Acute evacuation of 54 intracerebral hematomas (aICH) during the microsurgical clipping of a ruptured middle cerebral artery bifurcation aneurysm-illustration of the individual clinical courses and outcomes with a serial brain CT/MRI panel until 12 months.

PURPOSE: In aneurysmal intracerebral hemorrhage (aICH), our review showed the lack of the patient's individual (i) timeline panels and (ii) serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. METHODS: Our retrospective cohort consists of 54 consecutive aICH patients from a defined population who acutely underwent the clipping of a middle cerebral artery bifurcation saccular aneurysm (Mbif sIA) with the aICH evacuation at Kuopio University Hospital (KUH) from 2010 to 2019. We constructed the patient's individual timeline panels since the emergency call and serial brain CT/MRI slice panels through the aICH evacuation and neurointensive care until the final brain tissue outcome. The patients were indicated by numbers (1.-54.) in the pseudonymized panels, tables, results, and discussion. RESULTS: The aICH volumes on KUH admission (median 46 cm3) plotted against the time from the emergency call to the evacuation (median 8 hours) associated significantly with the rebleeds (n=25) and the deaths (n=12). The serial CT/MRI slice panels illustrated the aICHs, intraventricular hemorrhages (aIVHs), residuals after the aICH evacuations, perihematomal edema (PHE), delayed cerebral injury (DCI), and in the 42 survivors, the clinical outcome (mRS) and the brain tissue outcome. CONCLUSIONS: Regarding aICH evacuations, serial brain CT/MRI panels present more information than words, figures, and graphs. Re-bleeds associated with larger aICH volumes and worse outcomes. Swift logistics until the sIA occlusion with aICH evacuation is required, also in duty hours and weekends. Intraoperative CT is needed to illustrate the degree of aICH evacuation. PHE may evoke uncontrollable intracranial pressure (ICP) in spite of the acute aICH volume reduction.

Should individual timeline and serial CT/MRI panels of all patients be presented in acute brain insult cohorts? A pilot study of 45 patients with decompressive craniectomy after aneurysmal subarachnoid hemorrhage.

PURPOSE: Our review of acute brain insult articles indicated that the patients' individual (i) timeline panels with the defined time points since the emergency call and (ii) serial brain CT/MRI slice panels through the neurointensive care until death or final brain tissue outcome at 12 months or later are not presented. METHODS: We retrospectively constructed such panels for the 45 aneurysmal subarachnoid hemorrhage (aSAH) patients with a secondary decompressive craniectomy (DC) after the acute admission to neurointensive care at Kuopio University Hospital (KUH) from a defined population from 2005 to 2018. The patients were indicated by numbers (1.-45.) in the pseudonymized panels, tables, results, and discussion. The timelines contained up to ten defined time points on a logarithmic time axis until death ([Formula: see text]; 56%) or 3 years ([Formula: see text]; 44%). The brain CT/MRI panels contained a representative slice from the following time points: SAH diagnosis, after aneurysm closure, after DC, at about 12 months (20 survivors). RESULTS: The timelines indicated re-bleeds and allowed to compare the times elapsed between any two time points, in terms of workflow swiftness. The serial CT/MRI slices illustrated the presence and course of intracerebral hemorrhage (ICH), perihematomal edema, intraventricular hemorrhage (IVH), hydrocephalus, delayed brain injury, and, in the 20 (44%) survivors, the brain tissue outcome. CONCLUSIONS: The pseudonymized timeline panels and serial brain imaging panels, indicating the patients by numbers, allowed the presentation and comparison of individual clinical courses. An obvious application would be the quality control in acute or elective medicine for timely and equal access to clinical care.

Ergonomic exposures and control measures associated with mass fatality decedent handling in morgues and body collection points in a New York healthcare system during COVID-19: A case series.

INTRODUCTION: In April 2020, novel coronavirus SARS-CoV-2 (COVID-19) produced an ongoing mass fatality event in New York. This overwhelmed hospital morgues necessitating emergent expansion of capacity in the form of refrigerated trucks, trailers, and shipping containers referred to as body collection points (BCPs). The risks for musculoskeletal injury during routine and mass fatality mortuary operations and experiences of decedent handlers throughout the "first wave" of COVID-19 are presented along with mitigation strategies. METHODS: Awareness of the high rates of musculoskeletal injury among health care workers due to ergonomic exposures from patient handling, including heavy and repetitive manual lifting, prompted safety walkthroughs of mortuary operations at multiple hospitals within a health system in New York State by workforce safety specialists. Site visits sought to identify ergonomic exposures and ameliorate risk for injury associated with decedent handling by implementing engineering, work practice, and administrative controls. RESULTS: Musculoskeletal exposures included manual lifting of decedents to high and low surfaces, non-neutral postures, maneuvering of heavy equipment, and push/pull forces associated with the transport of decedents. DISCUSSION: Risk mitigation strategies through participatory ergonomics, education on body mechanics, development of novel handling techniques implementing friction-reducing aides, procurement of specialized equipment, optimizing BCP design, and facilitation of communication between hospital and system-wide departments are presented along with lessons learned. After-action review of health system workers' compensation data found over four thousand lost workdays due to decedent handling related incidents, which illuminates the magnitude of musculoskeletal injury risk to decedent handlers.

Contact networks in the emergency department: Effects of time, environment, patient characteristics, and staff role.

Emergency departments play a critical role in the public health system, particularly in times of pandemic. Infectious patients presenting to emergency departments bring a risk of cross-infection to other patients and staff through close proximity interactions or contacts. To understand factors associated with cross-infection risk, we measured close proximity interactions of emergency department staff and patients by radiofrequency identification in a working emergency department. The number of contacts (degree) is not related to patient demographic characteristics. However, the amount of time in close proximity (weighted degree) of patients with ED personnel did differ, with black patients having approximately 15 min more contact with staff than non-white patients. Patients arriving by EMS had fewer contacts with other patients than patients arriving by other means. There are differences in the number of contacts based on staff role and arrival mode. When crowding is low, providers have the most contact time with patients, while administrative staff have the least. However, when crowding is high, this differential is reversed. The effect of arrival mode is modified by the extent of crowding. When crowding is low, patients arriving by EMS had longer contact with administrative staff, compared to patients arriving by other means. However, when crowding is high, patients arriving by EMS had less contact with administrative staff compared to patients arriving by other means. Our findings should help designers of emergency care focus on higher risk situations for transmission of dangerous pathogens in an emergency department. For instance, the effects of arrival and crowding should be considered as targets for engineering or architectural interventions that could artificially increase social distances.

Maxillofacial Injury-Not Always a Difficult Airway.

The optimal method for securing the airway in injured patients is controversial. Maxillofacial injury has been shown to be a marker for difficult airway management; however, a delay in intubation may result in deterioration of intubating conditions due to further airway bleeding and swelling. Decisions on the timing and method of airway management depend on multiple factors, including patient characteristics, the skill set of the clinicians, and logistical considerations. This report describes the case of a multi-agency response to a motor-vehicle collision in a rural area in Ireland. One young male patient had sustained significant maxillofacial injuries, multiple limb injuries, and had a decreased level of consciousness. Further airway compromise occurred following extrication. Difficult intubation was predicted; however, abnormal jaw mobility from bilateral mandibular fractures enabled easy laryngoscopy and intubation. Although preparation must be made for difficult airway management in the setting of maxillofacial injury, appropriately trained and experienced practitioners should not be deterred from performing early intubation when indicated.

Emergency medical services provider comfort with prehospital analgesia administration to children.

INTRODUCTION: The undertreatment of pediatric pain is a significant concern among families, clinicians, and researchers. Although some have examined prehospital pain management, the deterrents to pediatric analgesia administration by Emergency Medical Services (EMS) have not yet been examined in Canada. Problem This study describes EMS pain-management practices and prehospital provider comfort treating pediatric pain. It highlights differences in pain management between adults and children and assesses the potential barriers, misconceptions, difficulties, and needs related to provision of pediatric analgesia. METHODS: A study-specific survey tool was created and distributed to all Primary Care Paramedics (PCPs) and Advanced Care Paramedics (ACPs) over four mandatory educational seminars in the city of Edmonton (Alberta, Canada) from September through December 2008. RESULTS: Ninety-four percent (191/202) of EMS personnel for the city of Edmonton completed the survey. The majority of respondents were male (73%, 139/191), aged 26-35 (42%, 80/191), and had been in practice less than 10 years (53%, 101/191). Seventy-four percent (141/191) of those surveyed were ACPs, while 26% (50/191) were PCPs. Although the majority of respondents reported using both pain scales and clinical judgement to assess pain for adults (85%, 162/191) and adolescents (86%, 165/191), children were six times more likely than adults (31%, 59/191 vs 5%, 10/191) to be assessed by clinical judgement alone. Emergency Medical Services personnel felt more comfortable treating adults than children (P < .001), and they were less likely to treat children even if they were experiencing identical types and intensities of pain as adults (all P values <.05) and adolescents (all P values < .05). Twenty-five percent of providers (37/147) assumed pediatric patients required less analgesia due to immature nervous systems. Three major barriers to treating children's pain included limited clinical experience (34%, 37/110), difficulty in communication (24%, 26/110) and inability to assess children's pain accurately (21%, 23/110). CONCLUSION: Emergency Medical Services personnel self-report that children's pain is less rigorously measured and treated than adults' pain. Educational initiatives aimed at increasing clinical exposure to children, as well as further education regarding simple pain measurement tools for use in the field, may help to address identified barriers and discomfort with assessing and treating children.

Intra-articular Placement of an Intraosseous Catheter.

Gaining vascular access is essential in the resuscitation of critically ill patients. Intraosseous (IO) placement is a fundamentally important alternative to intravenous (IV) access in conditions where IV access delays resuscitation or is not possible. This case report presents a previously unreported example of prehospital misplacement of an IO catheter into the intra-articular space of the knee joint. This report serves to inform civilian and military first responders, as well as emergency medicine physicians, of intra-articular IO line placement as a potential complication of IO vascular access. Infusion of large amounts of fluid into the joint space could damage the joint and be catastrophic to a patient who needs immediate IV fluids or medications. In addition, intra-articular IO placement could result in septic arthritis of the knee.

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.

Does the Implementation of an Advanced Life Support Quick Response Vehicle (QRV) in an Integrated Fire/EMS System Improve Patient Contact Response Time?

BACKGROUND: The current Fire/Emergency Medical Services (EMS) model throughout the United States involves emergency vehicles which respond from a primary location (ie, firehouse or municipal facility) to emergency calls. Quick response vehicles (QRVs) have been used in various Fire/EMS systems; however, their effectiveness has never been studied. OBJECTIVES: The goal of this study was to determine if patient response times would decrease by placing an Advanced Life Support (ALS) QRV in an integrated Fire/EMS system. METHODS: Response times from an integrated Fire/EMS system with an annual EMS call volume of 3,261 were evaluated over the three years prior to the implementation of this study. For a 2-month period, an ALS QRV staffed by a firefighter/paramedic responded to emergency calls during peak call volume hours of 8:00 am to 5:00 pm. The staging of this vehicle was based on historical call volume percentages using respective geocodes as well as system requirements during multiple emergency dispatches. RESULTS: Prior to the study, the citywide average response time for the twelve months preceding was 5.44 minutes. During the study, the citywide average response time decreased to 4.09 minutes, resulting in a 27.62% reduction in patient response time. CONCLUSION: The implementation of an ALS QRV in an integrated Fire/EMS system reduces patient response time. Having a QRV that is not staged continuously in a traditional fire station or municipal location reduces the time needed to reach patients. Also, using predictive models of historic call volume can aid Fire and EMS administrators in reduction of call response times.

A description of the prehospital phase of aortic dissection in terms of early suspicion and treatment.

PURPOSE: Aortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff. BASIC PROCEDURES: All patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age<18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables. MAIN FINDINGS: Of 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not). CONCLUSION: Among patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.

Glasgow Coma Scale Scoring is Often Inaccurate.

INTRODUCTION: The Glasgow Coma Scale (GCS) is widely applied in the emergency setting; it is used to guide trauma triage and for the application of essential interventions such as endotracheal intubation. However, inter-rater reliability of GCS scoring has been shown to be low for inexperienced users, especially for the motor component. Concerns regarding the accuracy and validity of GCS scoring between various types of emergency care providers have been expressed. Hypothesis/Problem The objective of this study was to determine the degree of accuracy of GCS scoring between various emergency care providers within a modern Emergency Medical Services (EMS) system. METHODS: This was a prospective observational study of the accuracy of GCS scoring using a convenience sample of various types of emergency medical providers using standardized video vignettes. Ten video vignettes using adults were prepared and scored by two board-certified neurologists. Inter-rater reliability was excellent (Cohen's κ = 1). Subjects viewed the video and then scored each scenario. The scoring of subjects was compared to expert scoring of the two board-certified neurologists. RESULTS: A total of 217 emergency providers watched 10 video vignettes and provided 2,084 observations of GCS scoring. Overall total GCS scoring accuracy was 33.1% (95% CI, 30.2-36.0). The highest accuracy was observed on the verbal component of the GCS (69.2%; 95% CI, 67.8-70.4). The eye-opening component was the second most accurate (61.2%; 95% CI, 59.5-62.9). The least accurate component was the motor component (59.8%; 95% CI, 58.1-61.5). A small number of subjects (9.2%) assigned GCS scores that do not exist in the GCS scoring system. CONCLUSIONS: Glasgow Coma Scale scoring should not be considered accurate. A more simplified scoring system should be developed and validated.

Preparing for Euro 2012: developing a hazard risk assessment.

INTRODUCTION: Risk assessment is a vital step in the disaster-preparedness continuum as it is the foundation of subsequent phases, including mitigation, response, and recovery. HYPOTHESIS/PROBLEM: To develop a risk assessment tool geared specifically towards the Union of European Football Associations (UEFA) Euro 2012. METHODS: In partnership with the Donetsk National Medical University, Donetsk Research and Development Institute of Traumatology and Orthopedics, Donetsk Regional Public Health Administration, and the Ministry of Emergency of Ukraine, a table-based tool was created, which, based on historical evidence, identifies relevant potential threats, evaluates their impacts and likelihoods on graded scales based on previous available data, identifies potential mitigating shortcomings, and recommends further mitigation measures. RESULTS: This risk assessment tool has been applied in the vulnerability-assessment-phase of the UEFA Euro 2012. Twenty-three sub-types of potential hazards were identified and analyzed. Ten specific hazards were recognized as likely to very likely to occur, including natural disasters, bombing and blast events, road traffic collisions, and disorderly conduct. Preventative measures, such as increased stadium security and zero tolerance for impaired driving, were recommended. Mitigating factors were suggested, including clear, incident-specific preparedness plans and enhanced inter-agency communication. CONCLUSION: This hazard risk assessment tool is a simple aid in vulnerability assessment, essential for disaster preparedness and response, and may be applied broadly to future international events.

Exertional heat illness: emerging concepts and advances in prehospital care.

Exertional heat illness is a classification of disease with clinical presentations that are not always diagnosed easily. Exertional heat stroke is a significant cause of death in competitive sports, and the increasing popularity of marathons races and ultra-endurance competitions will make treating many heat illnesses more common for Emergency Medical Services (EMS) providers. Although evidence is available primarily from case series and healthy volunteer studies, the consensus for treating exertional heat illness, coupled with altered mental status, is whole body rapid cooling. Cold or ice water immersion remains the most effective treatment to achieve this goal. External thermometry is unreliable in the context of heat stress and direct internal temperature measurement by rectal or esophageal probes must be used when diagnosing heat illness and during cooling. With rapid recognition and implementation of effective cooling, most patients suffering from exertional heat stroke will recover quickly and can be discharged home with instructions to rest and to avoid heat stress and exercise for a minimum of 48 hours; although, further research pertaining to return to activity is warranted.

Needle Thoracostomy for Patients with Prolonged Transport Times: A Case-control Study.

UNLABELLED: Introduction The use of prehospital needle thoracostomy (NT) is controversial. Some studies support its use; however, concerns exist regarding misplacement, inappropriate patient selection, and iatrogenic injury. Even less is known about its efficacy in situations where there is a delay to definitive care. Hypothesis/Aim To determine any differences in survival of patients who underwent NT in the setting of prolonged versus short transport times, and to describe differences in mechanisms and complications between the two groups. METHODS: This was a retrospective, matched, case-control study of trauma patients in a four county Emergency Medical Service (EMS) system from April 1, 2007 through April 1, 2013. This system serves an urban, rural, and wilderness catchment area. A prehospital database was queried for all patients in whom NT was performed, identifying 182 patients. When these calls were limited to those with prolonged transport times, the search was narrowed to 32 cases. A matched control group, based on age and gender, with short transport times was then created as a comparison. Data collected from prehospital and hospital records included: demographics; mechanism of injury; call status; response to NT; and final outcome. Univariate and multivariate analyses were conducted, as appropriate, to assess the primary outcome of survival and to further elucidate the descriptive data. RESULTS: There was no difference in survival between the case and control groups, either when evaluated with univariate (34% vs 25%; P=.41) or multivariate (odds ratio=0.99; 95% CI, 0.96-1.02; P=.57) analyses. Blunt trauma was the most common mechanism in both groups, but penetrating trauma was more common in the control group (30% vs 9%; P=.003). Patients in the control group were also more likely to have no vital signs on initial assessment (62% vs 31%; P=.003). More patients in the case group were described as having clinical improvement after NT (34% vs 19%; P=.03). No complications of NT were reported in either group. CONCLUSIONS: There was no significant difference in survival between patients with prolonged versus short transport times who underwent NT. Patients with prolonged transport times were more likely to have sustained blunt trauma, have vital signs on EMS arrival, and to have clinical improvement after NT.

A modified simple triage and rapid treatment algorithm from the New York City (USA) Fire Department.

INTRODUCTION: The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise. METHODS: A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n=1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n=110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system. RESULTS: Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2). CONCLUSIONS: The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.

Cardiopulmonary Resuscitation in Resource-limited Health Systems-Considerations for Training and Delivery.

In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public. Cardiopulmonary resuscitation can be considered a cost-effective intervention that requires minimal classroom training and low-cost equipment and supplies; it is commonly taught throughout much of the developed world. But, the simplicity of CPR training and its access for the general public may be misleading, as outcomes for patients in cardiopulmonary arrest are poor and survival is dependent upon a comprehensive "chain-of-survival," which is something not achieved easily in resource-limited health care settings. In addition to the significant financial and physical resources needed to both train and develop basic CPR capabilities within a community, there is a range of ethical questions that should also be considered. This report describes some of the financial and ethical challenges that might result from CPR training in low- and middle-income countries (LMICs). It is determined that for many health care systems, CPR training may have financial and ethically-deleterious, unintended consequences. Evidence shows Basic Life Support (BLS) skills training in a community is an effective intervention to improve public health. But, health care systems with limited resources should include CPR training only after considering the full implications of that intervention.

The Effect of Furosemide Dose Administered in the Out-of-hospital Setting on Renal Function Among Patients with Suspected Acute Decompensated Heart Failure.

BACKGROUND: The most effective dose of prehospital furosemide in acute decompensated heart failure (ADHF) has not yet been identified and concerns of worsening renal function have limited its use. OBJECTIVE: To assess if administering high-dose furosemide is associated with worsening renal function. METHODS: The authors conducted a 2-center chart review for patients who presented via a single Emergency Medical Service (EMS) from June 5, 2009 through May 17, 2013. Inclusion criteria were shortness of breath, primarily coded as ADHF, and the administration of furosemide prior to emergency department (ED) arrival. A total of 331 charts were identified. The primary endpoint was an increase in creatinine (Cr) of more than 0.3 mg/dL from admission to any time during hospital stay. Exploratory endpoints included survival, length-of-stay (LOS), disposition, urine output in the ED, change in BUN/Cr from admission to discharge, and change in Cr from admission to 72 hours and discharge. RESULTS: When treated as a binary variable, there was no association observed between an increase in Cr of more than 0.3 mg/dL and prehospital furosemide dose. Baseline characteristics found to be associated with dose were included in the logistic regression model. Lowering the dose of prehospital furosemide was associated with higher odds of attaining a 0.3 mg/dL increase in Cr (adjusted OR = 1.49 for a 20 mg decrease; P = .019). There was no association found with any of the exploratory endpoints. CONCLUSIONS: Patients who received higher doses of furosemide prehospitally were less likely to have an increase of greater than 0.3 mg/dL in Cr during the hospital course.

Prehospital Naloxone Administration as a Public Health Surveillance Tool: A Retrospective Validation Study.

BACKGROUND: Abuse or unintended overdose (OD) of opiates and heroin may result in prehospital and emergency department (ED) care. Prehospital naloxone use has been suggested as a surrogate marker of community opiate ODs. The study objective was to verify externally whether prehospital naloxone use is a surrogate marker of community opiate ODs by comparing Emergency Medical Services (EMS) naloxone administration records to an independent database of ED visits for opiate and heroin ODs in the same community. METHODS: A retrospective chart review of prehospital and ED data from July 2009 through June 2013 was conducted. Prehospital naloxone administration data obtained from the electronic medical records (EMRs) of a large private EMS provider serving a metropolitan area were considered a surrogate marker for suspected opiate OD. Comparison data were obtained from the regional trauma/psychiatric ED that receives the majority of the OD patients. The ED maintains a de-identified database of narcotic-related visits for surveillance of narcotic use in the metropolitan area. The ED database was queried for ODs associated with opiates or heroin. Cross-correlation analysis was used to test if prehospital naloxone administration was independent of ED visits for opiate/heroin ODs. RESULTS: Naloxone was administered during 1,812 prehospital patient encounters, and 1,294 ED visits for opiate/heroin ODs were identified. The distribution of patients in the prehospital and ED datasets did not differ by gender, but it did differ by race and age. The frequency of naloxone administration by prehospital providers varied directly with the frequency of ED visits for opiate/heroin ODs. A monthly increase of two ED visits for opiate-related ODs was associated with an increase in one prehospital naloxone administration (cross-correlation coefficient [CCF]=0.44; P=.0021). A monthly increase of 100 ED visits for heroin-related ODs was associated with an increase in 94 prehospital naloxone administrations (CCF=0.46; P=.0012). CONCLUSIONS: Frequency of naloxone administration by EMS providers in the prehospital setting varied directly with frequency of opiate/heroin OD-related ED visits. The data correlated both for short-term frequency and longer term trends of use. However, there was a marked difference in demographic data suggesting neither data source alone should be relied upon to determine which populations are at risk within the community.

Building health care system capacity to respond to disasters: successes and challenges of disaster preparedness health care coalitions.

INTRODUCTION: This research aimed to learn from the experiences of leaders of well-developed, disaster preparedness-focused health care coalitions (HCCs), both the challenges and the successes, for the purposes of identifying common areas for improvement and sharing "promising practices." HYPOTHESIS/PROBLEM: Little data have been collected regarding the successes and challenges of disaster preparedness-focused HCCs in augmenting health care system preparedness for disasters. METHODS: Semi-structured interviews were conducted with a sample of nine HCC leaders. Transcripts were analyzed qualitatively. RESULTS: The commonly noted benefits of HCCs were: community-wide and regional partnership building, providing an impartial forum for capacity building, sharing of education and training opportunities, staff- and resource-sharing, incentivizing the participation of clinical partners in preparedness activities, better communication with the public, and the ability to surge. Frequently noted challenges included: stakeholder engagement, staffing, funding, rural needs, cross-border partnerships, education and training, and grant requirements. Promising practices addressed: stakeholder engagement, communicating value and purpose, simplifying processes, formalizing connections, and incentivizing participation. CONCLUSIONS: Strengthening HCCs and their underlying systems could lead to improved national resilience to disasters. However, despite many successes, coalition leaders are faced with obstacles that may preclude optimal system functioning. Additional research could: provide further insight regarding the benefit of HCCs to local communities, uncover obstacles that prohibit local disaster-response capacity building, and identify opportunities for an improved system capacity to respond to, and recover from, disasters.

An educational measure to significantly increase critical knowledge regarding interfacility patient transfers.

BACKGROUND: Patient transfers among medical facilities are high-risk situations. Despite this, there is very little training of physicians regarding the medical and legal aspects of transport medicine. OBJECTIVES: To examine the effects of a one hour, educational intervention on Emergency Medicine (EM) residents' and Critical Care (CC) fellows' knowledge regarding the medical and legal aspects of interfacility patient transfers. METHODS: Prior to the intervention, physician knowledge regarding 12 key concepts in patient transfer was assessed using a pre-test instrument. A one hour, interactive, educational session followed immediately thereafter. Following the intervention, a post-intervention test was given between two and four weeks after delivery. Participants were also asked to describe any prior transportation-medicine-related education, their opinions as they relate to the relevance of the topic, and their comfort levels with patient transfers before and after the intervention. RESULTS: Only a minority of participants had received any formal training in patient transfers prior to the intervention, despite dealing with patient transfers on a frequent, often daily, basis. Both groups improved in several categories on the post-intervention test. They reported improved comfort levels with the medicolegal aspects of interfacility patient transfers after the intervention and felt well-prepared to manage transfers in their daily practice. CONCLUSION: A one hour, educational intervention objectively increased EM and CC physician trainees' understanding of some of the medicolegal aspects of interfacility patient transfers. The study demonstrated a lack of previous training on this important topic and improved levels of comfort with transfers after study participation.