Teaching how to stop the bleed: does it work? A prospective evaluation of tourniquet application in law enforcement officers and private security personnel.

INTRODUCTION: Stop the Bleed (STB) program was launched by the White House, for the use of bleeding control techniques at the scene of traumatic injury. The purpose of this study was to conduct an STB course in private security and law enforcement personnel. METHODS: Pre- and post-questionnaire using the Likert scale was shared with participants on their knowledge and comfort level with the use of tourniquets. Participants were also observed while placing tourniquets and the time for placement recorded. The didactic portion and practical session of the STB was then taught and participants were again observed placing tourniquets and a questionnaire distributed. Fisher's exact tests or Wilcoxon matched-pairs signed-ranks tests were used to compare pre-post measurements. RESULTS: A total of 151 subjects were enrolled over the course of seven sessions. The tourniquet was applied correctly by 17.2% (26/151) and 92.7% (140/151) at the pre- and post-instruction assessments, respectively (p < 0.001). Mean times to apply the tourniquet were 29.8 ± 18.5 and 18.7 ± 6.7 s, respectively (p < 0.001). Subjects reported their level of comfort with the tourniquet to be 5.1 ± 3.3 and 8.8 ± 2.2, respectively (p < 0.001), and their familiarity with anatomy and bleeding control to be 5.2 ± 3.1 and 8.2 ± 2.4, respectively (p < 0.001). At the end of the course, the mean score in response to a question about the extent to which the explanation had helped was 9.0 ± 1.9 (95% CI 8.7-9.4) and to a question about the extent to which teaching would make them feel more secure and safe was 9.2 ± 1.9 (95% CI 8.9-9.5). CONCLUSIONS: STB course improved correct tourniquet placement, demonstrated dramatic improvements in application time, and increased levels of comfort. These findings validate the need for ongoing teaching and education.

The Stage IV Shuffle: Elusiveness of Straight Talk About Advanced Cancer.

During the initial consultation with a patient to communicate a diagnosis of late-stage cancer, the oncologist may refrain from giving survival statistics, redirecting the conversation from the bad news (incurability) to the practical aspects of the patient's care (treatments, timetables, appointments, and testing to monitor response to treatment). Whether conscious or unconscious, this diversion helps cushion the impact of the disturbing news. This paper shows that clinicians' gingerly handling of harsh facts when they talk with patients also applies to health educators and researchers when they write about late-stage cancer. As a result, these cancer patients typically lack an understanding of their poor prognosis and the limited effectiveness of most available treatments, possibly compromising their ability to make informed choices. To remedy this problem, I describe an approach to straight talk about late-stage cancer that can give a patient realistic hopes instead of false hopes that are apt to betray later on. I also propose an enhanced method of displaying and interpreting comparative efficacy data that can facilitate understanding and serve as a basis for shared decision making.

Predictors of death within six months in patients with advanced AIDS.

OBJECTIVES: This study sought to identify potential predictive variables of death within 6 months in patients with advanced AIDS. METHODS: Investigators enrolled a consecutive series of patients with advanced AIDS admitted to a skilled nursing facility in New York City over a 1-year period. Demographic, clinical, laboratory, and outcome data were abstracted from medical records using a standardized data collection instrument. RESULTS: Of the 152 patients enrolled during the study period, 61 patients (40%) died within 6 months from date of admission. Serum albumin, percent deviation from ideal body weight, and number of comorbidities at the time of admission proved to be the best combination of predictors of death within 6 months. SIGNIFICANCE OF RESULTS: The decrease in AIDS mortality over the past decade, along with an increase in prevalence due to longer survival, has been attributed primarily to the successful use of highly active antiretroviral therapy (HAART). HAART regimens, however, can also produce both short-term adverse effects and long-term complications. The prognostic model developed by this study may be useful in guiding treatment decisions in patients with advanced AIDS for whom a more palliative care plan may be sought.

Seizure disorder as a risk factor for gastroesophageal reflux in children with neurodevelopmental disabilities.

The proportion of children with severe neurodevelopmental disabilities, in whom symptoms of gastroesophageal reflux develop after gastrostomy placement, has not been well studied. The medical records of children who received a gastrostomy tube (with or without a simultaneous antireflux procedure) at our institution between 1987 and 1997 were reviewed to identify neurologically related diagnoses at the time of the gastrostomy, diagnostic tests ordered to detect reflux, and dates and reasons for re-admissions within 2 years of discharge. Of 102 patients studied, 37 received a gastrostomy tube alone. Complete follow-up data were available for 30 of these patients, 7 of whom (23%) required subsequent antireflux surgery within 2 years. Patients with a seizure disorder had greater than a 4-fold risk of re-admission for this operation compared with other patients (57% [4/7] vs. 13% [3/23]; P=0.03). In a child with severe neurodevelopmental disability, the existence of a seizure disorder at the time of a gastrostomy operation increases the risk of subsequently requiring an antireflux procedure by a factor of 4.

Unrecognized thyroid dysfunction in patients with cancer.

Abnormal thyroid function can cause subtle medical symptoms in "healthy" individuals. Because cancer can cause similar symptoms, physicians may fail to suspect and test for thyroid abnormalities. We measured thyroid function in 158 patients with various types of cancers being followed at a comprehensive cancer center and found that 16% of them had a thyroid abnormality, which had not been diagnosed and treated in any of them. We conclude that thyroid dysfunction is usually unrecognized in cancer patients and may possibly contribute to their morbidity.