Robert Sapien

Emergency preparation in schools : A snapshot of a rural state

Objective To study emergency preparedness in public schools in a rural state. Method Questionnaires were mailed to school nurses registered with the State Department of Education. Data collected included school nurse and staff training, school location, emergency equipment available, and Emergency Medical Service (EMS) access. Results Seventy-two percent of the surveys were returned after one or two mailings. They report little emergency training for both school nurses and school staff. Emergency equipment available varies widely: oxygen 20%, artificial airways 30%, cervical collars 22%, splints 69%. Equipment was more likely to be available in communities with populations of less than 200,000. Sixty-seven percent of schools activate EMS for a student and 37% for an adult annually. Eighty-four percent of schools have a less than 10-minute EMS response time. Conclusions EMS activation to schools is a common occurrence. Schools are ill prepared to care for this acuity of student or staff as assessed by equipment and emergency training. Schools in smaller communities, however, are better prepared for emergencies.

Prolonged β-Agonist Infusion Does Not Induce Desensitization or Down-Regulation of β-Adrenergic Receptors in Newborn Sheep

ABSTRACT: In adult animals, prolonged β-agonist expo-sore leads to down-regulation of β-adrenergic receptors and deseasitization. Prior evidence from our lab suggests that this may not occur in developing animals. To study this, we measured the response to graded epinephrine infusion [2.7, 5.5,13.6, 273 μmol(kg · min), (0.5, 1.0, 2.5, 5.0 μg/ (kg · mm)], myocardial β-agonist receptor density, and components of the receptor-cyclase system in newborn lambs before (n = 6) and after (n = 5) 3 d of continuous isopro-terenol administration (2 μg/kg/min). β-Adrenergic receptors were measured by radioligand binding. Epinephrine dose-response curves were analyzed for the threshold and slope for changes in mean blood pressure, systolic blood pressure, and heart rate versus plasma epinephrine levels. Despite 3 d of continuous isoproterenol infusion, we observed no desensitization of the hemodynamic response to epinephrine. There was a reduction in receptor density when expressed per membrane protein [1553 ± 19.5 (controls) versus 73.2 ± 3.8 fmol/mg protein (agonist exposed), p < 0.05], but no alteration in receptor density when expressed per g cardiac wet weight [258.8 ± 39.9 (controls) versus 406.8 ± 74.0 fmol/g wet weight (agonist exposed)). There was no alteration in agonist affinity or in adenylyl cydase activity after adjustment for membrane protein recovery. Prolonged β-agonist infusion in newborn lambs does not desensitize hemodynamk responses to infused epinephrine. We propose that receptor regulation in developing animals is fundamentally different than in adult animals.

Analysis of childhood pedestrian deaths in New Mexico, 1986-1990

STUDY OBJECTIVE To determine if the mechanism of fatal childhood pedestrian injuries correlated with location, injury pattern, and age of the pedestrian and to determine ethnic differences in fatality rates. DESIGN Retrospective review of state medical investigator reports and autopsies from 1986 to 1990. Logistic regression and chi 2 were used to test for statistically significant differences between the groups in our data set. TYPE OF PARTICIPANTS New Mexican children, 0 to 14 years old fatally injured by moving vehicles. RESULTS Sixty-four children died for an overall fatality rate of 3.8 (per 100,000). Native American children and children younger than 5 years experienced the highest fatality rates. Children younger than 5 years were more likely to be crushed under the wheels of a slow-moving vehicle in both a nontraffic and a traffic location, whereas older children were found more often to have died from injuries from a high-speed impact event in a traffic location (P < .001). Leg fractures (P = .001) and spinal fractures (P = .02) occurred more frequently in impact than crush injuries. CONCLUSION Young children are at risk for a crush injury in both the traffic and nontraffic environment.

Prehospital Treatment of Acute Asthma in a Rural State

BACKGROUND Acute asthma exacerbations can be life threatening and are recognizable to emergency medical service (EMS) personnel; however, the therapies and medications which these emergency service personnel can use to treat exacerbations are limited. Several studies have demonstrated the effective use of beta2-agonist therapy in the treatment of patients complaining of wheezing or dyspnea, yet few EMS personnel can administer them. OBJECTIVE The purpose of this study was to determine what therapeutic interventions emergency personnel around the state of New Mexico could use when responding to a call for a severe asthma exacerbation. METHODS Questionnaires were distributed over a period of three years, 1992-1994, to all Emergency Service Agencies in New Mexico. RESULTS Eighty percent of the emergency medical personnel administer oxygen to patients experiencing acute asthma exacerbations. Seventeen percent of EMS personnel administer epinephrine, 4% administer steroids, and only 23% administer beta2 agonists. Only in more populated areas were EMS personnel allowed to administer beta2 agonists, and those personnel had to have at least intermediate-level training. Most emergency response teams in the state consisted of EMT Basics and provided only basic life support services. In rural New Mexico, transport to a hospital can often take over one hour, which left EMS crews feeling helpless. CONCLUSIONS We conclude that due to the rural nature of New Mexico, EMS personnel should be trained in the use of beta2 agonists and allowed to administer them to patients with acute asthma exacerbations. In addition, standard protocols for the pre-hospital management of acute asthma exacerbations should be instituted.

School Preparation for the Asthmatic Student

Questionnaires given to school nurses were used to collect data regarding emergency asthma equipment and plans. Sixty three percent reported <10 asthmatic visits per month, 25% reported 10-50, and 12% reported >50. Only 20% of school nurses reported that 75%-100% of asthmatic students had an emergency plan, and 24% did not know if asthmatic students had a plan. Only half of the nurses had input into the plan. Equipment varied: 16% had oxygen, 45% had peak flow meters, 0% had MDIs, and 20% had nebulizers available. Many asthmatic students lack emergency plans, and many school nurses are not involved in the plans.

Equipping and Preparing the Office for Emergencies

It is the practitioners responsibility to have a prepared office to aid the emergently ill child. Basic equipment and staff training are essential. The pediatrician and family practitioner are on the front lines of pediatric emergency care and, with minimal equipment and training, can serve a vital role in the initial stabilization of the critically ill child.

Rural‐Urban Disparities in School Nursing: Implications for Continuing Education and Rural School Health

PURPOSE Little is known about the professional and educational challenges experienced by rural school nurses. We conducted this study to describe disparities between the urban and rural professional school nurse workforce in New Mexico and to identify how best to meet the continuing education needs of New Mexicos rural school nurse workforce. METHODS We analyzed state data from a 2009 New Mexico Department of Health school nurse workforce survey (71.7% response rate). We included all survey respondents who indicated working as a school nurse in a public school setting in any grade K-12 and who identified their county of employment (N = 311). FINDINGS Rural school nurses were twice as likely as metropolitan nurses to provide clinical services to multiple school campuses (67.3% compared to 30.1%, P < .0001). They were less likely to hold a nursing degree at the baccalaureate level or higher (62.7% compared to 82.3%, P = .0002). Rural school nurses were less likely than metropolitan nurses to have received recent continuing education on anaphylaxis (P < .0001), asthma (P = .027), body mass index (BMI)/healthy weight (P = .0002), diabetes (P < .0001), lesbian, gay, bisexual and transgender (LGBT) health (P = .0004), and suicide risk identification and prevention (P = .015). Online courses and telehealth were identified by rural school nurses as among the preferred means for receiving continuing education. CONCLUSIONS Our findings support the provision of online courses and telehealth content to address urban-rural disparities in school nursing education and support rural school health.

Urban and Rural Patterns in Emergent Pediatric Transfer: A Call for Regionalization

CONTEXT National groups call for the regionalization of health care, to direct patients with high-risk conditions to designated hospitals with greater capabilities. Currently there is limited information detailing the characteristics and specific needs of acutely ill and injured children who require transfer to another institution, especially in underserved rural communities. PURPOSE To determine the epidemiology of pediatric transfers from urban and rural emergency departments (EDs). METHODS We analyzed data in the National Hospital Ambulatory Medical Care Survey from 1995 to 2010. Eligible children were <18 years of age seen in a United States ED, and transferred to another hospital after initial evaluation. FINDINGS Of all 283,232,058 pediatric ED visits, less than 0.5% resulted in a transfer, yielding a population-based estimate of 900,100 transfers nationally during this period. Urban and rural EDs showed similar transfer rates. Children transferred from rural EDs were older and more likely to arrive by emergency medical services than children transferred from urban EDs (12.1 vs 8.2 years of age, P < .01). Children from rural EDs were more than twice as likely to be transferred for a psychiatric indication (43.5% vs 19.5%, P < .01). CONCLUSIONS Emergency pediatric transfers are uncommon in the United States; transfer rates are similar in urban and rural settings. Rural children have additional obstacles to care, especially in access to emergency mental health services. Programs to study and implement regionalization of care should consider diverse patient populations and target improvement in coordination of care, transfer times, and outcomes.

Complementary and alternative medicine (CAM) use in women with pelvic floor disorders: a cohort study

Introduction and hypothesisThe objective of this study was to compare complementary and alternative medicine (CAM) use in women with and without pelvic floor disorders (PFD).MethodsWe conducted a survey of women presenting to a specialty urogynecology (Urogyn) and gynecology (Gyn) clinic that examined demographic data, CAM use, and the presence of PFD (validated questionnaires). T tests, Fisher’s exact tests, and logistic regression were used for analysis. To detect a 20% difference between groups, 234 Urogyn and 103 Gyn patients were needed.ResultsParticipants included 234 Urogyn and 103 Gyn patients. Urogyn patients reported more CAM use than Gyn patients, even when controlled for differences between groups (51% vs. 32%, adjusted p = 0.006). Previous treatment (61% vs. 39%, adjusted p < 0.001) and increased number of PFD was associated with increased CAM use (adjusted p = 0.02).ConclusionsWomen with PFD use CAM more frequently than women without PFD.

The choking child: What happens before the ambulance arrives?

OBJECTIVE To compare pre-EMS intervention (bystander intervention) with EMS intervention (performed by fire department/EMS personnel) in the management of airway foreign bodies in children. METHODS First-responding paramedic run reports for 1994 in the metropolitan area (city and county fire departments) pertaining to acute foreign body airway obstruction in children (aged 0-15 years) were reviewed. Data regarding age, gender, type of foreign body, method by which the airway was cleared, and mode of transportation were extracted. RESULTS There were 103 runs with an age distribution as follows: 0-11 months 39.8%; 1-5 years 50.5%; and >6 years 9.7%. Fifty-eight (56.3%) involved males and 45 (43.7%) involved females. Eighty-five percent of the airways were cleared before EMS arrival. Thirty-eight percent were self-cleared by the child. The chance of airway clearance before EMS arrival increased with increasing age: 78% of the children aged 0-11 months, 88.5% of the children 1-5 years of age, and 100% of the children aged 6 years or older had their airways cleared before EMS arrival. Forty-four percent of the children were not transported, and 27% were transported by private vehicle. Coins and food were the two most common foreign bodies. CONCLUSION The majority of airway foreign bodies were cleared before EMS arrival, especially in older children. This supports CPR training of new parents and the general population and has training implications for the EMS provider in managing the pediatric airway.