Brian J. Yun

Comparison of Video, Optical, and Direct Laryngoscopy by Experienced Tactical Paramedics

Abstract Objectives. While optical and video laryngoscopy have been studied in the emergency department, the operating room, and the routine prehospital setting, their efficacy in the tactical environment—in which operator safety is as important as intubation success—has not been evaluated. This study compared direct laryngoscopes to optical (AirTraq) and video (King Vision) laryngoscopes in a simulated tactical setting. Methods. This prospective institutional review board-approved simulation study evaluated each of the laryngoscopes in the hands of seven experienced tactical paramedics. After a one-hour training session, each tactical paramedic used each of the laryngoscopes, in a random order, on each of four different airway manikins. A tactical environment was simulated using auditory and visual immersion, and the intubations occurred on the ground with the paramedics in full tactical gear. Outcomes included time to successful ventilation, first-pass success rate, Cormack-Lehane grade, and intubator head height during the intubation. Statistical analysis included chi-squared and Wilcoxon rank sum tests, and multivariate logistic regression was performed to determine contributing factors to outcomes with significant variation. Results. A total of 84 intubations were performed by seven tactical paramedics. While there were no significant differences in time to successful ventilation or first-pass success rate, the optical and video laryngoscopes had significantly better Cormack-Lehane grades, defined as grade I or II (100% for both compared to 85.7%), while direct laryngoscopy resulted in significantly less maximum vertical exposure of the intubator (51.82 cm compared to AirTraqs 56.64 cm and King Visions 56.13 cm). Conclusion. Video and optical laryngoscopes can be used successfully by experienced tactical paramedics in a simulated tactical setting. The King Vision and AirTraq resulted in improved Cormack-Lehane glottic views but similar times to ventilation and first-pass success compared to direct laryngoscopy. Intubator head height was lower with direct laryngoscopy. Clarifying the role of optical and video laryngoscopes in a tactical environment, especially in the hands of less experienced intubators, requires further research.

The Cost of Penicillin Allergy Evaluation

BACKGROUND Unverified penicillin allergy leads to adverse downstream clinical and economic sequelae. Penicillin allergy evaluation can be used to identify true, IgE-mediated allergy. OBJECTIVE To estimate the cost of penicillin allergy evaluation using time-driven activity-based costing (TDABC). METHODS We implemented TDABC throughout the care pathway for 30 outpatients presenting for penicillin allergy evaluation. The base-case evaluation included penicillin skin testing and a 1-step amoxicillin drug challenge, performed by an allergist. We varied assumptions about the provider type, clinical setting, procedure type, and personnel timing. RESULTS The base-case penicillin allergy evaluation costs

Applying Systems Engineering Reduces Radiology Transport Cycle Times in the Emergency Department

220 in 2016 US dollars:

Cost savings associated with transfer of trauma patients within an accountable care organization

98 for personnel,

Implications of iodinated contrast media extravasation in the emergency department

119 for consumables, and

MR angiography can guide ED management of suspected acute aortic dissection

3 for space. In sensitivity analyses, lower cost estimates were achieved when only a drug challenge was performed (ie, no skin test,

Diagnostic Imaging Strategies for Occult Hip Fractures: A Decision and Cost-Effectiveness Analysis.

84) and a nurse practitioner provider was used (

The boarding experience from the patient perspective: the wait

170). Adjusting for the probability of anaphylaxis did not result in a changed estimate (

Imaging utilization from the ED: no difference between observation and admitted patients.

220); although other analyses led to modest changes in the TDABC estimate (

Opportunity to reduce transfer of patients with mild traumatic brain injury and intracranial hemorrhage to a Level 1 trauma center

214-