Innovative Approaches to Emergency Medical Services Fellowship Challenges.

INTRODUCTION: Since the development of an Accreditation Council of Graduate Medical Education (ACGME)-accredited emergency medical services (EMS) fellowship, there has been little published literature on effective methods of content delivery or training modalities. Here we explore a variety of innovative approaches to the development and revision of the EMS fellowship curriculum. METHODS: Three academic, university-based ACGME-accredited EMS fellowship programs each implemented an innovative change to their existing training curricula. These changes included the following: a novel didactic curriculum delivery modality and evaluation; implementation of a distance education program to improve EMS fellows' rural EMS experiences; and modification of an existing EMS fellowship curriculum to train a non-emergency medicine physician. RESULTS: Changes made to each of the above EMS fellowship programs addressed unique challenges, demonstrating areas of success and promise for more generalized implementation of these curricula. Obstacles remain in tailoring the described curricula to the needs of each unique institution and system. CONCLUSION: Three separate curricula and program changes were implemented to overcome specific challenges and achieve educational goals. It is our hope that our shared experiences will enable others in addressing common barriers to teaching the EMS fellowship core content and share similar innovative approaches to educational challenges.

Body Temperature after EMS Transport: Association with Traumatic Brain Injury Outcomes.

INTRODUCTION: Low body temperatures following prehospital transport are associated with poor outcomes in patients with traumatic brain injury (TBI). However, a minimal amount is known about potential associations across a range of temperatures obtained immediately after prehospital transport. Furthermore, a minimal amount is known about the influence of body temperature on non-mortality outcomes. The purpose of this study was to assess the correlation between temperatures obtained immediately following prehospital transport and TBI outcomes across the entire range of temperatures. METHODS: This retrospective observational study included all moderate/severe TBI cases (CDC Barell Matrix Type 1) in the pre-implementation cohort of the Excellence in Prehospital Injury Care (EPIC) TBI Study (NIH/NINDS: 1R01NS071049). Cases were compared across four cohorts of initial trauma center temperature (ITCT): <35.0°C [Very Low Temperature (VLT)]; 35.0-35.9°C [Low Temperature (LT)]; 36.0-37.9°C [Normal Temperature (NT)]; and ≥38.0°C [Elevated Temperature (ET)]. Multivariable analysis was performed adjusting for injury severity score, age, sex, race, ethnicity, blunt/penetrating trauma, and payment source. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) for mortality were calculated. To evaluate non-mortality outcomes, deaths were excluded and the adjusted median increase in hospital length of stay (LOS), ICU LOS and total hospital charges were calculated for each ITCT group and compared to the NT group. RESULTS: 22,925 cases were identified and cases with interfacility transfer (7361, 32%), no EMS transport (1213, 5%), missing ITCT (2083, 9%), or missing demographic data (391, 2%) were excluded. Within this study cohort the aORs for death (compared to the NT group) were 2.41 (CI: 1.83-3.17) for VLT, 1.62 (CI: 1.37-1.93) for LT, and 1.86 (CI: 1.52-3.00) for ET. Similarly, trauma center (TC) LOS, ICU LOS, and total TC charges increased in all temperature groups when compared to NT. CONCLUSION: In this large, statewide study of major TBI, both ETs and LTs immediately following prehospital transport were independently associated with higher mortality and with increased TC LOS, ICU LOS, and total TC charges. Further study is needed to identify the causes of abnormal body temperature during the prehospital interval and if in-field measures to prevent temperature variations might improve outcomes.

Sternothyroideus myotomy, staphylectomy, and oral caudal soft palate photothermoplasty for treatment of dorsal displacement of the soft palate in 102 thoroughbred racehorses.

OBJECTIVE: To compare racing performance before and after sternothyroideus myotomy, staphylectomy, and oral caudal soft palate photothermoplasty in Thoroughbred racehorses with intermittent dorsal displacement of the soft palate (DDSP). STUDY DESIGN: Retrospective study. ANIMALS: Thoroughbred racehorses (n=102) with DDSP. METHODS: Retrieved data included signalment, primary complaint, and upper respiratory tract endoscopic finding. Lifetime race records were compared for earnings per start before and after surgery, days to 1st start, and races won postoperatively. RESULTS: Comparing mean earnings per start for 3 races before (2792 dollars) and after (3806 dollars) surgery, racing performance improved significantly after surgery in 63% (46/73) of horses that competed in at least 1 race before and after surgery (P=.02). Mean and median days to 1st start after surgery were 109 and 69 days, respectively. Of horses that raced postoperatively 65% (60/92) won at least 1 race, and 77% (71/92) raced in >5 races after surgery. CONCLUSIONS: Sternothyroideus myotomy, staphylectomy, and oral caudal soft palate photothermoplasty significantly improved racing performance in experienced Thoroughbred racehorses with performance limiting DDSP, and overall had a similar outcome to other reported surgical techniques for treatment of DDSP. Clinical Relevance-Sternothyroideus myotomy, staphylectomy, and oral caudal soft palate photothermoplasty should be considered as a surgical approach to correction of DDSP in Thoroughbred racehorses; however, it is possible that staphylectomy may not be necessary to achieve a desirable outcome.