James Mayrose

Comparison of normal saline with tap water for wound irrigation

This study compared irrigation with tap water versus saline for removing bacteria from simple skin lacerations. The study was conducted in an animal model with a randomized, nonblinded crossover design using 10 500-g laboratory rats. Two full-thickness skin lacerations were made on each animal and inoculated with standardized concentrations of Staphylococcus aureus broth. Tissue specimens were removed before and after irrigation with 250 cc of either normal saline from a sterile syringe or water from a faucet. Bacterial counts were determined for each specimen and compared before and after irrigation. There was a mean reduction in bacterial counts of 81.6% with saline and 65.3% with tap water (P = .34). One tap water specimen had markedly aberrant bacterial counts compared with others. Excluding this specimen, the mean reduction for tap water was 80.2%. In this model, reduction in bacterial contamination of simple lacerations was not different comparing tap water with normal saline as an irrigant.

Utilization of virtual reality for endotracheal intubation training

Tracheal intubation is performed for urgent airway control in injured patients. Current methods of training include working on cadavers and manikins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time, the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The haptic device along with the real-time performance of the simulator give it both visual and physical realism. The three-dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many endotracheal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.

A telemedicine model for emergency care in a short-term correctional facility.

The primary objectives of this research were to determine the effectiveness of a personal computer-based telemedicine system for semi- and nonurgent complaints at a short-term correctional facility and to evaluate the system as a potential model for providing emergency care to remote locations. We performed a retrospective review of medical records of patients referred to the emergency department in person or via telemedicine during a 12-month period. The data included system utilization, chief complaints, physical examination, diagnostic testing, disposition, and outcomes in patients evaluated via telemedicine. Also identified were nursing diagnostic and procedure skills associated with successful evaluation via telemedicine. A total of 530 emergency care records were reviewed with 126 telemedicine consultations performed. Eighty-one of 126 (64%) telemedicine patients remained at the facility following consultation with the remaining 45 (36%) being transported to the emergency department. Rates of return to the emergency department within 7 days following consultation were comparable, patient acceptance and satisfaction was high, and there were no untoward outcomes in the group. Average total time of telemedicine consultation was 30 minutes versus a 2-hour and 45-minutes turnaround time for an emergency department evaluation. A variety of emergency complaints were managed effectively using relatively low-cost computer-based telemedicine technology, thereby eliminating the need for transportation of the patient to the emergency department. This system provides an emergency physician-nurse model for conduction limited emergency care in remote settings.

Predicted utilization of emergency medical services telemedicine in decreasing ambulance transports

Objective. To determine predicted utilization, decrease in ambulance transports, and target population for emergency medical services (EMS) if telemedicine capabilities were available to the medic units in the field. Methods. A retrospective chart review of 345 consecutive ambulance transports to four hospitals (Level I urban trauma center, urban tertiary care center, childrens hospital, and suburban community hospital) was performed by a panel of three board-certified emergency medicine physicians experienced and credentialed in emergency telemedicine. They independently reviewed the emergency department (ED) and EMS records and were asked to determine whether patients required ambulance transport for evaluation or whether disposition could be made following paramedic and emergency physician assessment via telemedicine. A five-point Likert scale was used to grade feasibility of telemedicine disposition (definitely yes, probably yes, maybe, probably no, definitely no). Other variables analyzed included age, sex, race, chief complaint, phone, private medical doctor, and call location by patient zip code, call site, and receiving hospital. Results. In 14.7% of cases (6% definitely yes and 8.7% probably yes), disposition could be made without transport using telemedicine. The age range for eliminating transport was 2 weeks through 92 years, with mean age of 26.6 years. Under the age of 50 years, 46 out of 238 patients (19.3%) could have possibly been managed by telemedicine. Conclusion. Use of EMS telemedicine could result in an approximately 15% decrease in ambulance transports when it alone is added to the prehospital care providers armamentarium. Emphasis for implementation should be placed on younger patients and an identified subset of chief complaints conducive to management using telemedicine.

An analysis of race and demographic factors among motor vehicle fatalities

BACKGROUND According to the National Highway Traffic Safety Administration, from 1982 through 1995 safety belts are estimated to have saved 74,769 lives. Even more lives could be saved and serious injuries avoided if there was increased seat belt use in the United States. METHODS This study analyzed safety belt use among drivers and passengers involved in fatal motor vehicle crashes from 1993 through 1995. Age, sex, race, safety belt use, and position in the vehicle were the demographic factors obtained from both the Fatality Analysis Reporting System and the National Highway Traffic Safety Administration. RESULTS Overall, safety belt use increased by an average of 1.3% per year for the entire study population. Forward logistic regression identified age, female gender, Caucasian race, and driver as significant predictors of safety belt use. CONCLUSION This study has identified younger males, African Americans, and passengers as high-risk populations for nonuse of safety belts among fatal motor vehicle crashes. These high-risk populations should be educated regarding the importance of safety belt use.

How Much Force Is Required to Dislodge an Alternate Airway

Abstract Introduction. Endotracheal tube (ETT) dislodgment is a potentially catastrophic adverse event. Newer alternate airway devices—esophageal-tracheal Combitube (ETC), King laryngeal tube disposable airway (King LT), and laryngeal mask airway (LMA)—are easier to insert, but their relative extubating forces remain unknown. Objective. To examine the applied forces required to dislodge an ETC, King LT, LMA, and ETT. Methods. We used five recently deceased adult unembalmed cadavers. In random order, we sequentially inserted an ETC, King LT, LMA, and standard ETT. Because commercial tube holders are not designed for all alternate airways, we secured the devices with a standard adhesive tape method. Using a precision digital force measuring device, we measured the minimum manually applied axial force (lb) that dislodged each airway device at least 4 cm. We compared required dislodgment forces between airway devices using a mixed-effects regression model, adjusting for cadaver height, weight, neck circumference, and thyromental distance. Results. Characteristics of the cadavers were as follows (median, interquartile range [IQR]): height 172 cm (167–177), weight 98 kg (84–120), neck circumference 46.5 cm (41–52), and thyromental distance 7.5 cm (7.5–8). Required axial dislodgment forces for each airway device were as follows (median, IQR): ETC 28.3 lb (19.0–28.6), King LT 12.5 lb (11.7–13.3), LMA 18.3 lb (14.0–21.9), and ETT 14.4 lb (13.5-22.1). The ETC required twice as much dislodgment force as the ETT (adjusted difference 16.7 lb, 95% confidence interval [CI]: 8.3 to 25.1). The King LT and LMA dislodgment forces were similar to that of the ETT (King LT vs. ETT adjusted difference 5.9 lb, 95% CI: –2.4 to 14.2; LMA vs. ETT 8.1 lb, 95% CI: –0.2 to 16.5). Conclusion. In a cadaver model of unintended airway dislodgment, the ETC required the most force for dislodgment. The King LT and LMA performed similarly to a standard ETT.

Consultation times in emergency telemedicine using realtime videoconferencing

We reviewed 2135 consecutive emergency teleconsultations, which were received at an academic emergency department from state correctional facilities. During the 52-week study period, an average of 5.8 video-consultations per day were performed. A total of 1522 consultations (71%) had complete start and end consultation times, and were included in the analysis. Of these, 923 were managed primarily by emergency medicine residents and physician assistants, while the remaining 599 were managed by attending physicians alone. Following consultation, the disposition of the patients included 940 who were transported to the emergency department, 351 who were discharged to the general facility population and 193 who were admitted to the local infirmary. Overall, 38% of patients avoided a journey to the emergency department. The average consultation time was 17 min (95% confidence interval [CI], 10–24). The average consultation time for residents and physician assistants was 16 min (95% CI, 8–24) and it was 19 min (95% CI, 11–27) for attending physicians. Consultation time for patients not transported to the emergency room was 21 min (95% CI, 13–29), while for patients transferred to an emergency department, consultation time was 15 min (95% CI, 9–21). These results may assist in planning the workforce requirements for emergency department-based telemedicine services.

Comparison of staples versus sutures in the repair of penetrating cardiac wounds.

BACKGROUND Several literature reports advocate the use of skin staplers for repair of penetrating cardiac wounds during emergency thoracotomy. Our study goal was to objectively determine if stapling is a more efficient method of closure compared with suturing without compromising the strength of the repair. METHODS This randomized, nonblinded study was conducted in a swine model. A total of four incisions, two per ventricle, were made in each animal. The 2-cm full-thickness incisions were repaired with either sutures or staples, and the time required to close each wound was recorded. After wound repair, the animals were killed. The four wounds were isolated by removing 4.0-cm strips of myocardium oriented perpendicular to the incision. Each strip was then placed on a tensile force testing machine, and the breaking strength of the sutures and staples was measured. RESULTS The tensile force test showed that stapled and sutured wounds have equivalent mechanical strength. The mean time of closure for stapled wounds was substantially less than that for sutured wounds. CONCLUSION In this swine model, stapling took significantly less time and had equal mechanical strength compared with suturing for repair of penetrating cardiac wounds. Stapling during emergent resuscitation may be preferable to suturing.

A virtual environment for esophageal intubation training.

Esophageal intubations are performed for urgent airway control in injured patients. Current methods of training include working on cadavers and mannequins, which lack the realism of a living human being. Work in this field has been limited due to the complex nature of simulating in real-time the interactive forces and deformations which occur during an actual patient intubation. This study addressed the issue of intubation training in an attempt to bridge the gap between actual and virtual patient scenarios. The two haptic devices along with the real-time performance of the simulator give it both visual and physical realism. The three dimensional viewing and interaction available through virtual reality make it possible for physicians, pre-hospital personnel and students to practice many esophageal intubations without ever touching a patient. The ability for a medical professional to practice a procedure multiple times prior to performing it on a patient will both enhance the skill of the individual while reducing the risk to the patient.

Comparison of the Force Required for Dislodgement Between Secured and Unsecured Airways

Abstract Introduction: Airway device placement and maintenance are of utmost importance when managing critically ill patients. The best method to secure airway devices is currently unknown. Study Objective: We sought to determine the force required to dislodge 4 types of airways with and without airway securing devices. Methods: We performed a prospective study using 4 commonly used airway devices (endotracheal tube [ETT], laryngeal mask airway [LMA], King laryngeal tube [King], and iGel) performed on 5 different mannequin models. All devices were removed twice per mannequin in random order, once unsecured and once secured as per manufacturers’ recommendations; Thomas Tube Holder (Laerdal, Stavanger, Norway) for ETT, LMA, and King; custom tube holder for iGel. A digital force measuring device was attached to the exposed end of the airway device and gradually pulled vertically and perpendicular to the mannequin until the tube had been dislodged, defined as at least 4 cm of movement. Dislodgement force was reported as the maximum force recorded during dislodgement. We compared the relative difference in the secured and unsecured force for each device and between devices using a random-effects regression model accounting for variability in the manikins. Results: The median dislodgment forces (interquartile range [IQR]) in pounds for each secured device were: ETT 13.3 (11.6, 14.1), LMA 16.6 (13.9, 18.3), King 21.7 (16.9, 25.1), and iGel 8 (6.8, 8.3). The median dislodgement forces for each unsecured device were: ETT 4.5 (4.3, 5), LMA 8.4 (6.8, 10.7), King 10.6 (8.2, 11.5), and iGel 3.9 (3.2, 4.2). The relative difference in dislodgement forces (95% confidence intervals) were higher for each device when secured: ETT 8.6 (6.2 to 11), LMA 8.8 (4.6 to 13), King 12.1 (7.2 to 16.6), iGel 4 (1.1 to 6.9). When compared to secured ETT, the King required greater dislodgement force (relative difference 8.6 [4.5–12.7]). The secured iGel required less force than the secured ETT (relative difference −4.8 [−8.9 to −0.8]). Conclusion: Compared with a secured device, an unsecured airway device requires only half the force to cause airway dislodgement. The secured King had the highest dislodgement force relative to the other studied devices.