Robotically applied hemostatic clamping for care-under-fire: harnessing bomb robots for hemorrhage control.

BACKGROUND: Early hemorrhage control after interpersonal violence is the most urgent requirement to preserve life and is now recognized as a responsibility of law enforcement. Although earlier entry of first responders is advocated, many shooting scenes remain unsafe for humans, necessitating first responses conducted by robots. Thus, robotic hemorrhage control warrants study as a care-under-fire treatment option. METHODS: Two bomb disposal robots (Wolverine and Dragon Runner) were retrofitted with hemostatic wound clamps. The robots' ability to apply a wound clamp to a simulated extremity exsanguination while controlled by 4 experienced operators was tested. The operators were randomly assigned to perform 10 trials using 1 robot each. A third surveillance robot (Stair Climber) provided further visualization for the operators. We assessed the success rate of the application of the wound clamp to the simulated wound, the time to application of the wound clamp and the amount of fluid loss. We also assessed the operators' efforts to apply the wound clamp after an initial attempt was unsuccessful or after the wound clamp was dropped. RESULTS: Remote robotic application of a wound clamp was demonstrated to be feasible, with complete cessation of simulated bleeding in 60% of applications. This finding was consistent across all operators and both robots. There was no difference in the success rates with the 2 robots (p = 1.00). However, there were differences in fluid loss (p = 0.004) and application time (p < 0.001), with the larger (Wolverine) robot being faster and losing less fluid. CONCLUSION: Law enforcement tactical robots were consistently able to provide partial to complete hemorrhage control in a simulated extremity exsanguination. Consideration should be given to using this approach in care-under-fire and care-behind-the-barricade scenarios as well as further developing the technology and doctrine for robotic hemorrhage control.

First-Time Grandparents' Role Satisfaction and Its Determinants.

This article focuses on satisfaction with the grandparent role at 1 and 2 years after the transition to grandparenthood. Three hundred and eighteen grandparents (male and female) were initially recruited and required to complete a well-validated self-report measure of grandparent satisfaction, together with self-report questionnaires assessing a range of characteristics which might predict role satisfaction. The main finding was that grandparent-grandchild attachment (bonding) was the most powerful predictor. Some predictors (e.g., generativity) appeared to have a direct effect on satisfaction, whereas the effect of others (e.g., grandchild temperament) appeared to be mediated via the grandparent-grandchild attachment relationship. Role satisfaction, aside from its probable relevance to grandparent wellbeing, is also likely to be of relevance to grandparents' willingness to provide childcare. The latter, besides impacting on well-being of both grandparents and parents, also powerfully influences workforce economics.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage in a Perfused Human Cadaver Model.

BACKGROUND: Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate. OBJECTIVES: We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT). METHODS: Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded. RESULTS: There was no significant difference between the fluid loss/no movement (p > 0.450) and fluid loss/movement (p > 0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p > 0.000) and movement (p > 0.000). The iTClamp was also significantly faster to apply than the Foley (p > 0.000). CONCLUSIONS: The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

A "human-proof pointy-end": a robotically applied hemostatic clamp for care-under-fire

Summary: Providing the earliest hemorrhage control is now recognized as a shared responsibility of all members of society, including both the lay public and professionals, consistent with the Stop the Bleed campaign. However, providing early hemorrhage control in a hostile environment, such as the scene of a mass shooting, is extremely challenging. In such settings, the first access to a bleeding victim may be robotic. An all-purpose bomb robot was thus retrofitted with a commercial, off-the-shelf wound clamp and successfully applied to an extremity exsanguination simulator as a demonstration of remote robotic hemorrhage control. As this method can potentially control extremity hemorrhage, further development of the techniques, equipment and, most importantly, the guidelines and rules of engagement should continue. We suggest that in order to minimize the loss of life during an active shooter incident, the armamentarium of prehospital medical resources may be extended to include law-enforcement robots.

The transition to grandparenthood: a prospective study of mental health implications.

OBJECTIVES: This study investigated the mental health of a cohort of 262 female and 168 male grandparents across the first two years of their transition to grandparenthood, with particular focus on the impact of providing childcare for the grandchild. METHOD: Baseline assessments were made during the pregnancy with the first grandchild, and subsequent assessments were at one and two years after the birth. The influence of demographic and psychosocial variables which could be expected to influence change in mental health from baseline was explored. RESULTS: The lack of change in mental health measures in this cohort was more prominent than change. Specifically, there was a small significant decrease in anxiety over the first year for females, and a small significant increase in depression for males. Other variables, not unique to the transition to grandparenthood such as physical health and adverse life events, were strongly associated with changes in mental health. Notably, more time spent babysitting the grandchild was associated with improvement in mental health. CONCLUSION: The transition to grandparenthood did not have any substantial adverse impact on five well-validated measures of mental health, in contrast to earlier American findings of adverse effects which implied that childcare was burdensome.

A Randomized Trial of Mentored vs Nonmentored Military Medics Compared in the Application of a Wound Clamp Without Prior Training: When to Shut Up and Just Watch!

INTRODUCTION: Hemorrhage control is a basic task required of first responders and typically requires technical interventions during stressful circumstances. Remote telementoring (RTM) utilizes information technology to guide inexperienced providers, but when this is useful remains undefined. METHODS: Military medics were randomized to mentoring or not from an experienced subject matter expert during the application of a wound clamp (WC) to a simulated bleed. Inexperienced, nonmentored medics were given a 30-second safety briefing; mentored medics were not. Objective outcomes were time to task completion and success in arresting simulated bleeding. RESULTS: Thirty-three medics participated (16 mentored and 17 nonmentored). All (100%) successfully applies the WC to arrest the simulated hemorrhage. RTM significantly slowed hemorrhage control (P = 0.000) between the mentored (40.4 ± 12.0 seconds) and nonmentored (15.2 ± 10.3 seconds) groups. On posttask questionnaire, all medics subjectively rated the difficulty of the wound clamping as 1.7/10 (10 being extremely hard). Discussion: WC application appeared to be an easily acquired technique that was effective in controlling simulated extremity exsanguination, such that RTM while feasible did not improve outcomes. Limitations were the lack of true stress and using simulation for the task. Future research should focus on determining when RTM is useful and when it is not required.

The iTClamp in the treatment of prehospital craniomaxillofacial injury: a case series study.

BACKGROUND: Craniomaxillofacial (CMF) injuries are very common in both civilian and military settings. Nearly half of all civilian trauma incidents include a scalp laceration and historical rates of CMF battle injuries increased from 16%-21% to 42.2%. The scalp is highly vascular tissue and uncontrolled bleeding can lead to hypotension, shock and death. Therefore, enabling on-scene providers, both military and civilian, to immediately manage scalp and face lacerations, in a manner that allows them to still function in a tactical way, offers operational advantages. This case series examines how effectively a wound-clamp (iTClamp) controlled bleeding from CMF injuries pre-hospital environment. METHODS: The use of the iTClamp for CMF (scalp and face laceration) was extracted from iTrauma Care's post market surveillance database. Data was reviewed and a descriptive analysis was applied. RESULTS: 216 civilian cases of iTClamp use were reported to iTrauma Care. Of the 216 cases, 37% (n=80) were for control of CMF hemorrhage (94% scalp and 6% face). Falls (n=24) and MVC (n=25) accounted for 61% of the mechanism of injury. Blunt accounted for 66% (n=53), penetrating 16% (n=13) and unknown 18% (n=14). Adequate hemorrhage control was reported in 87.5% (n=70) of cases, three respondents reported inadequate hemorrhage control and in seven cases hemorrhage control was not reported. Direct pressure and packing was abandoned in favor of the iTClamp in 27.5% (n=22) of cases. CONCLUSIONS: CMF injuries are common in both civilian and military settings. Current options like direct manual pressure (DMP) often do not work well, are formidable to maintain on long transports and Raney clips are a historical suggestion. The iTClamp offers a new option for control of external hemorrhage from open wounds within compressible zones.

Use of the iTClamp versus standard suturing techniques for securing chest tubes: A randomized controlled cadaver study.

OBJECTIVES: Tube thoracostomy (TT) is a common yet potentially life-saving trauma procedure. After successful placement however, securing a TT through suturing is a skillset that requires practice, risking that the TT may become dislodged during prehospital transport. The purpose of this study was to examine if the iTClamp was a simpler technique with equivalent effectiveness for securing TTs. MATERIALS AND METHODS: In a cadaver model, a 1.5 inch incision was utilized along the upper border of the rib below the 5th intercostal space at the anterior axillary line. TTs (sizes 28Fr, 32Fr, 36Fr and 40Fr) were inserted and secured with both suturing and iTClamp techniques according to the preset randomization. TT were then functionally tested for positive and negative pressure as well as the force required to remove the TT (pull test-up to 5 lbs). Time to secure the TT was also recorded. RESULTS: When sutured is placed by a trained surgeon, the sutures and iTClamp were functionally equivalent for holding a positive and negative pressure. Mean pull force for both sutures and iTClamp exceeded the 5 lb threshold; there was no significant difference between the groups. Securing the TT with the iTClamp was significantly faster (p < 0.0001) with the iTClamp having a mean application time of 37.0 ±â€¯22.8 s and using a suture had a man application time of 96.3 ±â€¯29.0 s. CONCLUSION: The iTClamp was effective in securing TTs. The main benefit to the iTClamp is that minimal skill is required to adequately secure a TT to ensure that it does not become dislodged during transport to a trauma center.

How forgiveness promotes offender pro-relational intentions: The mediating role of offender gratitude.

Although relationship restoration is an important outcome of forgiveness, little is known about how forgiveness facilitates such an outcome. In addition, in forgiveness research, little attention is paid to the perspective of the offender. We address these two shortcomings simultaneously, testing the idea that forgiveness promotes offender gratitude, which in turn encourages offender pro-relational intentions. Across three experimental studies, participants were induced to believe they had transgressed; recalled a time when they had transgressed; and imagined transgressing. In studies 1 and 2, forgiveness was manipulated; in Study 3, victim motivation for forgiving was manipulated. State gratitude--in comparison with guilt, indebtedness, and positive affect--was consistently found to play the primary mediating role between forgiveness and pro-relational intentions.

Remote just-in-time telementored trauma ultrasound: a double-factorial randomized controlled trial examining fluid detection and remote knobology control through an ultrasound graphic user interface display.

BACKGROUND: Remote-telementored ultrasound involves novice examiners being remotely guided by experts using informatic-technologies. However, requiring a novice to perform ultrasound is a cognitively demanding task exacerbated by unfamiliarity with ultrasound-machine controls. We incorporated a randomized evaluation of using remote control of the ultrasound functionality (knobology) within a study in which the images generated by distant naive examiners were viewed on an ultrasound graphic user interface (GUI) display viewed on laptop computers by mentors in different cities. METHODS: Fire-fighters in Edmonton (101) were remotely mentored from Calgary (n = 65), Nanaimo (n = 19), and Memphis (n = 17) to examine an ultrasound phantom randomized to contain free fluid or not. Remote mentors (2 surgeons, 1 internist, and 1 ED physician) were randomly assigned to use GUI knobology control during mentoring (GUIK+/GUIK-). RESULTS: Remote-telementored ultrasound was feasible in all cases. Overall accuracy for fluid detection was 97% (confidence interval = 91 to 99%) with 3 false negatives (FNs). Positive/negative likelihood ratios were infinity/0.0625. One FN occurred with the GUIK+ and 2 without (GUIK-). There were no statistical test performance differences in either group (GUIK+ and GUIK-). CONCLUSIONS: Ultrasound-naive 1st responders can be remotely mentored with high accuracy, although providing basic remote control of the knobology did not affect outcomes.

Condylar shape analysis using panoramic radiography units and conventional tomography.

OBJECTIVE: The objective of this study was to compare condyle shape between lateral temporomandibular joint (TMJ) images from axially corrected tomography and 3 panoramic radiography units with TMJ-specific programs. STUDY DESIGN: The TMJ from a single dry human skull was imaged with multidirectional tomography and the following 3 panoramic radiography units: Instrumentarium OP 100, Planmeca PM 2002 CC Proline, and Soredex Orthophos DS. A curve-fitting procedure (spline curves) was used to mathematically describe condyle outlines. One sample t tests were used to compare panoramic images against the tomograms (gold standard). RESULTS: A significant difference (P < .05) in condyle shape was found between TMJ tomography images and each of the 3 panoramic images. Images from the PM 2002 CC Proline demonstrated the smallest shape difference (13.4%), followed by the OP 100 (17.5%) and the Orthophos DS (24.8%). CONCLUSION: If panoramic radiography is to be used for the initial radiographic examination of the TMJ, practitioners should be aware of the potential for shape distortion of the condyle.

Remote Telementored Ultrasound-Directed Compression to Potentially Accelerate Hemostasis in Exsanguinating Junctional Vascular Injuries.

Bleeding to death has been identified as the leading cause of potentially preventable injury-related death worldwide. Temporary hemorrhage control could allow the patient to be transported to a site capable of damage- control surgery. A novel device that may offer a fast and effective means of controlling nontruncal bleeding (junctional and extremity) is the iTClamp (Innovative Trauma Care; http://innovativetraumacare.com). This case study demonstrated that a motivated and intelligent, but untrained, first responder could successfully localize the actual anatomic site of an exsanguinating bleed and then could relatively easily compress this site to control the bleeding site by using ultrasound-guided manual-compression techniques.

The accuracy of 4 panoramic units in the projection of mesiodistal tooth angulations.

The purpose of this study was to compare the mesiodistal tooth angulations determined with a typodont/skull testing device with the images of mesiodistal tooth angulations from 4 contemporary panoramic units (OP 100, Cranex 3+, Orthophos, PM 2002 EC). A typodont testing device was constructed, and the true mesiodistal tooth angulations relative to an orthodontic archwire were determined with a 3-dimensional coordinate-measuring machine and custom-designed software. A human skull served as the matrix into which the typodont was fixed for imaging. The skull was repeatedly imaged and repositioned 5 times for each panoramic unit. The images were scanned and digitized with custom software to determine the image mesiodistal angulations. Results revealed that the majority of image angles from the 4 panoramic units were statistically significantly different from the true angle measurements. However, definite trends were noted among the panoramic units. For the maxillary teeth, the images projected the anterior roots more mesially and the posterior roots more distally, creating the appearance of exaggerated root divergence between the canine and the first premolar. For the mandibular teeth, the images projected almost all roots more mesially than they really were, with the canine and the first premolar the most severely affected. The largest angular difference for adjacent teeth occurred between the mandibular lateral incisor and the canine, with relative root parallelism projected as root convergence. It was concluded that the clinical assessment of mesiodistal tooth angulation with panoramic radiography should be approached with extreme caution and with an understanding of the inherent image distortions.