Provider Fatigue During Direct Manual Compression for Life-Threatening Bleeding.

Introduction Trauma is a leading cause of death throughout the world, with hemorrhage being responsible for more than 35% of pre-hospital trauma deaths and more than 40% of deaths within the first 24 hours after injury. Despite first aid having a demonstrable effect on mortality from trauma, relatively little research has compared the best methods for bleeding control in the prehospital first aid setting. The most common first-line therapy for external bleeding control in the pre-hospital first aid setting is direct manual compression (DMC). However, a prior study demonstrated that the primary cause of failure in a simulated model of life-threatening bleeding was the inability to maintain adequate direct pressure for three minutes. In this study, we evaluated the effect of fatigue on DMC for the duration of a typical urban emergency medical services (EMS) response time. Methods We conducted a prospective observational trial of 33 participants, 18 years of age or older to measure the pressure generated on a model of life-threatening bleeding over an eight-minute period using a "CPR posture" for applying pressure. The primary analyses were longitudinal two-level multilevel models (MLM) with repeated measures of outcome (i.e., CPR posture pressure) nesting within participants. The demographic factors of gender, age, and weight were included as moderators in the analyses and each was analyzed independently. Results The participants' average age was 31 (SD = 11) and the average weight was 161 pounds (SD = 31). The sample consisted of 18 female participants (54.5%) and 15 male participants (45.5%). Applied DMC pressure declined over time, more sharply initially from the beginning to approximately 250 seconds, at which point the decrease in pressure was gradual. Of the demographic factors, gender was associated with a difference in cardiopulmonary resuscitation (CPR) posture pressure over time. Conclusion Rescuers should be aware that fatigue may occur and may affect the quality of direct manual compression for control of life-threatening bleeding. Further research is needed to define the external pressures needed to control life-threatening bleeding and the extent that rescuer fatigue affects this pressure.

Inconspicuous Presentation of Metastatic Neuroblastoma.

Neuroblastoma is a malignant tumor arising from nerve tissue that accounts for approximately 15 percent of pediatric cancer fatalities. Primary tumors most commonly arise in sympathetic nervous tissue of the abdomen and metastasize to the bone marrow, liver, and lymph nodes. This case report depicts a 3-year-old girl who presented with a recurring fever, runny nose, and a positive test for rhinovirus suggesting a simple case of the common cold. Further investigation, however, revealed stage 4 neuroblastoma. This patient experience emphasizes the importance of having a high level of suspicion to rule out more serious underlying pathology in a seemingly unremarkable patient presentation.

An ecohydraulic model to identify and monitor Moapa dace habitat.

Moapa dace (Moapa coriacea) is a critically endangered thermophilic minnow native to the Muddy River ecosystem in southeastern Nevada, USA. Restricted to temperatures between 26.0 and 32.0 °C, these fish are constrained to the upper two km of the Muddy River and several small tributaries fed by warm springs. Habitat alterations, nonnative species invasion, and water withdrawals during the 20th century resulted in a drastic decline in the dace population and in 1979 the Moapa Valley National Wildlife Refuge (Refuge) was created to protect them. The goal of our study was to determine the potential effects of reduced surface flows that might result from groundwater pumping or water diversions on Moapa dace habitat inside the Refuge. We accomplished our goal in several steps. First, we conducted snorkel surveys to determine the locations of Moapa dace on three warm-spring tributaries of the Muddy River. Second, we conducted hydraulic simulations over a range of flows with a two-dimensional hydrodynamic model. Third, we developed a set of Moapa dace habitat models with logistic regression and a geographic information system. Fourth, we estimated Moapa dace habitat over a range of flows (plus or minus 30% of base flow). Our spatially explicit habitat models achieved classification accuracies between 85% and 91%, depending on the snorkel survey and creek. Water depth was the most significant covariate in our models, followed by substrate, Froude number, velocity, and water temperature. Hydraulic simulations showed 2-11% gains in dace habitat when flows were increased by 30%, and 8-32% losses when flows were reduced by 30%. To ensure the health and survival of Moapa dace and the Muddy River ecosystem, groundwater and surface-water withdrawals and diversions need to be carefully monitored, while fully implementing a proactive conservation strategy.