Roland B. McGrath

In-house cardiopulmonary resuscitation — after a quarter of a century

Several variables could have influenced the results of resuscitation after two and one-half decades--selection of resuscitation candidates, resuscitation mechanics, pharmacologic interventions, and post-resuscitation management. However, the outcome of CPR remains consistently poor. It appears that only dramatic changes in candidacy or technique will change the likelihood of survival following in-house CPR.

Invasive bedside hemodynamic monitoring

NVASIVE BEDSIDE hemodynamic monitoring has been a clinical tool for 15 years. The validity of specific measurements has been debated, but there are few adequate alternatives to rapid onsite assessment of physiologic parameters. Cognizance of usual and less traditional morbidities is important. Justification for pulmonary artery catheter use is provided only by evidences of changes in decisions with respect to the course of therapy. Invasive bedside hemodynamic monitoring might be used to more accurately subset patients in critical care units so that better projections about outcome and therapies can be made. In addition, hemodynamic data could be used for surveillance and to monitor intervention titrations. Appreciation for these details of catheter use should precede participation in invasive hemodynamic monitoring, while future controlled studies in selected patient subsets will make cost benefit analyses more meaningful. Intravascular pressure monitoring has its origin in the early 18th Century when Rev Stephen Hale placed a brass pipe into the crural artery of a horse.’ Central venous pressure (CVP) monitoring

Secondary myocardial injuries.

This study identifies a subgroup of critically ill patients most likely to develop at least creatine kinasemyocardial isoenzyme (CK-MB) evidence of acute myocardial injury. This group is composed of patients with shock syndromes associated with some combination of anemia, hypoxemia, hypercarbia, acidemia, lactic acidosis, and hypotension. The mechanism of this secondary myocardial injury in shock is not clear but may be multifactorial. Certainly subgroups of patients admitted with critical illnesses may have CK-MB abnormalities usually associated with acute myocardial injury.

The Future of Emergency Medicine

BACKGROUND The specialty of emergency medicine (EM) continues to experience a significant workforce shortage in the face of increasing demand for emergency care. SUMMARY In July 2009, representatives of the leading EM organizations met in Dallas for the Future of Emergency Medicine Summit. Attendees at the Future of Emergency Medicine Summit agreed on the following: 1) Emergency medical care is an essential community service that should be available to all; 2) An insufficient emergency physician workforce also represents a potential threat to patient safety; 3) Accreditation Council for Graduate Medical Education/American Osteopathic Association (AOA)-accredited EM residency training and American Board of Medical Specialties/AOA EM board certification is the recognized standard for physician providers currently entering a career in emergency care; 4) Physician supply shortages in all fields contribute to-and will continue to contribute to-a situation in which providers with other levels of training may be a necessary part of the workforce for the foreseeable future; 5) A maldistribution of EM residency-trained physicians persists, with few pursuing practice in small hospital or rural settings; 6) Assuring that the public receives high quality emergency care while continuing to produce highly skilled EM specialists through EM training programs is the challenge for EMs future; 7) It is important that all providers of emergency care receive continuing postgraduate education.

Inadvertent gastric balloon inflation within the chest in the management of esophageal varices.

Balloon tamponade of esophageal variceal hemorrhage is palliative therapy which is associated with a certain incidence of morbidity, perhaps mortality. Three cases of intrathoracic inflation of the gastric balloon of such tubes are described. The precise mechanism of thoracic placement remains uncertain. Fluoroscopy or chest x-ray should be used to confirm appropriate tube tip placement.

The future of emergency medicine.

Physician shortages are being projected for most medical specialties. The specialty of emergency medicine continues to experience a significant workforce shortage in the face of increasing demand for emergency care. The limited supply of emergency physicians, emergency nurses, and other resources is creating an urgent, untenable patient care problem. In July 2009, representatives of the leading emergency medicine organizations met in Dallas, TX, for the Future of Emergency Medicine Summit. This consensus document, agreed to and cowritten by all participating organizations, describes the substantive issues discussed and provides a foundation for the future of the specialty.