Michael B. Heller

Model Curriculum for Physician Training in Emergency Ultrasonography

A model curriculum for the implementation and training of physicians in emergency medicine ultrasonography is described. Widespread use of limited bedside ultrasonography by emergency physicians will improve diagnostic accuracy and efficiency, increase the quality of care, and prove to be a cost-effective technique for the practice of emergency medicine.

Verification of endotracheal tube placement with colorimetric end-tidal CO2 detection

STUDY OBJECTIVE To determine the ability of a disposable colorimetric CO2 detector to accurately confirm or refute endotracheal tube placement. DESIGN Two hundred fifty prospective emergency intubations. SETTING Emergency intubations performed in the emergency department, helicopter, and prehospital ground environment. TYPE OF PARTICIPANTS Intubations were performed by emergency medicine residents, paramedics, and flight nurses. INTERVENTIONS The FEF CO2 detector was applied after 250 emergency intubations. Notation of color change indicating intratracheal placement was recorded in each case. Confirmation of refutation of the detectors results was determined subsequently through traditional methods. RESULTS The sensitivity for confirmation of endotracheal intubation in the 137 patients with a palpable pulse was 100%. However, only 76 of 103 patients (sensitivity, 72%) in cardiac arrest had endotracheal intubation confirmed by color change. The device was uniformly specific for tracheal intubation in 73 arrested patients in whom a color change was noted (100%). There was one instance (of a total of seven misintubations) in which a positive color change was noted, but the tube was not intratracheal (specificity, 86%). Overall sensitivity for tracheal intubation was 88% (95% confidence limits; range, 0.83 to 0.92), and specificity for tracheal intubation was 92% (95% confidence limits; range, 0.62 to 0.99). CONCLUSION The FEF colorimetric detector reliably detects intratracheal placement in the nonarrested patient. Its use in prolonged cardiac arrest merits further study.

Ultrasound for the Detection of Foreign Bodies in Human Tissue

STUDY OBJECTIVE To determine the accuracy of detection of wood and plastic foreign bodies in human tissue by relatively inexperienced clinicians using typical ultrasound equipment. METHODS Uniform wood and plastic foreign bodies were placed through small punctures into recently amputated human legs. Identical control punctures contained no foreign bodies; the sequence of foreign bodies and controls for the puncture sites was randomized. A second blinded investigator scanned each puncture site with a 7.5-MHz ultrasound probe to determine the presence or absence of foreign material. RESULTS Eighty punctures were scanned. Ultrasound detected 44 of 53 foreign bodies (83% sensitivity). Wood foreign bodies were detected 25 of 27 times (93%) and plastic foreign bodies 19 of 26 times (73%; P = 13). Overall, there were 11 false-positive readings (59% specificity). CONCLUSION Ultrasound is imperfect but may be useful in screening for superficial foreign bodies in human tissue. Clinical utility in the ED setting remains to be tested.

Aeromedical trauma sonography by flight crews with a miniature ultrasound unit

Backgound. While ultrasound has become an established diagnostic modality in trauma care, no study has evaluated its use in the prehospital setting. Objective. To examine the use of the focused abdominal sonography for trauma (FAST) exam in the prehospital setting. Methods. After a three-hour training session in the FAST exam, the nonphysician flight team of an emergency medical services (EMS) helicopter program attempted a FAST exam on trauma patients to determine the feasibility of such an intervention. Results. The majority (83%) of the 71 patients entered suffered blunt trauma. FAST exams could not be performed in 34 patients (48%) due to insufficient time (67%), inadequate patient access, or combativeness. Technical difficulties (difficult screen visualization due to ambient lighting, battery failure, and machine malfunction) prevented scanning in seven (19%) of the 37 in whom it was attempted. In those in whom scanning was successful, the pelvic view was most commonly obtained followed by the right upper quadrant (RUQ) and left upper quadrant (LUQ). Conclusion. Significant advances in training, technology, and/or patient access will be necessary for aeromedical FAST to be feasible.

Use of portable ultrasound to assist urine collection by suprapubic aspiration

Study objective: To determine whether portable ultrasound can improve the success rate of suprapubic aspiration (SPA). Design: Patients were randomly assigned to either ultrasound or no ultrasound groups. In the ultrasound group, patients underwent SPA if ultrasound revealed urine in the bladder; if no urine was present, patients underwent catheterization instead of SPA. In the no-ultrasound group, SPA was attempted without ultrasound. All unsuccessful SPAs were followed by catheterization and measurement of urine volume. Setting: Childrens hospital-based pediatric emergency department. Participants: Children less than 2 years old who required SPA. Interventions: Ultrasound versus no ultrasound. Results: Thirty-five patients were randomized to the ultrasound group, and 31 were randomized to the no-ultrasound group. SPA was successful in 79% of attempts in the ultrasound group compared with 52% in the no-ultrasound group ( P = .04). The sensitivity and specificity of ultrasound were 90% and 86%, respectively. Conclusion: Portable ultrasound can significantly improve the success rate of SPA and limit nonproductive attempts at SPA.

The safety of prehospital naloxone administration by paramedics

We performed a retrospective review to investigate the safety of prehospital naloxone administration by paramedics as part of a protocol for all patients presenting with an acutely depressed level of consciousness (LOC). The prevalence of naloxone-induced vomiting, seizures, hypotension, hypertension, and cardiac arrest was sought from the prehospital records of 813 patients treated during a 12-month period. The mean age of the treated patients was 42.4 +/- 9.7 years. The initial dose of naloxone was 0.4 to 0.8 mg, and the mean total dose was 0.9 +/- 0.6 mg. No patients lost a pulse within ten minutes of receiving naloxone. Two patients (0.2%) experienced a significant drop in systolic blood pressure, and one patient (0.1%) demonstrated a significant rise in systolic blood pressure within five minutes of naloxone administration. Vomiting occurred in two patients (0.2%), and one patient (0.1%) suffered a tonic-clonic seizure within five minutes of naloxone administration. Of the 813 patients treated, 60 patients (7.4%: mean age, 32.3 +/- 6.7 years) were judged to have an improved LOC after naloxone, with 27 (3.3%) regaining a normal LOC. We conclude that in the above doses, naloxone is safe as part of prehospital protocols for paramedics treating patients with an acutely depressed LOC. However, the vast majority of patients treated empirically with naloxone in the field demonstrated no benefit.

Confirmation of endotracheal tube placement: A miniaturized infrared qualitative Co2 detector

STUDY OBJECTIVES A miniaturized, infrared, solid-state, end-tidal CO2 detector was used to confirm emergency endotracheal tube (ETT) placement. DESIGN This prospective, clinical study used a miniature, infrared, solid-state end-tidal CO2 detector to confirm ETT placement in an acute setting. SETTING The ICU, emergency department, and hospital floor. TYPE OF PARTICIPANTS There were 88 consecutive adult patients requiring 100 emergency intubations. MEASUREMENTS AND MAIN RESULTS The indication for airway intervention was considered urgent in 79% and under arrest conditions in 21%. The mean number of intubation attempts was 1.83 (range, one to five) with difficulty of intubation of 6.48 and confirmation of 7.75, on a linear scale from 0 (lowest) to 10 (highest). Determination of ETT position revealed intratracheal intubation in 96% and esophageal intubation in 4%. Placement was confirmed by direct visualization or radiography in all cases. Sensitivity and specificity for ETT localization was 100% (P less than .0001). CONCLUSION This hand-held infrared capnometer reliably confirms ETT placement under emergency conditions.

Comparison of Transthecal Digital Block and Traditional Digital Block for Anesthesia of the Finger

STUDY OBJECTIVE To compare the newly described transthecal (TT) and traditional (TD) methods of digital block anesthesia with regard to length of time to achieve anesthesia and pain during infiltration. DESIGN Prospective, randomized, controlled, blinded study. PARTICIPANTS Healthy adult paid volunteers. INTERVENTIONS Each subject received a TT block on one hand and a TD block on the opposite hand. All blocks were performed by the same investigator and were rated by an evaluator who was blinded to the technique that was used. Time to loss of pin-prick sensation was measured, and the pain of the procedure was recorded by the subject on a 10-cm visual-analog scale. RESULTS A total of 162 blocks (81 TT and 81 TD) were performed in 31 different subjects. All blocks were successful. Mean time to anesthesia for TT block was 188 seconds compared with 152 seconds for the TD block (P < .01). Mean analog pain score was slightly higher for TT block than for TD block (1.7 versus 1.4, P = .02). CONCLUSION TT block is clinically equal to the TD method in terms of time to anesthesia and visual-analog pain score.

Design of a resident in-field experience for an emergency medicine residency curriculum

The importance of a resident training in emergency medical services (EMS) is emphasized by the recent development of formal curricula that attempt to prepare the graduating emergency physician for a leadership role in the EMS community. Despite the delineation of specific goals and objectives of such training, actual field exposure and experience in prehospital care have remained voluntary and often sporadic. We designed a resident experience for on-scene attendance at selected incidents and surveyed our residents for their opinion of the curriculum. We also examined field records to determine the nature of field calls and the numbers and types of procedures carried out by second- and third-year residents. During the six-month review period, 158 cardiac arrests were attended, 58 difficult intubations were carried out, 49 central or peripheral lines were started, and 24 severely injured patients were treated on-scene or en route to the hospital. The average response time by the resident to the scene was nine minutes, and the average on-scene time was 20 minutes. Residents completing the survey indicated support for the program and agreed that it has enriched their learning experience. Combined with an air (helicopter and fixed-wing) and ground critical care transport service, the EMS in-field experience has provided opportunities for residents to make rapid decisions, to appreciate the field teams perspective, to report concisely and clearly to colleagues, and to practice required advanced skills. We believe that a formal, planned, and balanced in-field curriculum can afford an opportunity for unique educational experiences that will enrich the graduate program in emergency medicine.

The practice of teaching endotracheal intubation on recently deceased patients

There are few data available regarding the emergency department practice of using recently dead patients (RDP) for practice and training in endotracheal intubation (ETI/RDP). We investigated several aspects of practice by means of a survey sent to all 5,397 emergency departments in the country. Of the 992 (18.3%) responses, 537 (54.1%) did practice ETI/RDP; 455 (45.8%) did not (P less than 0.005). ETI/RDP was used significantly more commonly for instruction of paramedics (411 institutions [77%]), than for other classes of health providers (P less than 0.0001). Overall, only 69 emergency departments (7%) had any written policy governing ETI/RDP; even among those actually practicing ETI/RDP, 84% had no written policy. Likewise, patients and families were rarely informed of the practice. In institutions where ETI/RDP does occur, only 15 (3%) of emergency departments have a policy which mandates such notification. There was widespread agreement as to the educational value of the practice, although it was more favored in hospitals practicing ETI/RDP than those that do not: 411 of 418 (98%) hospitals practicing ETI/RDP agreed that it was an important component of medical education, as did 240 (80%) of institutions not practicing it (P less than 0.0001). Nearly equal percentages of teaching hospitals (53.8%) and nonteaching facilities (57.9%) engage in ETI/RDP (P = 0.35). Objections to ETI/RDP had been noted in 25% of the institutions where it was practiced.