the primary outcome being time taken to complete each skill whilst suited. Analysis was undertaken using STATA (V9.2).

Results

Mean times differ considerably by skill (p<0.001). Overall, times to completion on attempt 2 were shorter than attempt 1 (p=0.045), though the reduction in time differed significantly by skill (p=0.004). LMA placement was on average completed nearly 45s faster than intubation, and IO cannulation was nearly 90s faster than IV cannulation. Whilst suited, 8% of intubation and 12% of intra-venous cannulation attempts were unsuccessful. Previous familiarity with CBRN-PPE did not improve performance (p=0.23). Professional groups differed significantly (p=0.009) with anaesthetists performing all skills faster than the other clinicians.

Conclusion

This study supports the concept of instigating airway and vascular access skills whilst wearing CBRN-PPE but challenges the sole reliance on ‘high-dexterity skills’. Intubation is feasible but must be considered within the context of the incident as the LMA may offer a viable alternative. Intra-venous access prior to casualty decontamination is arguably a pointless skill and should be replaced with IO access.

Out-of hospital advanced life support with or without a physician: Effects on quality of CPR and outcome

From Resuscitation:

Background

The presence of physicians is believed to facilitate optimal management of out-of-hospital cardiac arrest, but has not been sufficiently documented.

Methods

Adult non-traumatic cardiac arrests treated by Oslo EMS between May 2003 and April 2008 were prospectively registered. Patients were categorized according to being treated by the physician-manned ambulance (PMA) or by regular paramedic-manned ambulances (non-PMA). Patient records and continuous electrocardiograms (ECGs) with impedance signals were reviewed. Quality of cardiopulmonary resuscitation (CPR) and clinical outcomes were compared.

Results

Resuscitation was attempted in 1128 cardiac arrests, of which 151 treated by non-PMA and PMA together were excluded from comparative analysis. Of the remaining 977 patients, 232 (24%) and 741 (76%) were treated by PMA and non-PMA, respectively. The PMA group was more likely to have bystander witnessed arrests and initial VF/VT, and received better CPR quality with shorter hands-off intervals and pre-shock pauses, and having a greater proportion of patients being intubated. Despite uneven distribution of positive prognostic factors and better CPR quality, short-term and long-term survival were not different for patients treated by the PMA vs. non-PMA, with 34% vs. 33% (p=0.74) achieving return of spontaneous circulation (ROSC), 28% vs. 25% (p=0.50) being admitted to ICU and 13% vs. 11% (p=0.28) being discharged from hospital, respectively.

Conclusions

Survival after out-of-hospital cardiac arrest was not different for patients treated by the PMA and non-PMA in our EMS system.

More Leave Hospital Against Advice

From MedPage Today:

The number of people who check out of hospitals against medical advice has grown dramatically, according to the Agency for Healthcare Research and Quality. In 2007, the agency said, inpatient care ended that way 368,000 times, accounting for 1.2% of all hospital stays, compared with only 264,000 such discharges a decade earlier.

That 39% increase is markedly higher than the 13% increase in all other hospital stays during the period from 1997 through 2007, the agency noted in a statistical brief.

The finding is based on data from the agency’s Healthcare Cost and Utilization Project 2007 Nationwide Inpatient Sample.

On average, hospital stays that ended in discharge against medical advice were about 2.7 days (versus 5.1 days for all other stays) and cost about $5,300 (versus $10,400).

The chief reason for care in such cases was nonspecific chest pain, accounting for 7% of the total. But alcohol-related disorders, substance-related disorders, and mood disorders taken together accounted for more than twice as many cases (6.9%, 5.7%, and 3.8% of the total, respectively.)

Video: Emergency Room Stroke Exam with a Webcam

From Wired (2008 article):

Since 2004, doctors in rural emergency rooms have been using webcams to get an expert opinion before treating stroke patients.

A report, published on Aug. 3 in The Lancet Neurology says that the new technology helps them make the right decision.

“When a person suffers a stroke, time is of the essence,” says Brett Meyer, a UCSD professor who led the study.

Clot busting drugs, like alteplase, should be given within three hours of a stroke, but deciding which patients actually need that medication is tricky.

If a stroke specialist can see and hear their patient, zoom in on their pupils and facial muscles, and ask them questions, they are far more likely to offer the right advice. In fact, experts who examined patients with the webcam made the right decision 98 percent of the time, compared to 82 percent when they simply talked to the emergency room doctor by phone.

Whether It’s Really Swine Flu or Just Panic, Patients Will Come to the ED

From EM News:

Though it’s difficult to tell whether H1N1 will become a global disaster, it’s certain that emergency physicians will have to deal with it, and probably with a fair number of cases of panic disguised as swine flu.

The American College of Emergency Physicians recently released a plan to help emergency providers plan for the H1N1 surge expected as early as September. The National Strategic Plan for Emergency Department Management of Outbreaks of Novel H1N1 Influenza provides recommendations for EDs and first responders to manage swine flu cases, including appointing an officer for H1N1 preparedness, establishing connections between government and hospitals, and training all who may be involved.

When H1N1 first hit the United States this spring, we saw big surges in patients, many of whom had been sent to us by their primary care physicians, said Nicholas Jouriles, MD, the president of ACEP. We know the ER is the place people turn to in a medical crisis, and we are dedicated to being prepared for the worst-case scenarios, even as we hope they will not occur.

The plan was produced under contract to the Office of the Assistant Secretary for Preparedness and Response (ASPR) and the Emergency Care Coordination Center (ECCC). A collaboration of ASPR, ECCC, and ACEP, the strategy recommends ways to manage widespread influenza infection using threat awareness, protection and prevention, surveillance and detection, and response and recovery.

While H1N1′s virulence is not predictable, it is expected to be highly contagious, and will place added strains on the emergency care system, said Dr. Jouriles. Emergency medical and hospital planning for an H1N1 pandemic will be successful only if there is cooperation between first responders and public health officials.

Sidney Health Center to search for new physician

From the Sidney (MT) Herald:

The Sidney Health Center has started the recruiting process to have another primary care provider come to its facility.

Rick Haraldson, CEO of Sidney Health Center, has confirmed that Sidney Health Center offered a contract to Dr. Shirley Noronha, but she declined to sign it because of new stipulations made by Sidney Health Center. Her contract expires Sept. 30.

Haraldson explains the emergency room duties of some physicians have changed with the departure of Dr. Johnson early this summer. Doctors are needed to cover more emergency room hours, and Haraldson says Noronha, who has a young family, wasn’t comfortable with the expanded hours.

“We understand that, but we need a physician to cover the ER for us,” Haraldson said. “Our needs have changed from when we recruited her three years ago.”

The Herald contacted Noronha’s office, but the physician didn’t return the message for a comment.

The contract of Dr. Craig Levy is also in question. Levy’s contract expires at the end of December. Haraldson says Levy is willing to cover the emergency room during the day but is unable to at nights.

Levy and Noronha are married.

Haraldson says he doesn’t know of the physicians’ plans. They could start a private practice in Sidney if they desire.

Sidney Health Center will only recruit for one primary care physician for now. “When you recruit for two at the same time, it causes problems starting a practice.”

He explains industry analysis shows that Sidney Health Center meets the range for physician to community member ratio. If the two physicians are replaced by one, Sidney Health Center remains in the suggested range.

“It’s never good to lose a doctor,” Haraldson said. But making sure the emergency room is staffed is vital for local health care. “That’s a big commitment we have as a health facility to the community.”

Good Old Days of EMS

From StJoeNews.com:

Ambulance service was a raucous endeavor in the late 1960s and early 1970s.

It was a time when funeral homes — which for years had provided emergency services — gave the job to privately owned ambulance companies.

As you can imagine, the competition was fierce. At the time it was even humorous, as movies such as the 1976 “Mother, Jugs and Speed” spoofed these ambulance wars.

In St. Joseph, it was humorous and sometimes pretty dangerous. Here, rival ambulance companies often got involved in fist fights, gunplay and pulling false alarms on each other. Getting them at your home for an emergency could sometimes be a crapshoot, too. Most drove ill-equipped 1960 Buick Electra model ambulances. And the drivers had little more than a Red Cross citizen’s emergency training.

“One ambulance service would call the other one and say, ‘We need an ambulance up here at Krug Park place,’ or some other remote place, they’d chase up there and the other service would be sitting do

Emergency room volunteer serves up companionship, stat!

From FtMcMurrayToday.com:

Vilia Tosio is a friend of the emergency department.

She spends a few hours a week keeping patients waiting to be treated at the Northern Lights Regional Health Centre comfortable and comforted.

“There might be the perception out there that volunteering at a hospital is not so pleasant — that it may be yucky, but it’s not,” she said. “It’s about companionship, making people feel less scared. It’s being a friend; it may be something as simple as chatting with an elderly person who may have forgotten their glasses preventing them from reading a magazine.”

Tosio has been involved with the local hospital’s Friends of the Emergency Department program for a little more than a year, six months after she first moved to Fort McMurray with her husband.

Tosio, who is originally from South Africa, has also lived in Holland and New Zealand.

“I’ve always done volunteer work,” said Tosio. “Whether it is fundraiser for an orphanage in Turkey, collecting clothes for people in Romania and Africa or The Nelson Mandela Children’s Fund from South Africa … Ghandi once said that we must be the change we want to see.”

Tosio volunteers at the hospital once a week for an average of three to four hours.

“Even if you can give someone 15 minutes, that 15 minutes of interaction in an eight-hour day of waiting can make a difference,” she said. “Just imagine a mother who has a sick child and maybe she has other children with her too. Having kids in a confined space for up to eight hours is not easy.”

Tosio called volunteer work a rewarding experience.

“It’s always appreciated but you may not always see the results right away,” she said. “But somewhere down the line it’s going to make a difference.”

Tosio then showed Today an email sent to her last month from a woman she helped in 1998 who thanked her for her support at that time.

Jillian McIntosh, volunteer services co-ordinator at the Northern Lights Regional Health Centre, said volunteers at the hospital help relieve a lot of the stress and anxiety patients may feel.

“Isolation is a big thing with people who are in the hospital,” she said. “The reality is that staff can’t give their undivided attention to a single person and sit and chat with each patient for an hour or they would never get their work done. I think a lot of the families who have family members here are comforted knowing that we have great people who are here just volunteering their time to spend with their loved one. They really appreciate the fact that somebody who doesn’t even know their family member is taking the time to get to know them.”

McIntosh said the No. 1 quality the health centre looks for when selecting volunteers is “a genuine desire to help people.”

“It’s a great way to get to know their community, especially for newcomers to the city,” said McIntosh. “It’s also a great way to gain skills or develop ones that they already have.”

McIntosh said volunteers must also have Alberta Health Care coverage, go through a criminal record check, have references and even go through an interview process.

Along with the Friends of the Emergency Department program, the hospital also has volunteer opportunities for continuing care, pet therapy and a youth program.

Wisc. Dept. Debates Paramedics vs EMTs

From JEMS:

Members of the Big Bend Vernon Fire Department presented the fire board with two medical scenarios to demonstrate the difference between basic EMT care and paramedic care at the Aug. 17 fire board meeting.

Although all of the board members stayed to hear the first presentation on EMT care, two board members got up and walked out before the second presentation. Patrick Hays, Deputy Chief in charge of EMS for the BBV Fire Department, led the presentation, in which one scenario of a male patient with chest pain and shortness of breath, and who stops breathing and loses a pulse, was handled in two different ways.

In the first presentation, the patient received EMT basic level care without a paramedic. In the second presentation, the patient received care from an EMT basic, an intermediate IV tech and a paramedic. “People around the whole country have the impression that there are ambulance drivers and there are paramedics,” he said. “We wanted to show the different levels of EMS care.” During the first presentation, EMTs showed up to the scenario and took the patient’s vital signs, put him on oxygen, started CPR and transported the patient to the hospital.

Hays explained that if a patient has their own nitroglycerin, the EMT can assist the patient with it, but they cannot treat the patient with nitro. An EMT is also not authorized to give out any medications accept for aspirin, he said.

All of the fire board members listened to the presentation, but when it came time to present the paramedic scenario, Hays said board members Sue Fischer and Ellen Cole got up and walked out of the room. They completely left the building and stood outside until the presentation was done, he said. The two then returned to the meeting room once the presentation was complete. Hays said after the meeting he overheard the two tell one of the paramedics that it was nothing personal but that they “didn’t get paid for this.”

Hays said that the eight members on the fire board represent the 9,500 residents covered by the department and felt they owed it to the residents of the community to hear both presentations. “To me, this was the most amount of disrespect I have ever felt in my life,” he said. “It showed me they feel it’s not important to be educated about the fire department they are responsible for and that they don’t want to know what we do.”

Fire Board President Carol Shae said she was very pleased with the department’s presentation and learned a lot about paramedics that she never knew. “I was not aware they were going to do that (leave the meeting) and I consider it very unprofessional,” she said.

Rural Emergency Medicine: Patient Volume and Training Opportunities

From The Journal of Emergency Medicine:

Background: A paucity of board-certified Emergency Physicians practice in rural Emergency Departments (EDs). One proposed solution has been to train residents in rural EDs to increase the likelihood that they would continue to practice in rural EDs. Some within academic Emergency Medicine question whether rural hospital EDs can provide adequate patient volume for training an Emergency Medicine (EM) resident.

Study Objectives: To compare per-physician patient-volumes in rural vs. urban hospital EDs in Oklahoma (OK) and the proportion of board-certified EM physicians in these two ED settings.

Methods: A 21-question survey was distributed to all OK hospital ED directors. Analysis was limited to non-military hospitals with EDs having an annual census > 15,000 patient visits. Comparisons were made between rural and urban EDs.

Results: There were 37 hospitals included in the analysis. Urban EDs had a higher proportion of board-certified EM physicians than rural EDs (80% vs. 28%). There were 4359 vs. 4470 patients seen per physician FTE (full-time equivalent) in the rural vs. urban ED settings, respectively (p = 0.84).

Conclusions: Patient volumes per physician FTE do not differ in rural vs. urban OK hospital EDs, suggesting that an adequate volume of patients exists in rural EDs to support EM resident education. Proportionately fewer board-certified Emergency Physicians staff rural EDs. Opportunities to increase rural ED-based EM resident training should be explored.