Darryl Macias

Portable handheld ultrasound in austere environments: use in the Haiti disaster.

INTRODUCTION A 7.0 magnitude earthquake struck Haiti on January 12, 2010, resulting in 222,000 deaths and 300,000 injuries. Three weeks after the initial quake, the New Mexico Disaster Medical Assistance Team (NM DMAT-1) was deployed to Haiti for ongoing medical relief. During this deployment, a portable handheld ultrasound machine was tested for usefulness in aiding with patient care decisions. OBJECTIVE The utility of portable ultrasound to help with triage and patient management decisions in a major disaster setting was evaluated. METHODS Retrospective observational non-blinded images were obtained on 51 patients voluntarily presenting to the Gheskio Field clinic at Port-au-Prince. Ultrasound was used for evaluation of undifferentiated hypotension, torso trauma, pregnancy, non-traumatic abdominal pain, deep venous thrombosis and pulmonary embolism, and dyspnea-chest pain, as well as for assisting with procedures. Scans were obtained using a Signos personal handheld ultrasound machine with images stored on a microSD card. Qualitative data were reviewed to identify whether ultrasound influenced management decisions, and results were categorized in terms of percent of scans that influenced management. RESULTS Fifty-one ultrasound scans on 50 patients were performed, with 35% interpreted as positive, 41% as negative, and 24% as equivocal. The highest yields of information were for abdominal ultrasound and ultrasound related to pregnancy. Ultrasound influenced decisions on patient care in 70% of scans. Most of these decisions were reflected in the clinicians confidence in discharging a patient with or without non-emergent follow-up. CONCLUSION The use of a handheld portable ultrasound machine was effective for patient management decisions in resource-poor settings, and decreased the need to triage selected patients to higher levels of care. Ultrasound was very useful for evaluation of non-traumatic abdominal pain. Dynamic capability is necessary for ultrasound evaluation of undifferentiated hypotension and cardiac and lung examinations. Ultrasound also was useful for guidance during procedural applications, and for aiding in the diagnosis of parasitic diseases.

The management of open fractures

Abstract This is a review of Medline and PubMed articles on open fractures published in the English literature between 1945 and April 2005. The emphasis of most published articles has been placed on definitive treatment of these injuries at sophisticated referral hospitals. The prehospital emphasis has been on rapid evacuation and referral to ensure that definitive treatment can be initiated as quickly as possible. Little has been discussed about the management of these injuries in remote settings where evacuation may consume considerably more time. Contemporary recommendations for management of these injuries are reviewed.

Development of a Wilderness and Travel Medicine Rotation in an Academic Setting

Wilderness medicine courses tend to teach similar topics, but they can differ with respect to philosophy, teaching methods, and financing. Our not-for-profit course is academically based and is similar to other programs with regard to presentations of didactic material and outdoor training, but there are also important differences in teaching methodology that are not used by other programs to date. Innovative methods, such as problem-based learning and use of the human patient simulator, which are unique to our program, have been successful in our courses and may be of use to wilderness medical education. We hope that sharing information about our program will help make wilderness medicine training more standardized and uniform.

Clinically occult presentation of comminuted intertrochanteric hip fractures

Hip fractures in awake patients are rarely subtle in their clinical presentation. We report two cases of occult, comminuted, intertrochanteric hip fractures that occurred in awake, elderly patients who were brought to the emergency department for evaluation of other medical conditions. Neither patient complained of hip pain, and both were transported to the ED without spinal immobilization. Physical examination revealed no sign of hip fracture. Patient 1 was scheduled for admission and just prior to transfer out of the ED developed hip pain. Patient 2 was admitted for workup of possible transient ischemic attack and approximately 2.5 hours after admission complained of hip pain. Radiographs of both patients revealed comminuted intertrochanteric hip fractures. In an elderly, nonambulatory patient who may have fallen prior to evaluation, routine radiographs of the pelvis and hip should be performed followed by plain tomography, computed tomography, bone scan, or magnetic resonance imaging as indicated to rule out occult hip fracture. Even comminuted intertrochanteric hip fractures can present in an occult fashion; therefore, a high index of suspicion must be maintained for these injuries.

A New Approach to Teaching Prehospital Trauma Care to Paramedic Students

STUDY OBJECTIVE A modification of the standard Department of Transportation student paramedic curriculum encouraging individualized patient assessment decreases inappropriate on-scene procedures (OSPs) and scene time, measured on simulated patients. METHODS Scenario-based testing from 1991 through 1993 was videotaped for all students. A new trauma curriculum was introduced in 1992, individualizing patient assessment and prioritization of OSPs. Recorded OSPs included spinal immobilization, application of military antishock trousers, endotracheal intubation, cricothyrotomy, intravenous catheter insertion, and needle thoracostomy. Twenty videotaped random student performances of the 1991 class was compared with a similar sample of 20 from the 1993 class; scene times and the OSP numbers were measured. Two board-certified independent emergency physicians unfamiliar with the students or the new curriculum reviewed all 40 tests on a master videotape. Patient assessment appropriateness, scene time, OSPs, scenario difficulty, and number of inappropriate OSPs were evaluated using a linear analog scale. Data are presented as means with confidence intervals (CIs), analyzed by Students t test and the Mann-Whitney 2-sample test. RESULTS Scene time from 1991 to 1993 decreased overall with a mean of 4.3 minutes (95% CI 2.8 to 5.8 minutes), as did the number of OSPs: 3.1 versus 1.7 (mean difference, 1.45 OSPs per scenario; 95% CI.91 to 1.99). Physician reviewers noted improvements in the appropriateness of patient assessment, scene time, and OSPs from 1991 to 1993. There was no significant difference in scenario difficulty for 1991 compared with 1993. Inappropriate OSPs done on scene declined. Physician 1 indicated a mean of inappropriate procedures of 1.6 in 1991 versus.5 in 1993. Physician 2 indicated a mean of 1.4 in 1991 versus.3 in 1993. CONCLUSION This new paramedic curriculum decreased on-scene time and inappropriate use of procedures in stabilizing the condition of patients with simulated critical trauma.

Core content for wilderness medicine fellowship training of emergency medicine graduates

Wilderness medicine is the practice of resource-limited medicine under austere conditions. In 2003, the first wilderness medicine fellowship was established, and as of March 2013, a total of 12 wilderness medicine fellowships exist. In 2009 the American College of Emergency Physicians Wilderness Medicine Section created a Fellowship Subcommittee and Taskforce to bring together fellowship directors, associate directors, and other interested stakeholders to research and develop a standardized curriculum and core content for emergency medicine (EM)-based wilderness medicine fellowships. This paper describes the process and results of what became a 4-year project to articulate a standardized curriculum for wilderness medicine fellowships. The final product specifies the minimum core content that should be covered during a 1-year wilderness medicine fellowship. It also describes the structure, length, site, and program requirements for a wilderness medicine fellowship.