Clifton A. Sheets

Surgical cricothyrotomy performed by air ambulance flight nurses: A 5-year experience

Limited information exists in the current medical literature regarding the performance of surgical cricothyrotomy by flight nurse personnel. We undertook a retrospective review of all flight records from our regional air ambulance service. The flight team transported 2,188 patients during this time; 69 patients required surgical cricothyrotomy for airway access. In all cases, the procedure was performed by a flight nurse working under a predefined airway protocol. Indications for the procedure were predominantly for maxillofacial trauma. A secure airway was established in 98.5% of the cases (68/69). Acute complications involved hemorrhage (3) and placement (3) with a complication rate of 8.7%. We conclude that surgical cricothyrotomy can be performed by well-trained flight nurses with a high success rate and an acceptable complication rate.

A model preclinical, clinical, and graduate educational curriculum in emergency medicine for medical students and rotating residents

The Society for Academic Emergency Medicine model curriculum for medical students and rotating residents was developed over a two-year period. The document was created as a complementary work to the undergraduate Core Content to provide appropriate emphasis, structure, and suggestions on the teaching of emergency medicine core curriculum topics at all levels. Consensus on the curriculum contents was reached from a national sample of emergency medicine educators. An educational matrix format was used to enhance flexibility based on the educational level of the learner and the instructional strengths of the teacher, and allowing for incorporation of a problem-based learning format. An outline of document contents and representative samples from each section are included; the entire document is available from SAEM.

Needle emboli to lung following intravenous drug abuse

Presented is the case of a 36-year-old man using central venous sites for injection of street drugs. X-ray study revealed numerous retained subcutaneous needles as well as a needle that had embolized to the lung periphery. This represents, to the best of our knowledge, a previously unreported complication of central venous injection of street drugs.

Pharyngeal tracheal lumen airway training: Failure to discriminate between esophageal and endotracheal modes and failure to confirm ventilation

The pharyngeal tracheal lumen (PTL) airway is a new airway control device for emergency medical technicians (EMTs) and paramedics and functions as either an esophageal obturator or an endotracheal tube. We developed a ten-step PTL airway training protocol that included proper airway insertion, patient ventilation, and confirmation of tube placement by auscultation. We then prospectively evaluated the effectiveness of training by testing the ability of 32 EMTs and paramedics to discriminate between esophageal and endotracheal mode placement. Training consisted of a group demonstration followed by supervised individual practice on a Laerdal Adult Intubation Model. All 70 insertion attempts resulted in esophageal obturator mode placement. As a result, trainees did not have an opportunity to practice discrimination between esophageal and endotracheal placement. Six weeks after initial training, 19 of the entry group were randomly and blindly assigned to ventilate each of two Laerdal models that had been previously intubated with the PTL, one in esophageal mode and the other in endotracheal mode. In the esophageal mode, 15 of 19 trainees (79%) correctly selected the esophageal port to ventilate, but four (21%) could not decide and abandoned the airway. In the tracheal mode, 16 of 19 trainees (84%) correctly selected the tracheal port to ventilate, one (5%) was unable to decide, and two (10.5%) selected the wrong tube and attempted ventilation with the esophageal port even though the tracheal balloon was completely occluding the airway. Ventilation was confirmed with auscultation in only 50% of the attempts (19 of 38). Our study indicates that the training protocol was inadequate to teach critical decision-making in the use of the PTL airway.(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives to direct the training of emergency medicine residents on off-service rotations: Critical care medicine, Part 2

This article is the second of two parts outlining the objectives for resident rotations in intensive care units. It is part of a larger continuing series on the goals and objectives to direct the training of emergency medicine residents on off-service rotations. The critical care unit allows the resident an opportunity to provide continuing care for critically ill patients, many of whom enter the health care system through the emergency department. Critical care medicine is a natural continuum of emergency medicine, and provides the resident with the ability to follow the natural progression of seriously ill patients, as well as build confidence and experience in caring for the critically ill and injured. These objectives are designed to help focus the residents reading and study during the rotation.

OBJECTIVES TO DIRECT THE TRAINING OF EMERGENCY MEDICINE RESIDENTS ON OFF-SERVICE ROTATIONS: ORTHOPEDICS

In this third article in a continuing series on objectives for emergency medicine training, orthopedic objectives are presented. Orthopedic complaints are common in emergency medicine. Direction in mastering evaluative, cognitive, and procedural skills are provided utilizing behaviorally based objectives and references. These objectives provide a structure for systematically learning the content of orthopedics through enlightened patient care, questioning of attending physicians and supervisors, and directed reading.

Objectives to direct the training of emergency medicine residents on off-service rotations: Pulmonary

This article outlines the objectives for a resident rotation in pulmonary diseases. It is part of a continuing series on the goals and objectives to direct Emergency Medicine resident training on off-service rotations. Pulmonary disease accounts for a high percentage of presenting complaints and potentially life-threatening disease in the emergency department. Because of the frequency of respiratory disease in Emergency Medicine, many Emergency Medicine residencies offer individual off-service rotations in Pulmonary Medicine. The objectives of this article are viewed as a one-month component of an Internal Medicine Rotation in the first year of training. These objectives are designed to help focus the residents reading and study during a pulmonary off-service rotation.

Objectives to direct the training of emergency medicine residents on off-service rotations: Hand surgery

This is the fifth article in a continuing series on objectives to direct the training of emergency medicine residents. The emergency physician frequently must deal with hand injuries. Often these may appear innocuous; recognition of these injuries requires certain technical skills and a working knowledge of these entities. Specific objectives presented provide guidance for the didactic content as well as skill mastery for the resident experience.

Objectives to direct the training of emergency medicine residents in off-service rotations: dental emergencies.

Patients presenting for emergency care with complaints of dental origin are common. Rarely are dental topics systematically addressed during training rotations. In this second article in a continuing series on objectives for emergency medicine resident training, dental emergency objectives will be presented. Instructions for use of the references and objectives are provided. Cognitive and evaluative objectives are organized for mastery. A list of resources including references and audio visual materials are outlined. The objectives and reference materials presented provide a structure for the systematic study of dental emergencies in emergency medicine resident training.

Changes in somatosensory evoked potentials in dogs following cardiac arrest and resuscitation

The effect of cardiac arrest induced global cerebral ischemia on the peripheral, spinal cord, and cortical somatosensory evoked potentials (SSEP) was studied in 7 mongrel dogs. Following the recording of control responses in each animal, ventricular fibrillation was induced and the dogs were allowed to fibrillate for a random time varying between 30 s and 15 min. The animals were then resuscitated using a standardized resuscitation protocol, and evoked potentials were recorded at intervals up to 1 h post resuscitation. A grading scale was devised to categorize the evoked potentials according to degree of abnormality. We found that peripheral SSEPs were well preserved up to 22 min ischemia time. Spinal cord potentials became abnormal with ischemia times greater than 9.5 min. Cortical traces were essentially normal with less than 4 min ischemia time, variable with 4-9.5 min and markedly abnormal with greater than 9.5 min ischemia. Somatosensory evoked potentials may be a useful adjunct in the monitoring of cerebral function following cardiac arrest.