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INTRODUCTION: Video laryngoscope (VL) technology improves first-pass success. The novel i-view VL device is inexpensive and disposable. We sought to determine the first-pass intubation success with the i-view VL device versus the standard reusable VL systems in routine use at each site. METHODS: We performed a prospective, pragmatic study at two major emergency departments (EDs) when VL was used. We rotated i-view versus reusable VL as the preferred device of the month based on an a priori schedule. An investigator-initiated interim analysis was performed. Our primary outcome was a first-pass success with a non-inferiority margin of 10% based on the per-protocol analysis. RESULTS: There were 93 intubations using the reusable VL devices and 81 intubations using the i-view. Our study was stopped early due to futility in reaching our predetermined non-inferiority margin. Operator and patient characteristics were similar between the two groups. The first-pass success rate for the i-view group was 69.1% compared to 84.3% for the reusable VL group. A non-inferiority analysis indicated that the difference (-15.1%) and corresponding 90% confidence limits (-25.3% to -5.0%) did not fall within the predetermined 10% non-inferiority margin. CONCLUSIONS: The i-view device failed to meet our predetermined non-inferiority margin when compared to the reusable VL systems with the study stopping early due to futility. Significant crossover occurred at the discretion of the intubating operator during the i-view month.
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Intubação Intratraqueal , Laringoscópios , Humanos , Estudos Prospectivos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Feminino , Masculino , Pessoa de Meia-Idade , Idoso , Adulto , Serviço Hospitalar de Emergência , Reutilização de Equipamento , Laringoscopia/métodos , Laringoscopia/instrumentaçãoRESUMO
INTRODUCTION: Airway compromise is the second leading cause of potentially preventable death on the battlefield. Prehospital airway management is often unavoidable in a kinetic combat environment and expected to increase in future wars where timely evacuation will be unreliable and air superiority not guaranteed. We compared characteristics of survivors to non-survivors among combat casualties undergoing prehospital airway intubation. MATERIALS AND METHODS: We requested all Department of Defense Trauma Registry (DODTR) encounters during 2007-2023 with documentation of any airway intervention or assessment within the first 72-h after injury. We conducted a retrospective cohort study of all casualties with intubation documented in the prehospital setting. We used descriptive and inferential statistical analysis to compare survivors through 7 days post injury versus non-survivors. We constructed 3 multivariable logistic regression models to test for associations between interventions and 7-day survival after adjusting for injury severity score, mechanism of injury, and receipt of sedatives, paralytics, and blood products. RESULTS: There were 1377 of 48,301 patients with documentation of prehospital intubation in a combat setting. Of these, 1028 (75%) survived through 7 days post injury. Higher proportions of survivors received ketamine, paralytic agents, parenteral opioids, and parenteral benzodiazepines; there was no difference in the proportions of survivors versus non-survivors receiving etomidate. The multivariable models consistently demonstrated positive associations between 7-day survival and receipt of non-depolarizing paralytics and opioid analgesics. CONCLUSIONS: We found an association between non-depolarizing paralytic and opioid receipt with 7-day survival among patients undergoing prehospital intubation. The literature would benefit from future multi-center randomized controlled trials to establish optimal pharmacologic strategies for trauma patients undergoing prehospital intubation.
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Serviços Médicos de Emergência , Ferimentos e Lesões , Humanos , Estudos Retrospectivos , Manuseio das Vias Aéreas , Sistema de Registros , Intubação Intratraqueal , Ferimentos e Lesões/terapiaRESUMO
BACKGROUND: Elbow stiffness is one of the most common complications after operative fixation of distal humerus fractures; however, there is relatively limited literature assessing which factors are associated with this problem. The purpose of this study is to identify risk factors associated with dysfunctional elbow stiffness in distal humerus fractures after operative fixation. METHODS: A retrospective review of all distal humerus fractures that underwent operative fixation (AO/OTA 13A-C) at a single level 1 trauma center from November 2014 to October 2021. A minimum six-month follow-up was required for inclusion or the outcome of interest. Dysfunctional elbow stiffness was defined as a flexion-extension arc of less than 100° at latest follow-up or any patient requiring surgical treatment for limited elbow range of motion. RESULTS: A total of 110 patients with distal humerus fractures were included in the study: 54 patients comprised the elbow stiffness group and 56 patients were in the control group. Average follow-up of 343 (59 to 2,079) days. Multiple logistic regression showed that orthogonal plate configuration (aOR: 5.70, 95% CI: 1.91-16.99, p=0.002), and longer operative time (aOR: 1.86, 95% CI: 1.11-3.10, p=0.017) were independently associated with an increased odds of elbow stiffness. OTA/AO 13A type fractures were significantly associated with a decreased odds of stiffness (aOR: 0.16, 95% CI: 0.03-0.80, p=0.026). Among 13C fractures, olecranon osteotomy (aOR: 5.48, 95% CI: 1.08-27.73, p=0.040) was also associated with an increased odds of elbow stiffness. There were no significant differences in injury mechanism, Gustilo-Anderson classification, reduction quality, days to surgery from admission, type of fixation, as well as rates of ipsilateral upper extremity fracture, neurovascular injury, nonunion, or infection between the two groups. CONCLUSION: Dysfunctional elbow stiffness was observed in 49.1% of patients who underwent operative fixation of distal humerus fractures in the present study. Orthogonal plate configuration, olecranon osteotomy, and longer operative time were associated with an increased odds of dysfunctional elbow stiffness; however, 13A type fractures were associated with decreased odds of stiffness. Patients with these injuries should be counseled on their risk of stiffness following surgery, and modifiable risk factors like plate positioning and performing an olecranon osteotomy should be considered by surgeons.
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BACKGROUND/OBJECTIVE: Contrast-enhanced magnetic resonance imaging (MRI) is the preferred imaging modality for diagnosing pyogenic spinal infection (PSI), but it is not always available. Our objective was to describe pyogenic spinal infection imaging characteristics in patients presenting to a community emergency department (ED) and estimate the computed tomography (CT) sensitivity for these infections. METHODS: We examined the MRI reports from a cohort of 88 PSI patients whom we enrolled in a prospective cohort study and report the prevalence of each PSI type (spinal epidural abscess/infection, vertebral osteomyelitis/discitis, septic facet, and paravertebral abscess/infection) according to contemporary nomenclature. In a 14 patient subcohort who underwent both CT and MRI studies, we report the sensitivity for each PSI from a post hoc blinded overread of the CT imaging by a single neuroradiologist. RESULTS: Of the 88 PSI patients, the median age was 55 years, and 31% were female. The PSI prevalence included: spinal epidural abscess/infection (SEA) in 61(69%), vertebral osteomyelitis/discitis (VO/D) in 54 (61%), septic facet (SF) in 15 (17%), and paravertebral abscess/infection (PVA) in 53 (60%). Of the SEAs, 82% (50/61) were associated with other spinal infections, while 18% (11/61) were isolated SEAs. The overall CT sensitivity in a masked overread was 79% (11/14) for any PSI, 83% (10/12) for any infection outside the spinal canal, and only 18% (2/11) for SEA. CONCLUSION: Patients found to have vertebral osteomyelitis/discitis, septic facet, and paravertebral infections frequently had a SEA coinfection. CT interpretation by a neuroradiologist had moderate sensitivity for infections outside the spinal canal but had low sensitivity for SEA.
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Discite , Abscesso Epidural , Osteomielite , Discite/complicações , Discite/diagnóstico por imagem , Abscesso Epidural/complicações , Abscesso Epidural/diagnóstico por imagem , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Osteomielite/diagnóstico por imagem , Estudos Prospectivos , Tomografia Computadorizada por Raios XRESUMO
OBJECTIVE: To identify clinical characteristics associated with pyogenic spinal infection among adults presenting to a community emergency department (ED) with neck or back pain. A secondary objective was to describe the frequency of these characteristics among patients with spinal epidural abscess (SEA). METHODS: We conducted a prospective cohort study in a community ED enrolling adults with neck or back pain in whom the ED provider had clinical concern for pyogenic spinal infection. Study phase 1 (Jan 2004-Mar 2010) included patients with and without pyogenic spinal infection. Phase 2 (Apr 2010-Aug 2018) included only patients with pyogenic spinal infection. We performed univariate and multivariate analyses for association of clinical characteristics with pyogenic spinal infection. RESULTS: We enrolled 232 and analyzed 223 patients, 89 of whom had pyogenic spinal infection. The median age was 55â¯years and 102 patients (45.7%) were male. The clinical characteristics associated with pyogenic spinal infection on multivariate analysis of study phase 1 included recent soft tissue infection or bacteremia (OR 13.5, 95% CI 3.6 to 50.7), male sex (OR 5.0, 95% CI 2.5 to 10.0), and fever in the ED or prior to arrival (OR 2.8, 95% CI 1.3 to 6.0). Among patients with SEA (nâ¯=â¯61), 49 (80.3%) had at least one historical risk factor, 12 (19.7%) had fever in the ED, and 8 (13.1%) had a history of intravenous drug use. CONCLUSION: Male sex, fever, and recent soft tissue infection or bacteremia were associated with pyogenic spinal infection in this prospective ED cohort.
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Dor nas Costas/etiologia , Cervicalgia/etiologia , Doenças da Medula Espinal/diagnóstico , Adulto , Idoso , Bacteriemia/complicações , Serviço Hospitalar de Emergência/estatística & dados numéricos , Abscesso Epidural/epidemiologia , Abscesso Epidural/microbiologia , Feminino , Febre/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Fatores Sexuais , Infecções dos Tecidos Moles/complicações , Doenças da Medula Espinal/epidemiologia , Doenças da Medula Espinal/etiologia , Doenças da Medula Espinal/microbiologiaRESUMO
INTRODUCTION: Despite the declining incidence of coronary heart disease (CHD) in the United States, acute myocardial infarction (AMI) remains an important clinical entity, with many patients requiring emergency department (ED) management for mechanical, inflammatory, and embolic complications. OBJECTIVE: This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of post myocardial infarction mechanical, inflammatory, and embolic complications. DISCUSSION: While 30-day mortality rate after AMI has decreased in the past two decades, it remains significantly elevated at 7.8%, owing to a wide variety of subacute complications evolving over weeks. Mechanical complications such as ventricular free wall rupture, ventricular septal rupture, mitral valve regurgitation, and formation of left ventricular aneurysms carry significant morbidity. Additional complications include ischemic stroke, heart failure, renal failure, and cardiac dysrhythmias. This review provides several guiding principles for management of these complications. Understanding these complications and an approach to the management of various complications is essential to optimizing patient care. CONCLUSIONS: Mechanical, inflammatory, and embolic complications of AMI can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. In addition to understanding the natural progression of disease and performing a focused physical examination, an electrocardiogram and bedside echocardiogram provide quick, noninvasive determinations of the underlying pathophysiology. Management varies by presentation and etiology, but close consultation with cardiology and cardiac surgery is recommended.
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Aneurisma Cardíaco/etiologia , Ruptura Cardíaca Pós-Infarto/etiologia , Insuficiência da Valva Mitral/etiologia , Infarto do Miocárdio/complicações , Pericardite/etiologia , Ecocardiografia , Eletrocardiografia , Medicina de Emergência , Aneurisma Cardíaco/diagnóstico , Aneurisma Cardíaco/terapia , Ruptura Cardíaca Pós-Infarto/diagnóstico , Ruptura Cardíaca Pós-Infarto/terapia , Humanos , Insuficiência da Valva Mitral/diagnóstico , Insuficiência da Valva Mitral/terapia , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/fisiopatologia , Narração , Pericardite/diagnóstico , Pericardite/terapia , Exame Físico , Sistemas Automatizados de Assistência Junto ao Leito , Fatores de RiscoRESUMO
INTRODUCTION: Patients with acute myocardial infarction (AMI) may suffer several complications after the acute event, including dysrhythmias and heart failure (HF). These complications place patients at risk for morbidity and mortality. OBJECTIVE: This narrative review evaluates literature and guideline recommendations relevant to the acute emergency department (ED) management of AMI complicated by dysrhythmia or HF, with a focus on evidence-based considerations for ED interventions. DISCUSSION: Limited evidence exists for ED management of dysrhythmias in AMI due to relatively low prevalence and frequent exclusion of patients with active cardiac ischemia from clinical studies. Management decisions for bradycardia in the setting of AMI are determined by location of infarction, timing of the dysrhythmia, rhythm assessment, and hemodynamic status of the patient. Atrial fibrillation is common in the setting of AMI, and caution is warranted in acute rate control for rapid ventricular rate given the possibility of compensation for decreased ventricular function. Regular wide complex tachycardia in the setting of AMI should be managed as ventricular tachycardia with electrocardioversion in the majority of cases. Management directed towards HF from left ventricular dysfunction in AMI consists of noninvasive positive pressure ventilation, nitroglycerin therapy, and early cardiac catheterization. Norepinephrine is the first line vasopressor for patients with cardiogenic shock and hypoperfusion on clinical examination. Early involvement of a multi-disciplinary team is recommended when caring for patients in cardiogenic shock. CONCLUSIONS: This review discusses considerations of ED management of dysrhythmias and HF associated with AMI.
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Fibrilação Atrial/terapia , Bradicardia/tratamento farmacológico , Bloqueio Cardíaco/terapia , Insuficiência Cardíaca/terapia , Infarto do Miocárdio/complicações , Taquicardia Ventricular/terapia , Fibrilação Atrial/etiologia , Bradicardia/etiologia , Medicina de Emergência , Bloqueio Cardíaco/etiologia , Bloqueio Cardíaco/mortalidade , Insuficiência Cardíaca/etiologia , Humanos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Choque Cardiogênico/complicações , Taquicardia Ventricular/etiologiaRESUMO
STUDY OBJECTIVE: We compare aromatherapy with inhaled isopropyl alcohol versus oral ondansetron for treating nausea among emergency department (ED) patients not requiring immediate intravenous access. METHODS: In a randomized, blinded, placebo-controlled trial, we enrolled a convenience sample of adults presenting to an urban tertiary care ED with chief complaints including nausea or vomiting. We randomized subjects to 1 of 3 arms: inhaled isopropyl alcohol and 4 mg oral ondansetron, inhaled isopropyl alcohol and oral placebo, and inhaled saline solution placebo and 4 mg oral ondansetron. The primary outcome was mean nausea reduction measured by a 0- to 100-mm visual analog scale from enrollment to 30 minutes postintervention. Secondary outcomes included receipt of rescue antiemetic medications and adverse events. RESULTS: We enrolled 122 subjects, of whom 120 (98.3%) completed the study. Of randomized subjects, 40 received inhaled isopropyl alcohol and oral ondansetron, 41 received inhaled isopropyl alcohol and oral placebo, and 41 received inhaled saline solution placebo and oral ondansetron. The mean decrease in nausea visual analog scale score in each arm was 30 mm (95% confidence interval [CI] 22 to 37 mm), 32 mm (95% CI 25 to 39 mm), and 9 mm (95% CI 5 to 14 mm), respectively. The proportions of subjects who received rescue antiemetic therapy in each arm were 27.5% (95% CI 14.6% to 43.9%), 25.0% (95% CI 12.7% to 41.2%), and 45.0% (95% CI 29.3% to 61.5%), respectively. There were no adverse events. CONCLUSION: Among ED patients with acute nausea and not requiring immediate intravenous access, aromatherapy with or without oral ondansetron provides greater nausea relief than oral ondansetron alone.
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2-Propanol/administração & dosagem , Antieméticos/administração & dosagem , Náusea/tratamento farmacológico , Ondansetron/administração & dosagem , 2-Propanol/uso terapêutico , Administração por Inalação , Administração Oral , Adulto , Antieméticos/uso terapêutico , Aromaterapia/métodos , Método Duplo-Cego , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Ondansetron/uso terapêutico , Atenção Terciária à Saúde , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: The incidence of methicillin-resistant Staphylococcus aureus (MRSA) pediatric osteomyelitis has risen and been associated with a more severe clinical course than methicillin-susceptible Staphylococcus aureus (MSSA) infections. National databases have been underutilized to describe these trends. We compared demographics, clinical course, and outcomes for patients with MRSA versus MSSA osteomyelitis. METHODS: We queried the 2009 and 2012 Healthcare Cost and Utilization Project Kids Inpatient Database for discharge records with diagnosis codes for osteomyelitis and S. aureus. We explored demographics predicting MRSA and evaluated MRSA versus MSSA as predictors of clinical outcomes including surgery, sepsis, thrombophlebitis, length of stay, and total charges. RESULTS: A total of 4214 discharge records were included. Of those, 2602 (61.7%) had MSSA and 1612 (38.3%) had MRSA infections. Patients at Southern and Midwestern hospitals were more likely to have MRSA than those at Northeastern hospitals. Medicaid patients' odds of MRSA were higher than those with private insurance, and black patients were more likely to have MRSA compared with white patients. MRSA patients were more likely to undergo multiple surgeries compared with MSSA patients and were more likely to have complications including severe sepsis, thrombophlebitis, and pulmonary embolism. Patients with MRSA had longer lengths of stay than those with MSSA and higher total charges after controlling for length of stay. CONCLUSION: Review of a national database demonstrates MRSA is more prevalent in the South and Midwest regions and among black patients. MRSA patients have more surgeries, complications, and longer lengths of stay. LEVEL OF EVIDENCE: Level III.
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Antibacterianos , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Procedimentos Ortopédicos/estatística & dados numéricos , Osteomielite , Sepse , Infecções Estafilocócicas , Staphylococcus aureus/isolamento & purificação , Antibacterianos/economia , Antibacterianos/uso terapêutico , Criança , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Incidência , Masculino , Osteomielite/economia , Osteomielite/microbiologia , Osteomielite/terapia , Prevalência , Estudos Retrospectivos , Sepse/tratamento farmacológico , Sepse/economia , Sepse/etiologia , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/economia , Infecções Estafilocócicas/epidemiologia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: We evaluated a soft tissue oxygen saturation (Sto2) measurement at triage for predicting admission to the hospital in adults presenting to the emergency department (ED) in addition to data routinely gathered at triage. METHODS: This was a prospective, observational, single center study of adults presenting to the ED for evaluation. Research assistants obtained thenar eminence Sto2 measurements on subjects in ED triage. ED providers not involved in the study then made all management and disposition decisions. We prospectively collected data on each subject's final ED disposition (admission versus discharge). We identified the optimal Sto2 cutoff value for predicting admission. We then used logistic regression modeling to describe the added predictive value of Sto2 beyond routinely collected triage data including Emergency Severity Index level, age, and vital signs. RESULTS: We analyzed 2588 adult (>17years) subjects with 743 subjects (28.7%) admitted to the hospital. Sto2<76% was the optimal diagnostic cutoff for predicting admission. Of subjects with Sto2<76%, 158 of 384 (41.1%) underwent admission versus 585 of 2204 (26.5%) subjects with Sto2≥76. After controlling for age, vital signs, and ESI level in the logistic regression analysis, Sto2<76% had an odds ratio of 1.54 (95% confidence interval (CI), 1.19 to 1.98) for predicting admission. CONCLUSIONS: Sto2 may provide additional prognostic data to routine triage assessment regarding the disposition for undifferentiated adult patients presenting to the ED.
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Estado Terminal/terapia , Serviço Hospitalar de Emergência , Hospitalização/estatística & dados numéricos , Oximetria , Triagem/métodos , Adulto , Idoso , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Oximetria/métodos , Consumo de Oxigênio , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Curva ROC , Índice de Gravidade de Doença , Espectroscopia de Luz Próxima ao Infravermelho , Estados UnidosRESUMO
BACKGROUND: Peritoneal dialysis (PD) is a cost-effective alternative to hemodialysis (HD). PD catheters have traditionally been inserted through a small open incision, but insertion using laparoscopic visualization has become increasingly popular and is associated with less catheter malfunction. The aim of this study was to compare costs of laparoscopic and open insertion strategies while taking into account postoperative complications and future salvage procedures. METHODS: A decision analysis model was constructed to simulate 1 y outcomes after PD catheter insertion by either the open or laparoscopic approach. Possible outcomes after PD catheter placement included functional catheter, infection, and catheter malfunction. Ultimately, patients continued with successful PD or switched to HD. Baseline probabilities, costs, and ranges were determined from a critical review of the literature. Sensitivity analyses were performed to determine the model strength over a range of clinically relevant probabilities. RESULTS: The total annual costs, including postoperative management and dialysis treatment, were $69,491 for laparoscopic insertion and $69,960 for open insertion. In case of a catheter malfunction, an initial attempt at salvage by fluoroscopy-guided wire manipulation cost less than a first attempt by laparoscopic repositioning. CONCLUSIONS: When accounting for a year of postoperative management and treatment, laparoscopic insertion can be less costly than open insertion in the hands of an experienced surgeon. Despite higher initial costs, PD catheter insertion under laparoscopic visualization can have lower total costs due to fewer postoperative complications. With increasing emphasis on cost-effective care, laparoscopic insertion is a valuable tool for initiating PD.
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Cateterismo/economia , Falência Renal Crônica/economia , Laparoscopia/economia , Avaliação de Processos e Resultados em Cuidados de Saúde , Diálise Peritoneal/economia , Cateterismo/efeitos adversos , Cateterismo/métodos , Análise Custo-Benefício , Árvores de Decisões , Falha de Equipamento , Feminino , Humanos , Falência Renal Crônica/terapia , Laparoscopia/efeitos adversos , Masculino , Pessoa de Meia-Idade , Diálise Peritoneal/efeitos adversos , Diálise Peritoneal/instrumentação , Complicações Pós-Operatórias/prevenção & controleRESUMO
BACKGROUND: The aim of this study was to determine the risk of occupational musculoskeletal injury during a surgeon's career and the effects of these injuries for patients, providers, and institutions. We hypothesized that surgeons have occupational injuries, which affect work performance. MATERIALS AND METHODS: Electronic RedCAP surveys on workplace injury were distributed statewide via e-mail to the members of the Tennessee chapter of the American College of Surgeons. Descriptive statistics were used to analyze survey data. RESULTS: A total of 260 of 793 surveys (33%) were returned. Forty percent of surgeons sustained ≥ 1 injuries in the workplace. Although 50% of injured surgeons received medical care for their most recent injuries, only 20% of these injuries were reported to their institution. Twenty-two percent of injured surgeons missed work and 35% performed fewer operations while they were recovering from their injury. Fifty-three percent of injured surgeons reported that pain from their injury had a minimal or moderate effect on their performance in the operating room. CONCLUSIONS: Surgeons appear to be at moderate risk for occupation-related injuries. The low rate of institutional reporting for these injuries is concerning, as this is a required step to access institutional support once injured. Surgeon injury results in lost productivity due to missed workdays and may impact the quality of surgical care because of performance issues while recovering from injury.
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Traumatismos Ocupacionais/epidemiologia , Qualidade da Assistência à Saúde , Especialidades Cirúrgicas/estatística & dados numéricos , Feminino , Humanos , Masculino , Prevalência , Tennessee/epidemiologiaAssuntos
Antieméticos , Aromaterapia , Adulto , Serviço Hospitalar de Emergência , Humanos , OndansetronRESUMO
The potential impact of large-scale combat operations and multidomain operations against peer adversaries poses significant challenges to the Military Health System including large volumes of critically ill and injured casualties, prolonged care times in austere care contexts, limited movement, contested logistics, and denied communications. These challenges contribute to the probability of higher casualty mortality and risk that casualty care hinders commanders' forward momentum or opportunities for overmatch on the battlefield. Novel technical solutions and associated concepts of operation that fundamentally change the delivery of casualty care are necessary to achieve desired medical outcomes that include maximizing Warfighter battle-readiness, minimizing return-to-duty time, optimizing medical evacuation that clears casualties from the battlefield while minimizing casualty morbidity and mortality, and minimizing resource consumption across the care continuum. These novel solutions promise to "automate" certain aspects of casualty care at the level of the individual caregiver and the system level, to unburden our limited number of providers to do more and make better (data-driven) decisions. In this commentary, we describe concepts of casualty digital twins-virtual representations of a casualty's physical journey through the roles of care-and how they, combined with passive data collection about casualty status, caregiver actions, and real-time resource use, can lead to human-machine teaming and increasing automation of casualty care across the care continuum while maintaining or improving outcomes. Our path to combat casualty care automation starts with mapping and modeling the context of casualty care in realistic environments through passive data collection of large amounts of unstructured data to inform machine learning models. These context-aware models will be matched with patient physiology models to create casualty digital twins that better predict casualty needs and resources required and ultimately inform and accelerate decision-making across the continuum of care. We will draw from the experience of the automotive industry as an exemplar for achieving automation in health care and inculcate automation as a mechanism for optimizing the casualty care survival chain.
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INTRODUCTION: During high-fidelity simulations in the Critical Care Air Transport (CCAT) Advanced course, we identified a high frequency of insulin medication errors and sought strategies to reduce them using a human factors approach. MATERIALS AND METHODS: Of 169 eligible CCAT simulations, 22 were randomly selected for retrospective audio-video review to establish a baseline frequency of insulin medication errors. Using the Human Factors Analysis Classification System, dosing errors, defined as a physician ordering an inappropriate dose, were categorized as decision-based; administration errors, defined as a clinician preparing and administering a dose different than ordered, were categorized as skill-based. Next, 3 a priori interventions were developed to decrease the frequency of insulin medication errors, and these were grouped into 2 study arms. Arm 1 included a didactic session reviewing a sliding-scale insulin (SSI) dosing protocol and a hands-on exercise requiring all CCAT teams to practice preparing 10 units of insulin including a 2-person check. Arm 2 contained arm 1 interventions and added an SSI cognitive aid available to students during simulation. Frequency and type of insulin medication errors were collected for both arms with 93 simulations for arm 1 (January-August 2021) and 139 for arm 2 (August 2021-July 2022). The frequency of decision-based and skill-based errors was compared across control and intervention arms. RESULTS: Baseline insulin medication error rates were as follows: decision-based error occurred in 6/22 (27.3%) simulations and skill-based error occurred in 6/22 (27.3%). Five of the 6 skill-based errors resulted in administration of a 10-fold higher dose than ordered. The post-intervention decision-based error rates were 9/93 (9.7%) and 23/139 (2.2%), respectively, for arms 1 and 2. Compared to baseline error rates, both arm 1 (P = .04) and arm 2 (P < .001) had a significantly lower rate of decision-based errors. Additionally, arm 2 had a significantly lower decision-based error rate compared to arm 1 (P = .015). For skill-based preparation errors, 1/93 (1.1%) occurred in arm 1 and 4/139 (2.9%) occurred in arm 2. Compared to baseline, this represents a significant decrease in skill-based error in both arm 1 (P < .001) and arm 2 (P < .001). There were no significant differences in skill-based error between arms 1 and 2. CONCLUSIONS: This study demonstrates the value of descriptive error analysis during high-fidelity simulation using audio-video review and effective risk mitigation using training and cognitive aids to reduce medication errors in CCAT. As demonstrated by post-intervention observations, a human factors approach successfully reduced decision-based error by using didactic training and cognitive aids and reduced skill-based error using hands-on training. We recommend the development of a Clinical Practice Guideline including an SSI protocol, guidelines for a 2-person check, and a cognitive aid for implementation with deployed CCAT teams. Furthermore, hands-on training for insulin preparation and administration should be incorporated into home station sustainment training to reduced medication errors in the operational environment.
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INTRODUCTION: The primary objective of this study was to evaluate the association between the U.S. Air Force Critical Care Air Transport (CCAT) provider operational experience with compliance for lung protective ventilation (LPV) volumes recommended by Acute Respiratory Distress Syndrome Clinical Network guidelines. MATERIALS AND METHODS: We performed a retrospective cohort study of CCAT providers transporting combat casualties requiring mechanical ventilation from the Middle East to Germany from 2007 to 2012. We reviewed CCAT medical records from 2007 to 2012 for the total number of patient transports by CCAT physicians and respiratory care practitioners (RCPs). Center for Sustainment of Trauma and Readiness Skills Cincinnati process improvement questionnaire data described provider demographics and clinical backgrounds. We linked these data to patient demographics and in-flight ventilation management from a prior CCAT cohort study. Patient inclusion criteria included transport by CCAT from the Middle East to Germany for traumatic injury requiring mechanical ventilation between 2007 and 2012. We excluded patients with no documented height or tidal volume. LPV compliance was defined as tidal volumes ≤8 mL/kg of predicted body weight during en route critical care transport. We performed a logistic regression analysis. This study was reviewed and approved by the 59th Medical Wing institutional review board (IRB). RESULTS: We analyzed 491 patient transports conducted by 71 (RCPs and 84 physicians. Patients had a median age of 25 years (IQR 22-30), 98% were male, median injury severity score was 24 (IQR 17-34), and median preflight PaO2/FiO2 was 285 (IQR 220-365). Median experience was 26 missions (IQR 13-40) for RCPs and 23 missions (IQR 12-38) for physicians. All in-flight tidal volumes were LPV compliant in 58.3% of missions. Unadjusted analysis showed higher LPV compliance for RCPs with in-garrison critical care experience. Multivariate models did not find an association between missions flown and LPV compliance but did demonstrate a positive association with physician specialty of medical intensivist (OR 3.0, 95% CI 1.6-5.7) and a negative association with flights in 2008 (OR 0.4, 95% CI 0.2-0.7) for LPV compliance. CONCLUSION: No association was found between number of missions flown by CCAT providers and lung protective tidal volume compliance. Linkage of multiple data sources enabled investigation of clinical and operational currency associations with a care quality metric compliance in the combat en route care environment. Future studies should evaluate the impact of ongoing CCAT training and quality improvement interventions on LPV compliance.
Assuntos
Resgate Aéreo , Respiração Artificial , Humanos , Estudos Retrospectivos , Masculino , Feminino , Adulto , Respiração Artificial/métodos , Respiração Artificial/estatística & dados numéricos , Respiração Artificial/normas , Resgate Aéreo/estatística & dados numéricos , Resgate Aéreo/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Fidelidade a Diretrizes/normas , Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Cuidados Críticos/normas , Alemanha , Estudos de Coortes , Síndrome do Desconforto Respiratório/terapia , Militares/estatística & dados numéricos , Estados Unidos , Ferimentos e Lesões/terapia , Inquéritos e QuestionáriosRESUMO
INTRODUCTION: Current standards for hemoglobin monitoring during air transports of U.S. combat wounded are invasive and intermittent. Fielded pulse co-oximeters can noninvasively measure total hemoglobin, but this parameter is not currently utilized. The primary objective of this study was to assess the percentage of vital sign measurements with successful capture of total noninvasive hemoglobin measurement using spectrophotometry-based technology for Hb (SpHb) measurements in healthy participants during training flights. Secondary objectives were to assess the feasibility of a novel electronic data capture mechanism from usual patient movement items and perform a pilot analysis of SpHb changes in healthy participants during transitions from ground to air transport. METHODS: We conducted a feasibility study enrolling healthy participants who had hemodynamic monitoring during usual U.S. Air Force Critical Care Air Transport (CCAT) flight training exercises from 2022 to 2023. Usual CCAT monitoring equipment and currently used Masimo Rainbow® pulse co-oximeters had the capability to measure SpHb. After each training exercise, the study team wirelessly downloaded case files from patient monitors utilizing the Battlefield Assisted Trauma Distributed Observation Kit (BATDOKTM) Case Downloader application. We then calculated point and precision estimates for the percentage of time for successful SpHb capture during the exercise and compared this to pulse oximetry (SpO2) capture. An a priori precision analysis for percentage of flight-time with successful SpHb data capture and descriptive statistics were performed. This study received Exempt Determination by the 59th Medical Wing IRB. RESULTS: We analyzed 26 records with mean monitoring durations of 94.5 [59.3-119.9] minutes during ground phases and 78.0 [59.9-106.5] minutes during flight phases. SpHb measures were successfully captured for 97.7% (n = 4,620) of possible ground measurements and 97.2% (n = 3,973) of possible in-flight measurements compared to 99.5% ground and 98.2% in-flight capture for SpO2. Mean intervals of missing SpHb data were 2 ± 5 minutes on the ground and 4 ± 6 minutes in-flight. Mean SpHb increased by 0.93 ± 0.96 g/dL during the ground phase, but had minimal changes during ascent, cruising altitude or descent. The BATDOKTM Case downloader completed transfer for all files. CONCLUSION: Masimo Rainbow® SpHb pulse co-oximeters reliably captured continuous, noninvasive hemoglobin measurements using usual CCAT patient movement items in healthy participants during both ground and flight training. The BATDOKTM Case Downloader successfully imported case files from CCAT patient monitors. Mean SpHb measures had a small increase during the ground phase of monitoring followed by minimal changes when transitioning to flight altitude.
Assuntos
Oximetria , Humanos , Resgate Aéreo/estatística & dados numéricos , Estudos de Viabilidade , Voluntários Saudáveis/estatística & dados numéricos , Hemoglobinas/análise , Monitorização Fisiológica/métodos , Monitorização Fisiológica/instrumentação , Monitorização Fisiológica/estatística & dados numéricos , Monitorização Fisiológica/normas , Oximetria/métodos , Oximetria/normas , Oximetria/instrumentação , Oximetria/estatística & dados numéricos , Reprodutibilidade dos TestesRESUMO
BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is an advanced medical technology that is used to treat respiratory and heart failure. The U.S. military has used ECMO in the care of combat casualties during Operation Enduring Freedom and Operation Iraqi Freedom as well as in the treatment of patients during the recent Coronavirus Disease 2019 pandemic. However, few Military Health System personnel have training and experience in the use of ECMO therapy. To address this dearth of expertise, we developed and evaluated an accelerated ECMO course for military medical personnel. OBJECTIVES: To compare the efficacy of an accelerated ECMO course for Military Health System critical care teams. METHODS: Seventeen teams, each consisting of a physician and nurse, underwent a 5-h accelerated ECMO course. Similar to our previous live-tissue ECMO training program (phases I and II), each team watched prerecorded ECMO training lectures. Subjects then practiced priming the ECMO circuit, cannulating ECMO, initiating ECMO, and correcting common complications on an ECMO simulation model. An added component to this phase III project included transportation and telemedicine consultation availability. Training success was evaluated via knowledge and confidence assessments, and observation of each team attempting to initiate ECMO on a Yorkshire swine patient model, transport the patient model, and troubleshoot complications with the support of telemedicine consultation when desired. RESULTS: Seventeen teams successfully completed the course. All seventeen teams (100%) successfully placed the swine on veno-arterial ECMO. Of those, 15 teams successfully transitioned to veno-arterial-venous ECMO. The knowledge assessments of physicians and nurses increased by 12.2% from pretest (mean of 62.1%, SD 10.4%) to posttest (mean of 74.4%, SD 8.2%), P < .0001; their confidence assessments increased by 41.1% from pretest (mean of 20.1%, SD 11.8%) to posttest (mean of 61.2%, SD 18.6%). CONCLUSIONS: An abbreviated 1-day lecture and hands-on task-trainer-based ECMO course resulted in a high rate of successful skill demonstration and improvement of physicians' and nurses' knowledge assessments and confidence levels, similar to our previous live-tissue training program. When compared to our previous studies, the addition of telemedicine and patient transportation to this study did not affect the duration or performance of procedures.