Jonathan V. McCoy

Discordance between microcirculatory alterations and arterial pressure in patients with hemodynamic instability

PURPOSE Recent studies reported that microcirculatory blood flow alterations occur in patients with circulatory shock independent of arterial pressure but typically lack baseline microcirculatory data before the insult and after recovery. We selected cardiopulmonary bypass (CPB) patients with expected and rapidly reversible hemodynamic instability to test the hypothesis that microcirculatory alterations can occur independent of mean arterial pressure (MAP). METHODS Prospective observational study using sidestream darkfield videomicroscopy to measure sublingual microcirculatory flow preoperative (PRE), postoperatively after CPB (POST), and after recovery (REC). We determined the microcirculatory flow index (MFI) at each time point, blinded to all clinical data and compared change in MFI and MAP across time points using analysis of variance adjusted for multiple comparisons. RESULTS We enrolled 20 subjects, 17 of 20 required inotrope/vasopressor agents at CPB discontinuation, 7 of 20 were on inotrope/vasopressor agents at the time of imaging, 20 of 20 were receiving continuous nitroglycerin. We observed an increase in post-CPB MFI (PRE, 2.16 ± 0.29; POST, 2.45 ± 0.62; REC, 2.26 ± 0.25; P < .01) without a concomitant increase in MAP. CONCLUSION In this cohort of patients with hemodynamic instability, we observed discordance between microcirculatory blood flow and arterial pressure. These data support the concept that microcirculatory blood flow indices can yield physiologic information distinct from macrocirculatory hemodynamic parameters.

Continuous cardiac index monitoring: A prospective observational study of agreement between a pulmonary artery catheter and a calibrated minimally invasive technique

INTRODUCTION Continuous cardiac index (CCI) monitoring can provide information to assist in hemodynamic support. However, pulmonary artery catheters (PAC) pose logistic challenges in acute care settings. We hypothesized that CCI measured with a calibrated minimally invasive technique (LiDCO/PulseCO, UK) would have good agreement with the PAC. METHODS We performed a prospective observational study in post-operative cardiac surgery patients. All patients had a PAC with CCI monitoring capability. We connected the LiDCO apparatus to a radial artery line and performed a one-time calibration with a lithium dilution indicator. In order to test the least invasive method possible, we used a peripheral intravenous (IV) line for indicator delivery rather than the conventional central line technique. We recorded paired PAC/LiDCO-PulseCO CCI measurements every minute for 3h. We blinded investigators and clinicians to minimally invasive data with an opaque shield over the monitor. We assessed agreement with Bland-Altman analysis. RESULTS We obtained 1485 paired measurements in 8 subjects. The mean CI was 2.9L/min/m(2). By Bland-Altman plot, PAC and LiDCO measurements showed minimal bias (-0.01), but the 95% limits of agreement (+/-2SD) of+/-1.3L/min/m(2) were relatively wide with respect to the mean. CONCLUSIONS This calibrated minimally invasive (i.e. radial arterial line and peripheral IV) technique demonstrated low bias compared with CCI measured by PAC. However, the relatively wide confidence limits indicate that differences in the two measurements could still be clinically significant.

Diagnosis and Treatment of Acute Gout at a University Hospital Emergency Department

Background : Acute gout attacks account for a substantial number of visits to the emergency department (ED). Our aim was to evaluate acute gout diagnosis and treatment at a University Hospital ED. Methods : Our study was a retrospective chart review of consecutive patients with a diagnosis of acute gout seen in the ED 1/01/2004 - 12/31/2010. We documented: demographics, clinical characteristics, medications given, diagnostic tests, consultations and whether patients were hospitalized. Descriptive and summary statistics were performed on all variables. Results : We found 541 unique ED visit records of patients whose discharge diagnosis was acute gout over a 7 year period. 0.13% of ED visits were due to acute gout. The mean patient age was 54; 79% were men. For 118 (22%) this was their first attack. Attack duration was ≤ 3 days in 75%. Lower extremity joints were most commonly affected. Arthrocentesis was performed in 42 (8%) of acute gout ED visits. During 355 (66%) of ED visits, medications were given in the ED and/or prescribed. An anti-inflammatory drug was given during the ED visit during 239 (44%) visits. Medications given during the ED visit included: NSAIDs: 198 (56%): opiates 190 (54%); colchicine 32 (9%) and prednisone 32 (9%). During 154 (28%) visits an anti-inflammatory drug was prescribed. Thirty two (6%) were given no medications during the ED visit nor did they receive a prescription. Acute gout rarely (5%) led to hospitalizations. Conclusion : The diagnosis of acute gout in the ED is commonly clinical and not crystal proven. Anti-inflammatory drugs are the mainstay of treatment in acute gout; yet, during more than 50% of ED visits, anti-inflammatory drugs were not given during the visit. Thus, improvement in the diagnosis and treatment of acute gout in the ED may be required.

How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations

Introduction The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. Objective To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. Methods We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. Results When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient= −0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar results. When the data were controlled for effect of month of the year, only student test score remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases). Conclusion ED overcrowding does demonstrate a small but negative association with medical student performance on end-of-rotation examinations. Additional studies are recommended to further evaluate this effect.

Hand Washing Practices Among Emergency Medical Services Providers

Introduction Hand hygiene is an important component of infection control efforts. Our primary and secondary goals were to determine the reported rates of hand washing and stethoscope cleaning in emergency medical services (EMS) workers, respectively. Methods We designed a survey about hand hygiene practices. The survey was distributed to various national EMS organizations through e-mail. Descriptive statistics were calculated for survey items (responses on a Likert scale) and subpopulations of survey respondents to identify relationships between variables. We used analysis of variance to test differences in means between the subgroups. Results There were 1,494 responses. Overall, reported hand hygiene practices were poor among pre-hospital providers in all clinical situations. Women reported that they washed their hands more frequently than men overall, although the differences were unlikely to be clinically significant. Hygiene after invasive procedures was reported to be poor. The presence of available hand sanitizer in the ambulance did not improve reported hygiene rates but improved reported rates of cleaning the stethoscope (absolute difference 0.4, p=0.0003). Providers who brought their own sanitizer were more likely to clean their hands. Conclusion Reported hand hygiene is poor amongst pre-hospital providers. There is a need for future intervention to improve reported performance in pre-hospital provider hand washing.

What hemodynamic and perfusion variables are we monitoring in post-cardiac arrest patients…and why?.

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EMS Dispatches during Hurricanes Irene and Sandy in New Jersey

Abstract Background: Hurricanes Irene and Sandy heavily impacted New Jersey. Investigating EMS dispatch trends during these storms may allow us to prepare for future disasters. Objectives: Our objectives to characterize the types of EMS dispatches immediately before, during, and after landfall compared to a control period. Methods: This retrospective study was conducted at a large EMS dispatch center that provides first responders, Basic Life Support (BLS), Advanced Life Support (ALS), and critical care transport services to an area with approximately 20 receiving hospitals including a Level I Trauma Center. At peak staffing, there are 8–10 ALS vehicles, 25 BLS vehicles, and 3 critical care transport vehicles deployed. We included of the day of landfall and seven days before and after. We compared dispatch data to a control period in 2010 that mirrored Hurricane Sandy the dates of. Descriptive statistics and two way ANOVA were used to assess dispatch, gender and age differences. Results: We found Hurricane Sandy dispatches peaked 2 days after landfall. Both ALS and BLS had an increase in age in the post-Sandy period compared to the pre-Sandy (ALS 58.5 to 64.2, p = 0.005, ANOVA p = 0.078; BLS 47.4 to 56.3, p < 0.001, ANOVA p = 0.001). There were 17 “hurricane related” (loss of power related issues, oxygen supply depleted, evacuation) and 15 carbon monoxide dispatches in the post-Sandy period and none in the others, including peri-Irene. The average age of cardiac arrest dispatches was lower in the post-Irene group compared to pre-Irene (74.3 to 47.8, p = 0.023). There were no critical care requests before or after Hurricane Sandy, but there were 14 around Hurricane Irene and 10 surrounding the control period. Conclusions: Dispatch data can inform natural disaster planning. Education efforts can focus on geriatric patients, as well as resource distribution planning for an increase in geriatric populations. However, pattern variability between storms shows further study is needed to clarify exactly which resources should be utilized in order to maintain an ideal response to a natural disaster.

EMS providers do not use FOAM for education

BackgroundFree open access to medical education (FOAM, #FOAM) is the free availability of educational materials on various medicine topics. We hope to evaluate the use of social media and FOAM by emergency medical services (EMS) providers.MethodsWe designed an online survey distributed to EMS providers with questions about demographics and social media/FOAM use by providers. The survey was sent to the American College of Emergency Physicians (ACEP) EMS Listserv of medical directors and was asked to be distributed to their respective agencies. The survey was designed to inquire about the providers’ knowledge of FOAM and social media and their use of the above for EMS education.ResultsThere were 169 respondents out of a total of 523 providers yielding a response rate of 32.3%. Fifty-three percent of respondents are paramedics, 37% are EMT-Basic trained, and the remainder (16%) were “other.”The minority (20%) of respondents had heard of FOAM. However, 54% of respondents had heard of “free medical education online” regarding pertinent topics. Of the total respondents who used social media for education, 31% used Facebook and 23% used blogs and podcasts as resources for online education.Only 4% of respondents stated they produced FOAM content. Seventy-six percent of respondents said they were “interested” or “very interested” in using FOAM for medical education. If FOAM provided continuing medical education (CME), 83% of respondents would be interested in using it.ConclusionSocial media is not used frequently by EMS providers for the purposes of FOAM. There is interest within EMS providers to use FOAM for education, even if CME was not provided. FOAM can provide a novel area of education for EMS.

Organization and Operations Management at the Explosive Incident Scene

INTRODUCTION The scene of a mass casualty incident is a chaotic, stressful environment. Explosive incident scenes, especially those related to terrorism, add increased levels of fear and potential injury to both civilians and health care providers. They frequently destabilize infrastructure in multiple ways. This article discusses best practices for management of the out-of-hospital explosion scene. The majority of the recommendations are based on expert panel consensus as described in the introductory article. On completion of this article, the reader will have been introduced to several key concepts that may be applied to his or her system in planning for an explosive incident. Because health care and emergency response systems vary considerably from region to region, we do not provide detailed incident plans, but offer a strategic base on which a more specific plan may be built. In the world of disaster management, the Incident Command System is widely used and provides a common language for health care providers. The system is a framework developed to coordinate response to mass casualty incidents. The branches of the Incident Command System are divided into operations, logistics, planning, and finance/ administration. The Federal Emergency Management Agency (FEMA) Incident Command System for emergency medical services (EMS) introduces 6 stages of incident management: planning and training, initial response, operations, stabilization, demobilization, and termination. We will use these 6 stages in this article as a framework for the discussion of management at the explosive incident scene. Furthermore, the National Incident Management System is a standard approach to disaster management that implements the Incident Command System. It was designed to help integrate and coordinate between all levels of responding, from the municipal government through the

Response to the comment of den Uil et al. for the article by the Microcirculatory Alterations in Resuscitation and Shock (MARS) investigators

Dear Editor, We thank Dr. den Uil and colleagues (doi:10.1007/s00134-008-1272-8) for their interest and insights on our paper [1]. With respect to their first point, our microvascular flow index (MFI) values apply exclusively to small vessels (i.e. \20 lm in diameter). We examine larger vessels only for quality control (i.e. absence of pressure artifact). Their second point pertained to the individual patient data displayed in the Electronic Supplementary Material. Mean MFI values at Visit 2 were not significantly different between organ failure groups—the MFI for Sequential Organ Failure Assessment (SOFA) Improvers was 2.04 ± 0.50 versus 1.88 ± 0.54 for SOFA Nonimprovers, P = 0.37. However, our a priori aim was to test the hypothesis that changes during the resuscitation phase of therapy were associated with the development or resolution of organ failure. Therefore, we submit that serial monitoring during resuscitation may be the most informative. Last, we agree that future research is necessary in order to develop a bedside microcirculation-directed approach to sepsis resuscitation. Preliminary work from our group has demonstrated that a point-of-care assessment of the microcirculation is promising [2], and developing a bedside readout on the status of the microcirculation will be important for our long-range investigational aim of testing novel microcirculation-directed interventions in septic patients who manifest persistently impaired microcirculatory flow after conventional resuscitation endpoints have been achieved [3, 4].