The effect of display size on ultrasound interpretation.

OBJECTIVES: Ultrasound (US) is an essential component of emergency department patient care. US machines have become smaller and more affordable. Handheld ultrasound (HUS) machines are even more portable and easy to use at the patient's bedside. However, miniaturization may come with consequences. The ability to accurately interpret ultrasound on a smaller screen is unknown. This pilot study aims to assess how screen size affects the ability of emergency medicine clinicians to accurately interpret US videos. METHODS: This pilot study enrolled a prospective convenience sample of emergency medicine physicians. Participants completed a survey and were randomized to interpret US videos starting with either a phone-sized screen or a laptop-sized screen, switching to the other device at the halfway point. 50 unique US videos depicting right upper quadrant (RUQ) views of the Focused Assessment with Sonography in Trauma (FAST) examination were chosen for inclusion in the study. There were 25 US videos per device. All of the images were previously obtained on a cart-based machine (Mindray M9) and preselected by the study authors. Participants answered "Yes" or "No" in response to whether they identified free fluid. The time that each participant took to interpret each video was also recorded. Following the assessment, participants completed a post-interpretation survey. The goal of the pilot was to determine the accuracy of image interpretation on a small screen as compared to a laptop-sized screen. Statistical analyses were performed using MATLAB (The MathWorks, Inc., Natick, MA). Nonparametric statistical tests were utilized to compare subgroups, with a Wilcoxon signed rank test used for paired data and a Wilcoxon rank sum test for unpaired data. RESULTS: 52 emergency medicine physicians were enrolled in the study. The median accuracy of US interpretation for phone versus laptop image screen was 88.0% and 87.6% (p = 0.67). The mean time to interpret with phone versus laptop screen was 293 and 290 s (p = 0.66). CONCLUSIONS: The study found no statistically significant difference in the accuracy of US interpretation nor time spent interpreting when the pre-selected RUQ videos generated on a cart-based ultrasound machine were reviewed on a phone-sized versus a laptop-sized screen. This pilot study suggests that the accuracy of US interpretation may not be dependent upon the size of the screen utilized.

Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project.

INTRODUCTION: Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting. METHODS: An East of England physician-paramedic PHEM team adopted VL as first line for undertaking all prehospital advanced airway management. The study period was 2016-2020. Statistical process control charts were used to assess whether use of VL altered first-pass intubation success, frequency of intubation-related hypoxia and laryngeal inlet views. A survey was used to collect the team's views of VL introduction. RESULTS: 919 patients underwent advanced airway management during the study period. The introduction of VL did not improve first-pass intubation success, view of laryngeal inlet or intubation-associated hypoxia. VL improved situational awareness and opportunities for training but performed poorly in some environments. CONCLUSION: Despite the lack of objective improvement in care, subjective improvements meant that overall PHEM clinicians wanted to retain VL within their practice.

Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Agents and robots for collaborating and supporting physicians in healthcare scenarios.

Monitoring patients through robotics telehealth systems is an interesting scenario where patients' conditions, and their environment, are dynamic and unknown variables. We propose to improve telehealth systems' features to include the ability to serve patients with their needs, operating as human caregivers. The objective is to support the independent living of patients at home without losing the opportunity to monitor their health status. Application scenarios are several, and they spread from simple clinical assisting scenarios to an emergency one. For instance, in the case of a nursing home, the system would support in continuously monitoring the elderly patients. In contrast, in the case of an epidemic diffusion, such as COVID-19 pandemic, the system may help in all the early triage phases, significantly reducing the risk of contagion. However, the system has to let medical assistants perform actions remotely such as changing therapies or interacting with patients that need support. The paper proposes and describes a multi-agent architecture for intelligent medical care. We propose to use the beliefs-desires-intentions agent architecture, part of it is devised to be deployed in a robot. The result is an intelligent system that may allow robots the ability to select the most useful plan for unhandled situations and to communicate the choice to the physician for his validation and permission.

High Tensile Strength Increases Multifunctional Use of Survival Blankets in Wilderness Emergencies.

INTRODUCTION: Metallic survival blankets are multifunctional medical devices frequently used to provide thermal insulation in sport and leisure activities and in emergency care. To assess further properties of survival blankets, we investigated their breaking strength under laboratory conditions. METHODS: An experimental study was performed with 2 commercially available survival blankets used by emergency medical services. Breaking strength measured with a tensile testing machine was determined consecutively with 10 tests conducted per brand. RESULTS: Breaking strength (mean±SD) of the tested brands was 3.8±0.4 kN, (range: 2.8-4.1 kN) and 4.0±0.5 kN (range: 3.2-4.6 kN). When using the windlass of a commercially available tourniquet for the longitudinally folded survival blanket, the windlass bent at a force of 0.8 kN; when using a carabiner, the force exceeded 3.6 kN before failure occurred in both blanket brands. CONCLUSIONS: Both brands of survival blankets show impressive tensile strength, indicating that they have the potential to serve as temporary pelvic binders or even as makeshift tourniquets when urgent bleeding control is needed.

Physiological and Technical Considerations of Extracorporeal CO2 Removal.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .

An Exploratory Study of Sectra Table Visualization Improves the Effectiveness of Emergency Bedside Echocardiography Training.

OBJECTIVES: Echocardiography is an essential tool in emergency medicine, and its training is the most challenging of all types of bedside ultrasound (US) training. This study investigated the effectiveness of the Sectra Table (Sectra AB, Linköping, Sweden), an anatomy visualization and collaboration tool, in improving the quality of echocardiography training for emergency medicine physicians. METHODS: We conducted an exploratory prospective observational study from 2015 to 2017 and enrolled 66 trainees who participated in a 2.5-day bedside US course organized by the emergency department (ED) of Peking Union Medical College Hospital. The study participants underwent 2 different training programs: the first group received standard training, and the second group was trained with Sectra Table experiences integrated into the echocardiography training curriculum. After the training sessions, both groups were evaluated for their hands-on echocardiography performance. RESULTS: The new training program with the Sectra Table significantly increased trainees' self-confidence in performing bedside echocardiography. The Sectra Table trainees had a higher performance rating than the trainees in the traditional program, with a mean total assessment score of 40.5 versus 26.5 for traditional training (P < .01). The improved performance was evident for all subcategories of echocardiography. The higher performance rating of the Sectra Table trainees was also statistically significant after adjusting for confounders, including prior training experiences, baseline confidence in independently performing ED US examinations, the number of ED US examinations performed, years in ED practice, and physician seniority. CONCLUSIONS: Our analysis suggests that integrating the Sectra Table into echocardiography training may improve the effectiveness of training programs.

Scientific Publication Productivity of Emergency Physicians: A Bibliometric Analysis of the Last Decade.

BACKGROUND: A significant increase has been observed in scientific research in emergency medicine in the past 10 years. However, the contribution of emergency physicians (EPs) to the emergency medicine literature is not known. OBJECTIVE: The aim of this study was to analyze the contribution of EPs to the emergency medicine literature and their scientific publication productivity during a recent 10-year period. METHODS: Manuscripts published by EPs in emergency medicine journals in the Science Citation Index Expanded database during a recent 10-year period (2008-2017) were included in the study. The number of articles published by EPs, the distribution of the manuscripts by country and year, the impact factors, the citations per article, and the Hirsch (H) index were determined. RESULTS: A total of 15,281 original articles were published in a total of 24 journals by all EPs worldwide between 2008 and 2017. EPs from the United States published the highest number of articles (54.4% of all articles), followed by Canada (7.2%), Australia (6.2%), Turkey (4.3%), and the UK (4.1%). The countries with the highest H index were the United States (80), Canada (43), and the UK (40), respectively. South Korea had the highest increase in scientific production during the 10-year period (average annual growth rate of 17.89%). CONCLUSIONS: The number of articles increased from 2008 to 2017 in the whole world and in the United States. EPs from the United States were the most productive, both qualitatively and quantitatively.

Prospective study of the sensitivity of the Wood's lamp for common eye abnormalities.

OBJECTIVE: The Wood's lamp, a handheld instrument that uses long-wave ultraviolet (UV) light with magnification of 2-3 times, is commonly used by non-ophthalmologists for examining patients with eye complaints. The goal of current research was to determine the sensitivity and specificity of the Wood's lamp for common eye abnormalities. STUDY DESIGN: We examined a convenience sample of patients, 18 years of age and older, who presented for eye complaints to an urgent clinic of a large ophthalmology practice. This prospective observational trial was performed from December 2016 until July 2017. An ophthalmologist examined the patient's eyes with a Wood's lamp, followed by examination of the eyes using a slit lamp. The Wood's lamp was compared with the slit lamp, which served as the gold standard. RESULTS: There were 73 patients recruited. The mean age of study subjects (29 female and 44 male) was 49 years. The overall sensitivity of the Wood's lamp was 52% (38/73; 95% CI 40% to 64%). Based on the principal final diagnosis made with the slit lamp, the Wood's lamp only detected 9 of 16 corneal abrasions, 5 of 10 corneal ulcers, 5 of 9 corneal foreign bodies, 0 of 4 cases of non-herpetic keratitis, 1 of 2 cases of herpes keratitis, 1 of 5 rust rings and 18 of 28 other diagnoses. CONCLUSIONS AND RELEVANCE: Examination using the Wood's lamp fails to detect many common eye abnormalities. Our findings support the need for a slit lamp examination of patients with eye complaints whenever possible.

Investigation of Stethoscope Technology for En Route Care.

OBJECTIVE: Occupational challenges in air transport domains make auscultation with traditional stethoscopes difficult. This study aimed to investigate two commercial off-the-shelf stethoscopes for use in high noise military patient transport environments. The stethoscopes were assessed by Aeromedical Evacuation providers in a simulated C-130 trainer on live standardized mock patients. Device 1 was a dual-mode stethoscope developed for rotary wing military airframes. Device 2 was an electronic stethoscope developed for high noise civilian environments. Twenty clinicians performed cardiopulmonary auscultation using the devices on the same two standardized patients in a simulated C-130 then completed a subjective questionnaire on their ability to identify heart and lung sounds. Results indicated the dual-mode stethoscope had limited utility with clinician likeliness of use rated as low (median = 2; interquartile range = 1.75-3.25), whereas the electronic stethoscope had potential utility with likeliness of use rated as good (median = 4; interquartile range = 3.25-5). We conclude that further examination of devices capable of auscultation in high noise military environments is needed. In-flight testing of device 2 for use by end users has been completed and will be reported in a separate manuscript.

A method for the analysis and visualization of clinical workflow in dynamic environments.

The analysis of clinical workflow offers many challenges, especially in settings characterized by rapid dynamic change. Typically, some combination of approaches drawn from ethnography and grounded theory-based qualitative methods are used to develop relevant metrics. Medical institutions have recently attempted to introduce technological interventions to develop quantifiable quality metrics to supplement existing purely qualitative analyses. These interventions range from automated location tracking to repositories of clinical data (e.g., electronics health record (EHR) data, medical equipment logs). Our goal in this paper is to present a cohesive framework that combines a set of analytic techniques that can potentially complement traditional human observations to derive a deeper understanding of clinical workflow and thereby to enhance the quality, safety, and efficiency of care offered in that environment. We present a series of theoretically-guided techniques to perform analysis and visualization of data developed using location tracking, with illustrations using the Emergency Department (ED) as an example. Our framework is divided into three modules: (i) transformation, (ii) analysis, and (iii) visualization. We describe the methods used in each of these modules, and provide a series of visualizations developed using location-tracking data collected at the Mayo Clinic ED (Phoenix, AZ). Our innovative analytics go beyond qualitative study, and includes user data collected from a relatively modern but increasingly ubiquitous technique of location tracking, with the goal of creating quantitative workflow metrics. Although we believe that the methods we have developed will generalize well to other settings, additional work will be required to demonstrate their broad utility beyond our single study environment.

Medical equipment deployment in pediatric emergency prehospital medical units in Japan.

The deployment status of pediatric emergency equipment in ambulances in Japan is unknown. To investigate the status of and issues associated with prehospital emergency medical care for pediatric patients, we conducted a descriptive epidemiological study. We carried out a Web-based survey of 767 fire defense headquarters in Japan, of which 671 responded (valid response rate, 88%). Most of the fire defense headquarters equipped all of their ambulances with oxygen masks (82%), bag-valve masks (for neonates, 83%; for children, 84%), straight laryngoscope blades (for neonates, 47%; for children 68%), blood pressure cuffs for children (91%), oximeter probes (78%), and stiff neck collars (91%); but despite the need for other equipment such as nasopharyngeal and oropharyngeal airways, and Magill forceps, they were insufficiently deployed. In Japan, prehospital emergency medical equipment deployment does not meet the needs of pediatric patients. Minimum equipment standards need to be established for pediatric prehospital care.

"Cold Card" to Guide Responders in the Assessment and Care of Cold-Exposed Patients.

INTRODUCTION: A concise, easy-to-use decision aid "Cold Card" that can be carried in the field by wilderness search and rescue teams or medical responders to advise on assessment and care of cold-exposed patients was created. METHODS: A 2-sided card was designed to summarize the important principles established by the Wilderness Medical Society practice guidelines for hypothermia. The card was continually updated through feedback from several content experts. The card was then distributed for further feedback from members of the Search and Rescue Volunteer Association of Canada and enrollees of the Baby It's Cold Outside web-based educational program. This additional feedback was used to create the final iteration of the card. RESULTS: On the front "ASSESS COLD PATIENT" side, the level of cold exposure or hypothermia is accomplished by evaluating (as either normal or impaired function) consciousness, movement, shivering, and alertness on a series of concentric rings. The important treatment actions are provided for each cold-exposure level. The back "CARE FOR COLD PATIENT" side provides the required elements and principles of use for a hypothermia wrap. The Cold Card is available for free download and unlimited use for education or in-field instruction by any individual or group. The card should be printed on heavy, waterproof stock (13×18 cm) for use in all weather conditions. CONCLUSIONS: Key elements of hypothermia evaluation and field care have been summarized on a small portable card for laypersons, trained rescuers, and first responders.

Prehospital Emergency Medicine at the Beach: What Is the Effect of Fins and Rescue Tubes in Lifesaving and Cardiopulmonary Resuscitation After Rescue?

OBJECTIVE: To analyze the influence of fins and rescue tube use in a water rescue, assessed by time and distance to salvage position, physiological parameters, and cardiopulmonary resuscitation (CPR). METHODS: Twenty professional lifeguards (10 men, 10 women) conducted 3 tests: a baseline test of 5 minutes of CPR and 2 water rescues, 1 without rescue equipment (NRE), and the other with fins and rescue tube (FRT). They also had to perform 5 minutes of CPR after each rescue. Time and distance of the rescues, physiological parameters (blood lactate concentration and heart rate), and quality of CPR were analyzed. RESULTS: CPR quality worsened by 26 to 28% (P < .001) after rescue. However, there were no differences using FRT. The use of rescue equipment reduced the time (FRT: 216±57 seconds; NRE: 319±127 seconds; P < .001) and distance covered (FRT: 265±52 m; NRE: 326±41 m; P < .001). No differences were found in lactate levels between FRT and NRE just after the rescues, but there were some after 5 minutes of subsequent CPR (FRT: 10.7±2.2 mmol/L; NRE: 12.6±1.8 mmol/L; P < .001). Comparing women with men, we found significant differences in lactate concentrations only in FRT (women: 9.6±1.4 mmol/L; men: 8.1±1.2 mmol/L; P = .031). CONCLUSIONS: The use of fins and rescue tube provides a comprehensive benefit in an aquatic emergency. However, FRT did not have any effect on the quality of the postrescue CPR.

Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science.

The purpose of this review is to summarize tourniquet science for possible translation to wilderness settings. Much combat casualty data has been studied since 2005, and use of tourniquets in the military has changed from a last resort to first aid. The US Government has made use of tourniquets a health policy aimed to improve public access to bleeding control items. International authorities believe that education in first aid should be universal, as all can and should learn first aid. The safety record of tourniquet use is mixed, but users are reliably safe if trained well. Well-designed tourniquets can reliably attain bleeding control, may mitigate risk of shock progression, and may improve survival rates, but conclusive proof of a survival benefit remains unclear in civilian settings. Even a war setting has a bias toward survivorship by sampling mostly survivors in hospitals. Improvised tourniquets are less reliable than well-designed tourniquets but may be better than none. The tourniquet model used most often in 2016 by the US military is the Combat Application Tourniquet (C-A-T), and civilians use an array of various models, including C-A-T. Evidence on tourniquet use to date indicates that most uses are safe and effective in civilian settings. Future directions for study relevant to the wilderness setting include consideration of research priorities, study of the burdens of injury or capability gaps in caregiving for various wilderness settings, determination of the skill needs of outdoor enthusiasts and wilderness caregivers, and survey of wilderness medicine stewards regarding bleeding control.

Feasibility study of a novel intraosseous device in adult human cadavers.

BACKGROUND & OBJECTIVES: Intraosseous (IO) access is an alternative to difficult intravenous (iv) access during emergency clinical situations. Existing IO solutions are expensive, require power supply and trained manpower; limiting their use in resource constrained settings. To address these limitations, a novel IO device has been developed. The objectives of this study were to evaluate functionality and safety of this device in adult human cadavers. METHODS: The ability of the IO device to penetrate the proximal and/or distal tibia was evaluated in three adult cadavers. Subjective parameters of loss of resistance, stable needle hold, easy needle withdrawal and any damage to the device were evaluated during the study. The insertion time was the objective parameter measured. Four sets of radiographs per insertion confirmed the position of the needle and identified complications. RESULTS: A single physician performed 12 IO access procedures using the same device. Penetration of proximal and/or distal tibia was achieved in all instances. It was successful in the first attempt in eight (66.7%) and during second attempt in the remaining. The mean time to insertion was 4.1 ± 3.1 sec. Appropriate insertion of needle in the intra-medullary space of bone was confirmed with radiological examination in 10 (83.3%) insertions. In two occasions after penetrating the cortical layer of bone, the device overshot the intra-medullary space, as detected by radiological examination. Device got bent during insertion in one instance. There was no evidence of needle breakage or bone fracture. The needle could be withdrawn effortlessly in all instances. INTERPRETATION & CONCLUSIONS: The novel IO device could successfully penetrate the adult cadaver bones in most cases. Further studies are needed to confirm these results on a large sample.

Comparison of the accuracy of hemoglobin point of care testing using HemoCue and GEM Premier 3000 with automated hematology analyzer in emergency room.

The laboratory analysis provides accurate, but time consuming hemoglobin level estimation especially in the emergency setting. The reliability of time-sparing point of care devices (POCT) remains uncertain. We tested two POCT devices accuracy (HemoCue®201+ and Gem®Premier™3000) in routine emergency department workflow. Blood samples taken from patients admitted to the emergency department were analyzed for hemoglobin concentration using a laboratory reference Beckman Coulter LH 750 (HBLAB), the HemoCue (HBHC) and the Gem Premier 3000 (HBGEM). Pairwise comparison for each device and HbLAB was performed using correlation and the Bland-Altman methods. The reliability of transfusion decision was assessed using three-zone error grid. A total of 292 measurements were performed in 99 patients. Mean hemoglobin level were 115 ± 33, 110 ± 28 and 111 ± 30 g/l for HbHC, HbGEM and HbLAB respectively. A significant correlation was observed for both devices: HbHC versus HbLAB (r2 = 0.93, p < 0.001) and HBGEM versus HBLAB (r2 = 0.86, p < 0.001). The Bland-Altman method revealed bias of -3.7 g/l (limits of agreement -20.9 to 13.5) for HBHC and HBLAB and 2.5 g/l (-18.6 to 23.5) for HBGEM and HBLAB, which significantly differed between POCT devices (p < 0.001). Using the error grid methodology: 94 or 91 % of values (HbHC and HbGEM) fell in the zone of acceptable difference (A), whereas 0 and 1 % (HbHC and HbGEM) were unacceptable (zone C). The absolute accuracy of tested POCT devices was low though reaching a high level of correlation with laboratory measurement. The results of the Morey´s error grid were unfavorable for both POCT devices.

[Interdisciplinary consensus statement on alternative airway management with supraglottic airway devices in pediatric emergency medicine: Laryngeal mask is state of the art]. / Interdisziplinär konsentierte Stellungnahme zum Atemwegsmanagement mit supraglottischen Atemwegshilfen in der Kindernotfallmedizin: Larynxmaske ist State-of-the-art.

BACKGROUND: Airway management with supraglottic airway devices (SGA) in life-threatening emergencies involving children is becoming increasingly more important. The laryngeal mask (LM) and the laryngeal tube (LT) are devices commonly used for this purpose. This article presents a literature review and consensus statement by various societies on the use of SGA in pediatric emergency medicine. MATERIAL AND METHODS: Literature search in the database PubMed and classification of studies according to the criteria of the Oxford Centre for Evidence-based Medicine levels of evidence. RESULTS: The evidence for successful application of the various types of LM is significantly higher than for LT application. Reports of smaller series of successful applications of LT are currently limited to selected research groups and centers. Insufficient evidence currently exists for the successful application of the LT especially for children below 10 kg body weight and, therefore, its routine use cannot currently be recommended. SGAs used for emergencies should have a possibility for gastric drainage. DISCUSSION: Considering the scientific data and the large clinical experience with the LM in medical routine and emergency situations in children, currently only the LM can be recommended for alternative (i.e. non-intubation) airway management in children. If alternative airway management is part of a local emergency strategy, the LM should be provided in all pediatric sizes (1, 1.5, 2, 2.5, 3, 4 and 5) for prehospital and in-hospital emergency use and all users should be regularly trained in its application.