Raquel M. Schears

Prehospital resuscitation practices: a survey of prehospital providers.

Numerous factors affect decision making in the prehospital provision of resuscitative care. This study was undertaken to determine current practices involved in the initiation, continuation and termination of resuscitative efforts, and the impact of advance directives, in the prehospital resuscitation setting. This cross-sectional mailed questionnaire surveyed 3807 members of the National Association of Emergency Medical Technicians. The study instrument included questions regarding the termination and withholding of resuscitative efforts in the prehospital setting, as well as survival rates, local protocols and compliance with advance directives. Of 1546 respondents (41% response rate), with a mean 9.0 years of experience, most (89%) indicated that they would withhold resuscitative efforts in the presence of an official state-approved advance directive. However, very few providers would withhold resuscitative efforts if only an unofficial document (4%) or verbal report of an advance directive (10%) were available. Providers with more than 10 years experience were more likely to withhold resuscitation attempts in the presence of only a verbal report of an advance directive (p = 0.02, Chi-square), and were more likely to withhold resuscitation attempts in situations they considered futile (p = 0.001, Chi-square). Most (77%) respondents have local EMS guidelines for termination of resuscitation in the prehospital setting, but 23% of those consider existing guidelines to be inadequate. The majority of prehospital providers stated that they honor official state-approved advance directives, but do not follow directives from unofficial documents or verbal reports of advance directives. More experienced providers stated that they withhold resuscitative efforts more often in futile situations, or in the presence of unofficial advance directives. Advance directives should be utilized more uniformly among patients who wish to forgo resuscitative efforts in the event of cardiac arrest. Because many local protocols are judged to be inadequate, we support the institution of improved clinical guidelines regarding the prehospital termination of resuscitative efforts.

Low-dose nesiritide in human anterior myocardial infarction suppresses aldosterone and preserves ventricular function and structure: a proof of concept study

Background: B-type natriuretic peptide (BNP, nesiritide) has anti-fibrotic, anti-hypertrophic, anti-inflammatory, vasodilating, lusitropic and aldosterone-inhibiting properties but conventional doses of BNP cause hypotension, limiting its use in heart failure. Objective: To determine whether infusion of low-dose BNP within 24 h of successful reperfusion for anterior acute myocardial infarction (AMI) would prevent adverse left ventricular (LV) remodelling and suppress aldosterone. Methods: A translational proof-of-concept study was carried out to determine tolerability and biological activity of intravenous BNP at 0.003 and 0.006 μg/kg/min, without bolus started within 24 h of successful reperfusion for anterior AMI. 24 patients with first anterior wall ST elevation AMI and successful revascularisation were randomly assigned to receive 0.003 (n = 12) or 0.006 (n = 12) μg/kg/min of IV BNP for 72 h in addition to standard care during hospitalisation for anterior AMI. Results: Baseline characteristics, drugs and peak cardiac biomarkers for myocardial damage were similar between both groups. Infusion of BNP at 0.006 μg/kg/min resulted in greater biological activity than infusion at 0.003 μg/kg/min as measured by higher mean (SEM) plasma cGMP levels (8.6 (1) vs 5.5 (1) pmol/ml, p<0.05) and suppression of plasma aldosterone (8.0 (2) to 4.6 (1) ng/dl, p<0.05), which was not seen in the 0.003 μg/kg/min group. LV ejection fraction (LVEF) improved significantly from baseline to 1 month (40 (4)% to 54 (5)%, p<0.05) in the 0.006 group but not in the 0.003 group. Infusion of BNP at 0.006 μg/kg/min was associated with a decrease of LV end-systolic volume index (61 (9) to 43 (8) ml/m2, p<0.05) at 1 month, which was not seen in the 0.003 group. No drug-related serious adverse events occurred in either group. Conclusions: 72 h infusion of low BNP at the time of anterior AMI is well tolerated and biologically active. Patients treated with low-dose BNP had improved LVEF and smaller LV end-systolic volume at 1 month.

Extracorporeal Life Support: Utilization, Cost, Controversy, and Ethics of Trying to Save Lives

Since the first successful application of extracorporeal membrane oxygenation (ECMO) in 1972, ECMO’s role in the management of respiratory and circulatory collapse continues to be refined and debated. Randomized clinical trials aimed at establishing efficacy and patient selection criteria have been fraught with ethical challenges. Growing concerns over rising health care costs require that careful evaluations of cost, utilization, and ethical issues surrounding heroic life-saving interventions such as ECMO are undertaken. Continued analyses of ECMO’s place in the medical management of respiratory and circulatory failure will help ensure that ECMO is used for not only prolonging life but also for providing a chance for “quality of life” following recovery from near-fatal illnesses.

Emergency physicians' role in end-of-life care.

End-of-life care, as it merges with emergency medicine, raises as many ethical issues as it does clinical judgments. The role of the ED physician as it pertains to end-of-life treatment options encompasses a vast array of variables that should nevertheless center on patient welfare. The choice between ethical responses and trained reactions is an ever-present reality in emergency medicine, and the instinct to perform aggressive procedures may overshadow the professional purpose to inform, comfort, counsel, and treat. The exercise of clinical judgment should be balanced by previously reasoned ethical conduct codes when it comes to end-of-life emergent care.

Race and Ethnicity Influences Collection of Granulocyte Colony–Stimulating Factor–Mobilized Peripheral Blood Progenitor Cells from Unrelated Donors, a Center for International Blood and Marrow Transplant Research Analysis

Little information exists on the effect of race and ethnicity on collection of peripheral blood stem cells (PBSC) for allogeneic transplantation. We studied 10,776 donors from the National Marrow Donor Program who underwent PBSC collection from 2006 to 2012. Self-reported donor race/ethnic information included Caucasian, Hispanic, Black/African American (AA), Asian/Pacific Islander (API), and Native American (NA). All donors were mobilized with subcutaneous filgrastim at an approximate dose of 10 μg/kg/day for 5 days. Overall, AA donors had the highest median yields of mononuclear cells per liter and CD34(+) cells per liter of blood processed (3.1 × 10(9) and 44 × 10(6), respectively), whereas Caucasians had the lowest median yields at 2.8 × 10(9) and 33.7 × 10(6), respectively. Multivariate analysis of CD34(+) per liter mobilization yields using Caucasians as the comparator and controlling for age, gender, body mass index, and year of apheresis revealed increased yields in overweight and obese AA and API donors. In Hispanic donors, only male obese donors had higher CD34(+) per liter mobilization yields compared with Caucasian donors. No differences in CD34(+) per liter yields were seen between Caucasian and NA donors. Characterization of these differences may allow optimization of mobilization regimens to allow enhancement of mobilization yields without compromising donor safety.

Universal screening for interpersonal violence: inability to prove universal screening improves provision of services.

Objective: Universal screening for interpersonal violence is recommended despite a lack of confirmed efficacy. We hypothesized that the detection of violence via universal screening would result in high intervention rates for victims. Methods: Women aged 18–65 years presenting to an emergency department were screened using a standard protocol. Medical and social work records were reviewed for positively screened patients. Outcomes included whether victims received counseling/referral services. Secondary outcomes were the documentation of services offered and safety assessment performed. Results: A total of 1732 patients were evaluated; 615 (35.5%) responded positively to at least one query. Patients had a mean age of 34.7±12 years, 79% were non-white, 19% were married, and 76% had completed high school. Twenty-five out of 606 victims (4%) had documentation of violence. Residents were more likely than faculty or nurses to document domestic violence [3.3% (95% confidence interval 1.8–4.8%) versus 2.1 (0.9–3.4) versus 0.7 (0.0–1.4)]. The documentation of police contact, suicide/homicide risk, weapon presence, safety assessment and outside resource referrals occurred in less than 2% of charts. Only two victims were referred to social work (0.3%; 0–0.9%). Conclusion: Even in an institution with a heavy emphasis and training on interpersonal violence and alternative mechanisms for universal screening we could not prove that the identification of victims resulted in counseling/referral being offered in the emergency department.

Impact of pre-transplant depression on outcomes of allogeneic and autologous hematopoietic stem cell transplantation

To evaluate the impact of depression before autologous and allogeneic hematopoietic cell transplantation (HCT) on clinical outcomes post‐transplantation.

The Ethics of Health Care Reform: Impact on Emergency Medicine

The recent enactment of the Patient Protection and Affordable Care Act (ACA) of 2010, and the ongoing debate over reform of the U.S. health care system, raise numerous important ethical issues. This article reviews basic provisions of the ACA; examines underlying moral and policy issues in the U.S. health care reform debate; and addresses health care reforms likely effects on access to care, emergency department (ED) crowding, and end-of-life care. The article concludes with several suggested actions that emergency physicians (EPs) should take to contribute to the success of health care reform in America.

Donation After Cardiac Death and the Emergency Department: Ethical Issues

Organ donation after cardiac death (DCD) is increasingly considered as an option to address the shortage of organs available for transplantation, both in the United States and worldwide. The procedures for DCD differ from procedures for donation after brain death and are likely less familiar to emergency physicians (EPs), even as this process is increasingly involving emergency departments (EDs). This article explores the ED operational and ethical issues surrounding this procedure.

Analysis of the Effect of Race, Socioeconomic Status, and Center Size on Unrelated National Marrow Donor Program Donor Outcomes: Donor Toxicities Are More Common at Low-Volume Bone Marrow Collection Centers

Previous studies have shown that risks of collection-related pain and symptoms are associated with sex, body mass index, and age in unrelated donors undergoing collection at National Marrow Donor Program centers. We hypothesized that other important factors (race, socioeconomic status [SES], and number of procedures at the collection center) might affect symptoms in donors. We assessed outcomes in 2726 bone marrow (BM) and 6768 peripheral blood stem cell (PBSC) donors collected between 2004 and 2009. Pain/symptoms are reported as maximum levels over mobilization and collection (PBSC) or within 2 days of collection (BM) and at 1 week after collection. For PBSC donors, race and center volumes were not associated with differences in pain/symptoms at any time. PBSC donors with high SES levels reported higher maximum symptom levels 1 week after donation (P = .017). For BM donors, black males reported significantly higher levels of pain (OR, 1.90; CI, 1.14 to 3.19; P = .015). No differences were noted by SES group. BM donors from low-volume centers reported more toxicity (OR, 2.09; CI, 1.26 to 3.46; P = .006). In conclusion, race and SES have a minimal effect on donation-associated symptoms. However, donors from centers performing ≤ 1 BM collection every 2 months have more symptoms after BM donation. Approaches should be developed by registries and low-volume centers to address this issue.