Nelson Tang

Cardiopulmonary resuscitation in pediatric trauma patients : Survival and functional outcome

BACKGROUND Although injury is the leading cause of cardiac arrests in children older than 1 year, few studies have examined the survival and functional outcome of cardiopulmonary resuscitation (CPR) in pediatric trauma patients. METHODS A historical cohort of 957 trauma patients younger than 15 years who received CPR at the scene of injury or at the admitting hospital was constructed on the basis of the National Pediatric Trauma Registry. The rate of survival to discharge and factors related to survival were examined. Functional impairments were documented for surviving patients. RESULTS The overall survival rate was 23.5%. With adjustment for the Injury Severity Score, the risk of fatality after CPR increased for children with systolic blood pressure below 60 mm Hg at admission (odds ratio [OR] 24.5, 95% confidence interval [CI] 8.6-69.3), for those who were comatose at admission (OR, 4.7; 95% CI, 1.9-11.6), for those with penetrating injury (OR, 4.4; 95% CI, 1.5-13.3), and for those with CPR initiated at the hospital (OR, 2.4; 95% CI, 1.5-3.9). Surviving patients stayed in hospitals for an average of 24.3 days; at discharge, 64% had at least one impairment in the functional activities of daily living. CONCLUSIONS Survival outcome of CPR in pediatric trauma patients appears to be comparable to that reported in adults of mixed arrest causes. Future research needs to identify factors underlying the excess mortality associated with penetrating trauma.

Determinants of Emergency Department Procedure- and Condition-Specific Universal (Barrier) Precaution Requirements for Optimal Provider Protection

STUDY OBJECTIVE To determine potential blood and body fluid (B/BF) contacts with specific body areas associated with procedures commonly performed in the emergency department and to thereby delineate appropriate procedure-specific precautions. DESIGN Prospective, observational study assessing procedure-related B/BF contacts by use of stratified, blocked sampling of shifts. PARTICIPANTS ED patients in an inner-city tertiary care university hospital. RESULTS Of 2,529 procedures performed in 1,025 patients, 1,621 (64%) were associated with barrier-protected or unprotected B/BF contact; 92% involved blood or bloody BF. Chest tube placement, lumbar puncture, and examination of the bleeding patient all resulted in B/BF contact with the facial area. All of the 18 procedure categories observed, with the exception of i.m. injection, resulted in B/BF contact with hands. Many procedures resulted in contact with the body or feet. Procedure type, provider, length of time, number of procedures per patient, and successful completion were each independently associated with B/BF contact. Number of attempts, adverse conditions, and triage acuteness were not associated with increased likelihood of contact. CONCLUSION Virtually all ED procedures require gloves. Barrier protection for the body may be appropriate for all but the simplest procedures. Protection for the face seems appropriate, especially in invasive procedures such as lumbar puncture or physical examination of the bleeding patient. This study, along with other published data, has aided development of detailed guidelines for appropriate barrier precautions to be taken for common ED procedures.

Likelihood of reroute during ambulance diversion periods in central Maryland

Objectives. To determine the proportion of patients rerouted during ambulance diversion periods andfactors associated with reroute. Methods. A retrospective cohort design was used to examine reroute practices of prehospital providers in central Maryland in 2000. Ambulance transport anddiversion data were merged to identify transports that occurred during diversion periods. The proportion of patients rerouted when the closest hospital was on diversion was determined. Generalized estimating equation modeling identified patient, transport, andhospital factors that influenced the likelihood of reroute. Results. Central Maryland hospitals were on diversion 25% of the time in 2000, although it varied by hospital (range of 1–34%). There were 128,165 transports during the study period, of which 18,633 occurred when the closest hospital was on diversion. Of these, only 23% were rerouted. More than half of all transports during a diversion period (53%) occurred when multiple neighboring hospitals were also on diversion. The factors that influenced the likelihood of reroute the most were hospital-related factors. Large volume hospitals andhospitals that spent more time on diversion were less likely to have transports rerouted to them. Conclusions. Rerouted transports more frequently go to lower volume, less busy hospitals. However, only a small proportion of patients were rerouted. Prehospital providers have limited options because often when one hospital is on diversion, other nearby hospitals are as well. Although ambulance diversion may be an important signal of hospital distress, in this region it infrequently resulted in its intended outcome, rerouting patients to less crowded facilities.

Strategies to improve sleep during extended search and rescue operations.

Objective. This study investigated strategies to improve sleeping conditions during search andrescue operations during disaster response. Methods. Forty members of the Montgomery County (Maryland) Urban Search andRescue Team were surveyed for individual sleep habits andsleeping aids used during extended deployments. Team members were also asked to suggest methods to improve sleep on future deployments. Results. The average amount of sleep during field operations was 5.4 hours with a range of 4–8 hours. Eight percent surveyed would prefer another schedule besides the 12-hour work day, all of whom proposed three 8-hour shifts. Fifteen percent of participants were interested in a pharmacological sleeping aid. Fifty percent of search andrescue members interviewed would consider using nonpharmacological sleeping aids. Furthermore, 40% of participants stated they had successfully devised self-employed methods of sleep aids for previous deployments, such as ear plugs, massage, mental imagery, personal routines, music andheadphones, reading, andblindfolds. Conclusions. This study suggests that availability of both pharmacological andnonpharmacological sleeping aids to search andrescue workers via the team cache could impact the quantity of sleep. Further investigation into methods of optimizing sleep during field missions could theoretically show enhanced performance through various aspects of missions including mitigation of errors, improved productivity, andimproved overall physiological andemotional well-being of search andrescue personnel.

Air-medical transport experience in emergency medicine residencies: Then and now

OBJECTIVE The appropriate activation and effective utilization of air-medical transport (AMT) services is an important skill for emergency medicine physicians in the United States. Previous studies have demonstrated variability with regards to emergency medical services (EMS) experience during residency training. This study was designed to evaluate the nature and extent of AMT training of the emergency medicine residency programs in the United States. METHODS An identity-unlinked survey of the program directors of all Accreditation Committee for Graduate Medical Education (ACGME) approved emergency medicine residency programs was conducted. The survey focused on EMS and AMT resident training opportunities and was conducted in two phases (1999 and 2006) using near-identical methodologies. RESULTS Response rates of 82% and 84% were achieved in 1999 and 2006, respectively. Percentages of programs offering AMT experiences were similar between the two study phases (76% in 1999 and 65% in 2006). The roles of residents during AMT experiences ranged widely between observer-only, active team member, and medical director/team leader in both 1999 and 2006. Compared to those in 1999, programs in 2006 demonstrated a greater frequency of EMS rotations being provided earlier, by year of training during emergency medicine residency. Residencies located in non-metropolitan centers only were slightly more likely to offer AMT training than were those in metropolitan locations. CONCLUSIONS A majority of emergency medicine residency programs offer AMT experience that includes both scene responses and inter-facility transports. The role of residents during AMT training varies widely, as does the timing of their experiences during residency. The geographical locations of programs do not appear to impact the availability of AMT training.

Role of Tactical EMS in Support of Public Safety and the Public Health Response to a Hostile Mass Casualty Incident

On the morning of August 1, 1966 a lone student ascended the campus tower of the University of Texas at Austin and killed between 13 and 16 people and wounded 31 others in what was at the time the deadliest mass shooting in this nation’s history. As this massacre unfolded, a large albeit chaotic public safety response ensued that included onand off-duty city police officers, sheriff’s deputies, and state police troopers, as well as armed civilians who arrived to assist. This tragic and then unprecedented incident demonstrated to law enforcement agencies that increased preparedness and specialized response teams were necessary to deal with crises requiring intervention beyond the normal capabilities of patrol officers.

Efficacy of a Federal Law Enforcement Tactical Medicine Program Following a Catastrophic Natural Disaster: The Dhs Ice Srt Response To Hurricane Katrina

On August 29, 2005, Hurricane Katrina struck the Gulf Coast of Louisiana with an unprecedented degree of destruction. Both the initial impact and widespread aftermath of this natural disaster were an order of magnitude not previously experienced by this country. While the nation’s disaster and emergency management response resources were being activated and mobilized toward the affected regions of the United States, a federal law enforcement tactical response program and its medical element was deployed in support of police and public safety needs in the area. While not intended primarily as a disaster response initiative, this tactical medical asset encountered frequent, sustained medical needs and was able to provide effective active medical support in this capacity.

Prehospital emergency care training practices regarding lesbian, gay, bisexual, and transgender patients in Maryland (USA)

INTRODUCTION Prehospital Emergency Medical Services (EMS) providers are expected to treat all patients the same, regardless of race, gender identity, sexual orientation, or religion. Some EMS personnel who are poorly trained in working with lesbian, gay, bisexual, and transgender (LGBT) patients are at risk for managing such patients incompletely and possibly incorrectly. During emergency situations, such mistreatment has meant the difference between life and death. METHODS An anonymous survey was electronically distributed to EMS educational program directors in Maryland (USA). The survey asked participants if their program included training cultural sensitivity, and if so, by what modalities. Specific questions then focused on information about LGBT education, as well as related topics, that they, as program directors, would want included in an online training module. RESULTS A total of 20 programs met inclusion criteria for the study, and 16 (80%) of these programs completed the survey. All but one program (15, 94%) included cultural sensitivity training. One-third (6, 38%) of the programs reported already teaching LGBT-related issues specifically. Three-quarters of the programs that responded (12, 75%) were willing to include LGBT-related material into their curriculum. All programs (16, 100%) identified specific aspects of LGBT-related emergency health issues they would be interested in having included in an educational module. CONCLUSION Most EMS educational program directors in Maryland are receptive to including LGBT-specific education into their curricula. The information gathered in this survey may help guide the development of a short, self-contained, open-access module for EMS educational programs. Further research, on a broader scale and with greater geographic sampling, is needed to assess the practices of EMS educators on a national level.

Interfacility Transport of the Pregnant Patient: A 5-year Retrospective Review of a Single Critical Care Transport Program

Abstract Introduction: Interfacility transport of the pregnant patient poses a challenge for prehospital providers as it is an infrequent but potentially high acuity encounter. Knowledge of clinically significant events (CSEs) that occur during these transports is important both to optimize patient safety and also to help enhance crew training and preparedness. This study evaluated a critical care transport program’s 5-year longitudinal experience transporting pregnant patients by ground and air, and described CSEs that occurred during the out-of-hospital phase of care. Methods: This study was a retrospective review of pregnant patients transported by a single critical care transport system into and within a large academic healthcare system. Patients who were pregnant, and were transported from a referring facility to one of the 2 receiving centers within Johns Hopkins Health System between January 1, 2012 and December 31, 2016 were included in this study. The primary outcome of interest was the occurrence of a predefined clinically significant event (CSE) during transport, while a secondary outcome of interest was the indication for transfer. Results: During the study period 1,223 pregnant patients were transported by our critical care transport service. There were 1,101 patients who met inclusion criteria; 693 (62.9%) of whom were transported by ground and 408 (37.1%) who were transported by rotor wing aircraft. The top 3 indications for transfer comprised 71.4% of all patients and included; preterm labor, hypertensive disorder of pregnancy, and other maternal life threatening disorder. The most common events that occurred across all transports were: exacerbation of hypertensive disease requiring intervention (4.5%), hypotension (1.3%), and altered mental status (0.2%). Conclusions: Incidence of CSEs during the interfacility transport of pregnant patients within our critical care transport system is low (6.0%). Knowledge of the clinically significant events that occur during EMS transport is a vital component of ensuring system quality and optimizing patient safety. This data can be used to augment and focus provider education and training to mitigate and optimize response to future events.