Paul Rega

Investigation of Bone Developmental and Histopathologic Changes From Intraosseous Infusion

STUDY OBJECTIVE To evaluate clinical and cellular changes of bone through the rapid growth phase of development after intraosseous infusion of hypertonic or isotonic solutions at slow or fast infusion rates in a pig model. METHODS This was a prospective, randomized, partially blinded, comparative study using a porcine model in an urban teaching hospital laboratory with further development in a local farm environment. Sixty pigs weighing 12 to 30 kg were anesthetized and endotracheally intubated, and a no. 15 Jamshidi bone marrow needle was inserted into a front forelimb. Hypertonic (mannitol) or isotonic (saline) solutions of 8 mL/kg were infused through the intraosseous site at a rapid or slow infusion rate. Animals were observed for approximately 6 months, after which they were killed and the front forelimbs harvested for gross pathologic and histologic evaluation. RESULTS No clinical complications were noted in any of the animal groups. No substantial histologic differences were found between the hypertonic and isotonic groups. Although gross pathologic lesions were found in 32% of the hypertonic groups and in fewer than 5% of the isotonic groups, this difference was not statistically significant. Equal bone changes were found in the slow- and rapid-infusion groups. CONCLUSION The rate of intraosseous infusion and the osmolarity of the infused fluid did not appear to be related to any gross pathologic or histologic cellular or marrow changes or to any clinical complications in animal development in this study.

Immersive Simulation Education: A Novel Approach to Pandemic Preparedness and Response

Pandemic management involves strategic and tactical concepts rarely experienced with other disasters. To comprehend the enormity of these tasks and experience the critical decision-making required, local public health and other stakeholders participate in tabletop and functional exercises. Students in Master of Public Health (MPH) programs not only rarely experience this educational format, but also are seldom afforded substantive time to appreciate the critical decision making that is unique to pandemics. An immersive semester-long simulation exercise was created to educate graduate public health students about pandemics. Students in a MPH course were divided into groups representing county health departments. During the semester, students collaborated and completed incident command training, received audio lectures, and materials concerning an imminent pandemic. The students then participated in the 2.5-hr facilitated tabletop exercises in the classroom. A survey was developed to assess their perceptions of the experience. Most students felt more knowledgeable afterward and thought that this training style was innovative, entertaining, educational, and recommended it to fellow students and colleagues. The students believed that delivering a tabletop exercise in this fashion was educational and entertaining. It gave the students a better appreciation of the role of public health in managing the complexities associated with pandemics.

The Delivery of a Health Promotion Intervention by a Public Health Promotion Specialist Improves Patient Satisfaction in the Emergency Department

OBJECTIVES The objective was to introduce a public health promotion specialist (PHPS) into the hospital emergency department (ED) to provide a brief health promotion intervention to patients and to determine the effect of the initiative on patient satisfaction. METHODS Patients in the intervention group were offered and received a 5- to 10-minute presentation about exercise, heart health, healthy eating on a budget, or weight control by a trained PHPS. Patients in the control group received usual ED care. Both groups completed the patient satisfaction instrument. Ordinal logistic regression models were used to compare the two groups on patient satisfaction questions and to identify predictors of the likelihood of patients referring others to the ED. RESULTS Subjects in the intervention group were more likely to rate the services as great in areas of patient satisfaction such as provider listening, staff being friendly and helpful, comfort and safety, and privacy. Those in the intervention group were three times more likely than those in the control group to state that they would refer others to the ED. CONCLUSIONS Health promotion and disease prevention interventions carried out by PHPS in the ED can improve patient satisfaction.

Single-Breath-Count Test: An Important Adjunct in the Triaging of Patients in a Mass-Casualty Incident Due to Botulism

Clostridium botulinum toxins, the most poisonous substance known to humankind, are considered to be a [US] Centers for Disease Control and Prevention Category A bioterrorist agent. Despite this concern, little has been published with regard to the tactical aspects of triaging a mass-casualty event involving botulism victims arriving at an emergency department. Because neuromuscular-ventilatory failure is a principal reason for botulisms early morbidity and mortality, using a quick and sensitive test to evaluate this possibility is imperative. The purpose of this article is to propose the adoption of the Single-Breath-Count Test (SBCT). The ease and validity of the use of the SBCT in evaluating complications associated with various neuromuscular disorders make it an attractive adjunct for triage during a mass-casualty incident due to botulism. While education, immune globulin, antitoxin, and invasive airway techniques are well-recognized steps in treating botulism, incorporating a time-honored technique such as the SBCT, will be an important addition to the triage process.

Interdisciplinary Simulation Education in Disaster Medicine

To The Editor, We read with great interest Kaplan and colleagues’ article on Use of an Emergency Preparedness Disaster Simulation with Undergraduate Nursing Students (Kaplan, Connor, Ferranti, Holmes, & Spencer, 2011). We congratulate the authors on the professionalism of their writing as well as their apparent success for taking disaster management/medicine education to a level that is rarely considered let alone achieved. Based on their article, we wish to submit our endeavors at our university’s simulation center, which we feel is a novel addition to the use of simulation in disaster medicine education. The university incorporates the Colleges of Nursing, Medicine (including a PA program), and Pharmacy. As part of these students’ education during their emergency medicine rotation at the university medical center, sessions would be conducted at the simulation center to hone their history taking, examination, and psychomotor skills. Tandem with that, the faculty would create scenarios that would emphasize the interdisciplinary interactions and communications that are embedded within all of medicine, but with particular emphasis on emergencies. This interdisciplinary activity proctored by faculty from each of the colleges and the paramedic technicians has enriched the educational experience for both students and Emergency Medicine (EM) residents. This format, integrating simulators, multidisciplinary learners (at early in their education), and an interdisciplinary faculty, has not been reported in the literature as far as we can determine. It does, to a certain extent, address the challenge of using simulation to educate health care students in delivering emergency care (Small et al., 1999). Now, with that as a foundation, we are utilizing this interdisciplinary approach with regard to disasters and disaster medicine. We have created scenarios, such as a multiple victim bomb explosion, an organophosphate/nerve gas exposure and a crush syndrome victim, and have brought EM resident-and-student nurse teams together to manage the crisis at hand. The scenarios’ emphasis is on team safety, patient care, and interdisciplinary communication. We are now taking this to the level of practicing physicians and nurses, who are interested in deepening their knowledge of disaster medicine. Our nonscientific polling of the learners has demonstrated to the faculty that the experience was much appreciated and that there is a desire to have more of these learning activities. While we agree with the Kaplan et al. concept, we also must acknowledge that each of these simulations is labor-intensive and that to get the fullest flavor of the experience, learners would be best served when they are receiving education from all the disciplines simultaneously. Indeed, we believe it is a rare situation to have a patient case dissected in real time by an emergency physician, a nurse, and a paramedic, each one offering his/her unique perspective and experience. Nevertheless, we applaud the important advance Kaplan et al. have achieved in disaster education and

Salivary protein changes in response to acute stress in medical residents performing advanced clinical simulations: a pilot proteomics study

Abstract Context: Quantitative changes of salivary proteins due to acute stress were detected. Objective: To explore protein markers of stress in saliva of eight medical residents who performed emergency medicine simulations. Materials and methods: Saliva was collected before the simulations, after the simulations, and following morning upon waking. Proteins were separated by sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE), identified by mass spectrometry (MS), and relatively quantified by densitometry. Results: Salivary alpha-amylase and S–type cystatins significantly increased, while the ∼26 kDa and low-molecular weight (MW) (<10 kDa) SDS-PAGE bands exhibited changes after stress. Discussion and conclusion: Alpha-amylase and cystatins are potential salivary markers of acute stress, but further validation should be performed using larger sample populations.

Active Shooter Exercise Training for Nurses in Emergency Medicine

The recent horrific events surrounding San Bernardino and Paris underscore the conceit that active shooter incidents must be included into the new reality of day-to-day existence in virtually every part of the world. In the United States, the incidence of active shooter events has more than doubled, comparing the period 2000-2006 with 2007-2013 [1-5]. The literature indicates that many countries share this concern [6-20]. With a recent report indicating global terror groups are planning more attacks upon the western industrialized countries, there should be no expectation that this increase in active shooter events is an aberration. Among the soft targets that remain a cause of concern for federal and state agencies is the healthcare system [21]. In fact, active shooter incidents have increased in hospitals from nine per year in 2000-2005 to 16.7 per year in 2006-2011 [1]. Granted, most of the incidents target specific individuals, but it does underscore the vulnerability of healthcare facilities, their staff and clients.

AED Education: A Dilemma for Public Health and a Challenge for Critical Care Specialists

Objective: The proper management of out-of-hospital cardiac arrests (OHCA) includes proper CPR and early defibrillation with a public access AED (automated external defibrillator). However, the general public is largely ignorant of their role in OHCA. This behavior has resulted in only a minority of OHCA patients being successfully resuscitated and leaving the hospital neurologically intact. One particularly revealing study demonstrated that American college students not only were hesitant to employ an AED, they did not even know its location within their own campus. The purpose of this study was to ascertain whether this was true even among healthcare students in a healthcare academic environment. Method: A local university population of students and faculty in nursing, medicine, public health, physician assistant, pharmacy, and biological sciences completed a survey which included not only the AED training and knowledge aspects, but also whether or not they knew the location of the nearest AED. A total of 553 participants (532 students and 21 faculty) agreed to participate and completed the anonymous IRB-approved survey. Results: Of those that completed the survey, 89.5% received AED training, 55.3% within the prior twelve months. However, only 110 of those who received AED/ CPR education (19.9%) knew the location of the AED in the building where they received the majority of their education. This lack of knowledge crossed all the disciplines. It ranged from as low as 17.5% for medical students up to 22.5% for PA students. These data reached statistical significance. Conclusion: Health professionals and the general public need to know not only how to use an AED but where the nearest one is located to actually save lives in the pre-hospital environment. Critical care specialists and intensivists are advised to work with the local public health infrastructure to ensure that AED/CPR training includes empowering the trainees to actively seek out AED locations at the more popular public venues in a community. Knowledge of CPR and defibrillator training alone are useless if the individual cannot find the device in a timely manner.

Botulism Questionnaire: a tactical tool for community use in a mass casualty incident.

A botulism-induced mass casualty incident has the potential to severely compromise a communitys health-care infrastructure, based upon its lethality, rare occurrence, and duration of symptoms, which require extensive support and care. Although early recognition and treatment with antitoxin or botulism immunoglobulin are essential to the effective management of this type of an incident, the two major challenges in recognition and treatment are the hundreds, if not thousands, of casualties or potential casualties requiring rapid screening and the fact that most clinicians remain ignorant of the management of botulism. The purpose of this article is to present the Botulism Questionnaire, which will assist with the screening of casualties, provide educational and diagnostic cues for clinicians and the lay public, and create a layer of protection for the health-care infrastructure. The applications of this questionnaire in various formats, the numerous points of distribution, and the variety of platforms from which it can be launched will be explored.

Chikungunya virus: An emerging condition in the industrialized world

Once found only in developing tropical nations, CHIKV has spread to the world at large. With proper management and close communication with authorities, it can be contained.