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:


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.


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.


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).


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.


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:


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


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.


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.


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


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