Nancy Fenn Buderer

Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery.

ObjectiveTo determine hospital mortality, weaning from mechanical ventilation, long-term survival, and functional health status in patients receiving ≥7 days of mechanical ventilation after cardiac surgery. DesignRetrospective chart review and prospective patient interviews. SettingA university-affiliated, tertiary care medical center. PatientsA total of 124 patients that received ≥7 days of mechanical ventilation after cardiac surgery. InterventionsNone. Main Outcome MeasuresHospital and long-term death, liberation from mechanical ventilation, and functional health status. Measurements and Main ResultsA total of 19 (15%) patients died in hospital. Of the 105 survivors, 104 (99%) were completely weaned from mechanical ventilation. Patients who died in the hospital were more likely to have had a preoperative stroke or to have a new postoperative stroke, more likely to have postoperative renal failure, and less likely to have chronic obstructive pulmonary disease. Kaplan-Meier survival was 59% at 5 yrs and expected median survival was 6.2 yrs. Patients who died anytime after discharge were more likely to have preoperative renal dysfunction or stroke, took longer to be weaned from mechanical ventilation and to be discharged, and were more likely to have postoperative complications such as stroke or renal dysfunction. Also, they were more likely to be too debilitated to walk or eat. By multivariate analysis, admitting creatinine, aortic valve surgery, number of ventilator days, and discharged on tube feedings remained significant predictors of mortality. A total of 40 of 53 survivors were interviewed. Participants were similar to nonparticipants (p > .10 for all characteristics). A few (16%) had limitations of their activities of daily living (eating, dressing, bathing), and most had limitations of moderate activity (60%) and vigorous activity (94%). Only 36% could climb stairs or walk uphill without limitations, 54% could walk a block, and 41% had no limitations in house or job work. Half the participants had no body pain; 38% had moderate and 4% severe pain. Most (59%) described their general health as good to excellent. Only 10% said it was poor. ConclusionPatients’ chances of being liberated from mechanical ventilation are excellent. Their long-term survival and health status are good.

Comparative study of risk factors for skin breakdown with cervical orthotic devices: Philadelphia and Aspen.

PURPOSE To compare risk factors for skin breakdown between Philadelphia and Aspen cervical collars. METHODS Crossover design. Twenty healthy volunteers wore Philadelphia and Aspen cervical collars in random order. Occipital pressure, relative skin humidity, and skin temperature measured at 0 and 30 minutes. Paired t-tests compared changes between collars from 0 to 30 minutes. FINDINGS Occipital pressure and skin temperature were not statistically different between collars. Relative skin humidity increased more in Philadelphia (29% +/- 17%) than Aspen (8% +/- 9%), p < 0.001. CONCLUSIONS Aspen resulted in lower relative skin humidity.

End-of-Life Care: Perspectives of Family Members of Deceased Patients

This study was undertaken to determine the opinions of family members of deceased patients regarding end-of-life care. This multisite cross-sectional survey was administered to 969 volunteer participants during 1997 to 2000. Eligible participants included immediate family members of deceased patients at five local institutions in a regional health system. Among 969 respondents, most (84.4 percent) indicated that the care for their family member was excellent. Reasons cited for satisfaction included overall care (40.2 percent), staff effort (23.2 percent), and communication (16.4 percent). Reasons cited for dissatisfaction included perceived incompetence (9.7 percent), perceived uncaring attitude (8.4 percent), and perceived understaffing (3.7 percent). Respondents were more satisfied with communication from nursing staff (88 percent) than physicians’ communication (78 percent, p < 0.001, Bowker’s test). Respondents indicated higher overall satisfaction with nursing (90 percent) and pastoral care (87 percent), than with physician care (81 percent, p < 0.001 and p = 0.006, Bowker’s test). A unique survey instrument can be used to measure family perceptions and opinions regarding end-of-life care.

End-of-life decisions: family views on advance directives.

A cross-sectional survey was administered to family members of patients who died at 1 of the 5 Catholic institutions comprising Mercy Health Partners, a health care system in Ohio, to determine their opinions about patient and family participation in decisions about end-of-life care. Among 165 respondents, 118 (86%) of 138 agreed that the family was encouraged to join in decisions and 133 (91%) of 146 that their family members health care choices were followed. Most agreed that nurses answered their questions (93%, 141/151) and that the doctor communicated well with family members (83%, 128/155). Seventy percent (107/152) indicated that their family member had at least 1 advance directive. There were no differences in whether health care choices were followed when patients with formal advance directives (92%, 92/100) were compared with patients without formal advance directives (88%, 35/40). A unique survey instrument can be used to measure family perceptions and opinions of participation in decisions about end-of-life care.

Effects of simulated mouth-to-mouth ventilation during external cardiac compression or active compression-decompression in a swine model of witnessed cardiac arrest.

STUDY OBJECTIVE To assess the effects of simulated mouth-to-mouth (MTM) ventilation on blood gases, gas exchange, and minute ventilation during external cardiac compression (ECC) or active compression-decompression (ACD) in a swine model of witnessed cardiac arrest and bystander CPR. METHODS Twenty swine were anesthetized, intubated, ventilated with room air, and monitored for aortic and right atrial pressure and blood gas sampling. After 1 minute of ventricular fibrillation cardiac arrest, ECC or ACD was manually performed at a rate of 100 per minute for 12 minutes. Animals in the room air group had their endotracheal tubes open to air, whereas those in the MTM group were mechanically ventilated with a gas mixture of 16% oxygen and 4% carbon dioxide. Arterial and venous PO2, PCO2, and pH values; oxygen consumption (VO2); carbon dioxide production (VCO2); and minute ventilation (VE) were measured at baseline and 1, 5, 9, and 13 minutes after induction of cardiac arrest. RESULTS MTM ventilation did not alter arterial or venous PO2 values in comparison with room air but did result in higher arterial PCO2 values at 5 and 9 minutes (although the mean PCO2 was 40 mm Hg or less [5.3 kPa] in all groups) and significant central venous hypercarbic acidosis at 9 and 13 minutes. Arterial PO2 values were greater in the ACD than the ECC groups at 5, 9, and 13 minutes, although all groups maintained acceptable PO2 (mean values > or = 60 mm Hg [8.0 kPa]) through 9 minutes of CPR and through 13 minutes in all but the ECC-room air group. PCO2 values were lower in the ACD groups beyond 1 minute, with the ACD-room air group showing extreme hyperventilation (mean PCO2 < or = 20 mm Hg [2.7 kPa]). MTM ventilation resulted in negative VO2 and VCO2 for the first few minutes, reflecting changes in pulmonary gas stores. As equilibrium was approached, VO2 and VCO2 approached zero in all groups, reflecting low cardiac output. MTM ventilation did not improve VE over room air at any time during ACD. It did improve VE during ECC, but only at the 12th interval. CONCLUSION In this swine model of witnessed CPR, simulated MTM ventilation was not beneficial for blood gases, gas exchange, or ventilation during ECC or ACD CPR.

Collaboration among emergency medicine physician researchers and statisticians: resources and attitudes.

We examined the statistical resources within emergency medicine residency programs, and the attitudes of emergency medicine physician researchers toward activities wherein collaboration with a statistician is useful. Anonymous surveys were mailed to 104 emergency medicine physician researchers (1/program). Sixty-four (62%) responses were analyzed. Sixty-seven percent of respondents were their programs research director. Their highest level of statistical training was self-taught/nondegree course work for 88% of respondents. Forty-two percent said they were the person used most often by their program for statistical expertise. One-quarter of programs employed a full-time statistician. Collaboration among researchers and statisticians was considered sometimes or always useful for protocol development (aims 84%, design 99%, outcomes 99%, procedures 73%, sampling 97%, inclusion criteria 93%, number of subjects 100%); data entry 73%; statistical analysis 100%; and manuscript preparation 86%. Although most emergency medicine residencies lacked statistical resources within their program, physician researchers expressed positive attitudes toward collaboration with a statistician for all aspects of research.

Assessment of U.S. helicopter emergency medical services' planning and preparedness for disaster response

INTRODUCTION Helicopter emergency medical services (HEMS) roles in disaster response vary significantly from routine operation, and as reported in the literature, such responses have not been without difficulty. We identified nine criteria (written policy, triage and incident command training disaster drill participation, ground and air communications plan, critical incident stress management, annual review, policy sharing) that may significantly affected an air medical programs disaster preparedness, response, and recovery. Of these criteria, a written policy is considered of primary importance. METHODS A written survey was developed and mailed in July 1995 to 187 U.S. rotor-wing members of the Association of Air Medical Services. The survey was designed to identify the programs that had a written policy and fulfilled the guideline criteria, had a written policy and partially fulfilled the criteria, or did not have a written policy. RESULTS Surveys were returned from 104 (56%) programs. Of the 103 qualifying respondents, 16 (16%) meet the criteria, 55 (53%) partially met the criteria, and 32 (31%) did not have written policies. CONCLUSION Most U.S. HEMS programs have not fully addressed disaster preparedness, response, and recovery. HEMS disaster response guidelines should be established, and these criteria should be incorporated.