Colleen Buono

The Effectiveness of a Novel, Algorithm-Based Difficult Airway Curriculum for Air Medical Crews Using Human Patient Simulators

Introduction. Airway management is one of the most important skills possessed by flight crews. However, few data exist about the efficacy of various educational approaches. Traditional models for airway training, including cadaver labs, operating room exposure, andclinical apprenticeships, are scarce andoffer variable educational quality. The objective of this analysis was to evaluate the effectiveness of a simulator-based difficult airway curriculum in a large, aeromedical company. Methods. Simulation training was integrated into existing airway training for all crew members; an original difficult airway algorithm was used to guide scenarios. To evaluate its effectiveness, rapid sequence intubation (RSI) success before andafter curriculum implementation was determined. In addition, crew members rated their confidence with various aspects of airway management before andafter exposure to the airway workshops. Results. First attempt andoverall ETI success improved from 71.3% and89.3% before (n = 261) to 87.5% and94.6% after (n = 504) implementation of the algorithm andsimulation training, whereas the incidence of hypoxic arrests during RSI decreased from 2.7% to 0.2% (p < 0.01 for all comparisons). Crew members reported improvements in confidence with regard to all aspects of airway management following participation in the simulation workshops. Conclusions. A novel, integrated airway management curriculum using treatment algorithms andsimulation appeared to be effective for improving RSI success among air medical crews in this program.

Predictors of Intubation Success andTherapeutic Value of Paramedic Airway Management in a Large, Urban EMS System

Background. Endotracheal intubation (ETI) is commonly used by paramedics for definitive airway management. The predictors of success andtherapeutic value with regard to oxygenation are not well studied. Objectives. 1) To explore the relationship between intubation success andperfusion status, Glasgow Coma Scale (GCS) score, andend-tidal carbon dioxide (EtCO2); 2) to describe the incidence of unrecognized esophageal intubations with use of continuous capnometry; and3) to document the incremental benefit of invasive versus noninvasive airway management techniques in correcting hypoxemia. Methods. This was a prospective, observational study conducted in a large urban emergency medical services system. Paramedics completed a telephone debriefing interview with quality assurance personnel following delivery of all patients in whom invasive airway management had been attempted. Continuous capnometry was used for confirmation of tube position in all patients. Descriptive statistics were used to document airway management performance, including first-attempt ETI success, overall ETI success, andCombitube insertion (CTI) success. In addition, the incidence of unrecognized esophageal intubation was recorded. The relationship between intubation success andperfusion status, GCS score, andinitial EtCO2 value was explored using logistic regression. Finally, recorded SpO2 values andthe incidence of hypoxemia (SpO2 < 90%) at baseline, following noninvasive airway maneuvers, andafter invasive airway management were compared for perfusing patients. Results. A total of 703 patients were enrolled over 12 months. First-attempt ETI success was 61%, andoverall ETI success was 81%; invasive airway management (ETI or CTI) was unsuccessful in 11% of patients. A single unrecognized esophageal intubation was observed (0.1%). A clear relationship between airway management success andperfusion status, GCS score, andinitial EtCO2 value was observed. Only EtCO2 demonstrated an independent association with ETI success after adjusting for the other variables. Significant improvements in mean SpO2 andthe incidence of hypoxemia over baseline were observed with both noninvasive andinvasive airway management techniques in 168 perfusing patients. Conclusions. A relationship between intubation success andperfusion status, GCS score, andinitial EtCO2 value was observed. Capnometry was effective in eliminating unrecognized esophageal intubations. Both noninvasive andinvasive airway management strategies were effective in increasing SpO2 values anddecreasing the incidence of hypoxemia, with additional benefit observed with invasive airway maneuvers in some patients.

WIISARD: a measurement study of network properties and protocol reliability during an emergency response

This paper describes the design, deployment, and empirical evaluation of WIISARD - a novel emergency response system that provides reliable communication in dynamic wireless environments without extensive communication infrastructure. The main contribution of this paper is an in-depth empirical study of network properties that emerge during a drill in which WIISARD is deployed with minimal infrastructure support. The drill involves 19 first responders and 41 victims. The properties of links established among first responders vary between phases of the drill and depend upon the responders role in the drill. The rescue phase - in which responders are highly mobile as they triage victims - poses significant challenges to reliable communication. During this phase, the contacts between responders are short-lived; however, they are reestablished within minutes. Once a contact between responders is established, the quality of the link between those responders is usually high. The connectivity graph observed during the rescue phase is usually connected and has a small diameter although there are times when it has a large diameter or it is partitioned. While mobility increases network dynamics, we also observe that the mobility patterns characteristic of the emergency response workflow can be leveraged to disseminate data efficiently through data muling. WIISARD employs a gossip-based protocol and supports data dissemination through local communication and data muling to achieve 98% reliability during the drill exercise. These results indicate the feasibility of providing reliable communication in emergency response with minimal infrastructure in spite of network dynamics.

Secure scalable disaster electronic medical record and tracking system.

Introduction: Electronic medical records (EMR) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. As the prehospital disaster EMR allows for more robust content including Protected Health Information (PHI), security measures must be instituted to safeguard these data. Objectives: To develop a secure prehospital disaster triage/EMR system that prevents unintentional disclosure of private information, may be used by prehospital personnel during the MCI triage process, and can be relayed via wireless system to local and distant medical assets. Methods: The Wireless Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld linked wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. Results: This system has been field tested in a number of exercises with excellent results and future iterations will incorporate robust security measures. Conclusions: A secure prehospital triage EMR improves documentation quality during disaster drills.

False-Positive Urine Phencyclidine Immunoassay Screen Result Caused by Interference by Tramadol and Its Metabolites

Phencyclidine is one of the drugs of abuse included in qualitative urine drug screens that are frequently ordered in the emergency department despite concerns about specificity and clinical utility. Many drugs have been described to cause false-positive results for phencyclidine. We present 2 cases of false-positive phencyclidine qualitative urine drug screen results in patients with seizures from tramadol misuse or abuse. The involvement of tramadol and its active metabolite, N-desmethyltramadol, was confirmed by in vitro testing. These cases illustrate that tramadol and its metabolites can trigger a false-positive phencyclidine urine drug screen result in nonfatal cases and highlight the lack of specificity of the phencyclidine qualitative urine drug screen.

Secure scalable disaster electronic medical record and tracking system

Introduction: Electronic medical records (EMR) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability. As the prehospital disaster EMR allows for more robust content including Protected Health Information (PHI), security measures must be instituted to safeguard these data. Objectives: To develop a secure prehospital disaster triage/EMR system that prevents unintentional disclosure of private information, may be used by prehospital personnel during the MCI triage process, and can be relayed via wireless system to local and distant medical assets. Methods: The Wireless Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld linked wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. Results: This system has been field tested in a number of exercises with excellent results and future iterations will incorporate robust security measures. Conclusions: A secure prehospital triage EMR improves documentation quality during disaster drills.