ABSTRACT
OBJECTIVES: We aimed to characterize the clinical experiences of patients in whom heparin-induced thrombocytopenia (HIT) complicated heparin therapy for venous thromboembolism (VTE) and who switched to argatroban. DESIGN: A retrospective analysis of previously reported prospective, multicentre, historical-controlled Argatroban-911 and Argatroban-915 studies of argatroban therapy in HIT. SETTING: Inpatient. SUBJECTS: Patients (n = 145) administered heparin for VTE and who developed HIT were identified. INTERVENTIONS: Patients were treated with argatroban 2 mcg kg(-1) min(-1) for up to 14 days, adjusted to maintain activated partial thromboplastin times 1.5 to three times baseline. Patient characteristics, anticoagulation and outcomes were summarized. The primary end-point was a composite of death, amputation, or new thrombosis within 37 days of argatroban initiation. RESULTS: During heparin therapy, platelet counts decreased (mean +/- SD nadir: 78 +/- 67 x 10(9) L(-1)), and 75 (52%) patients developed thrombosis. After heparin was discontinued, patients received argatroban (mean dose 2.1 +/- 1.2 mcg kg(-1) min(-1)) for 6.8 +/- 4.3 days. By day 6 of argatroban therapy, the mean platelet count rose to >150 x 10(9) L(-1). The primary end-point occurred in 41 (28.3%) patients (values of 26-44% are reported for argatroban therapy of HIT from any heparin indication). Seventeen (11.7%) patients, including 12 who had also experienced thrombosis whilst on heparin, developed new thrombosis after argatroban initiation, typically on the day argatroban was discontinued or later (n = 10). Seven (4.8%) patients experienced major bleeding. CONCLUSIONS: For VTE patients with HIT, argatroban provides effective anticoagulation, with outcomes comparable with those reported for other argatroban-treated HIT patients. New thrombosis in this setting occurred most often in patients with existing HIT-associated thrombosis, before HIT recognition or either at/after argatroban discontinuation.
Subject(s)
Anticoagulants/adverse effects , Heparin/adverse effects , Thrombocytopenia/chemically induced , Thromboembolism/drug therapy , Amputation, Surgical/methods , Anticoagulants/administration & dosage , Arginine/analogs & derivatives , Drug Administration Schedule , Female , Hemorrhage/etiology , Heparin/administration & dosage , Humans , Male , Middle Aged , Pipecolic Acids/administration & dosage , Pipecolic Acids/therapeutic use , Platelet Count , Randomized Controlled Trials as Topic , Recurrence , Retrospective Studies , Sulfonamides , Thrombocytopenia/mortality , Thrombocytopenia/surgery , Thromboembolism/surgery , Treatment Outcome , Warfarin/therapeutic useABSTRACT
The need for collaboration in medical education is increasingly evident as allopathic and osteopathic physician communities continue to train physicians cooperatively. Therefore, ventures that hold dual accreditation in continuing medical education (CME) have increasing appeal to both physician groups. The Berkshire Medical Conference, a nationally accredited CME activity held annually in western Massachusetts and cosponsored by the University of Massachusetts Medical School, Berkshire Medical Center, and Berkshire Area Health Education Center, offered dual accreditation to allopathic and osteopathic physicians for the first time in its 16-year history. This dually accredited conference is the first such collaborative venture in the region. The specific criteria for accreditation for both physician groups were fulfilled, and the content also proved to be equally relevant. Evaluations indicated that learning objectives were met and the collaboration was successful in terms of the information learned by and about each group of physicians. As collaborative CME activities develop in the medical community, it is hoped that the lessons learned from the 16th Annual Berkshire Medical Conference, "Collaborations in Medicine," will serve as a model for future conferences and cooperative ventures between allopathic and osteopathic physicians.
Subject(s)
Accreditation , Education, Medical, Continuing , Osteopathic Medicine/education , Societies, Medical/organization & administration , American Medical Association , Cooperative Behavior , Humans , Interinstitutional Relations , Massachusetts , United StatesABSTRACT
Approximately 1,000 people in the United States suffer cardiac arrest each day, most often as a complication of acute myocardial infarction (AMI) with accompanying ventricular fibrillation or unstable ventricular tachycardia. Increasing the number of patients who survive cardiac arrest and minimizing the clinical sequelae associated with cardiac arrest in those who do survive are the objectives of emergency medical personnel. In 1990, the American Heart Association (AHA) suggested the chain of survival concept, with four links--early access, cardiopulmonary resuscitation (CPR), defibrillation, and advanced care--as the way to approach cardiac arrest. The recently published International Resuscitation Guidelines 2000 of the AHA have addressed advances in our understanding of the chain of survival. While the chain of survival concept has withstood a decade of scrutiny, there are only a few scientifically rigorous research studies that support changes in prehospital patient care. Additional research efforts carried out in the prehospital setting are needed to support the concepts included in the chain of survival for cardiac arrest patients. Participants at the second Turtle Creek Conference, a meeting of experts in the field of emergency medicine held in Dallas, Texas, on March 29-31, 2000, discussed these and other issues associated with prehospital emergency care in the cardiac arrest patient. This paper addresses a number of the issues associated with each of the links of the chain of survival, the evidence that exists, and what should be done to achieve the clinical evidence needed for true clinical significance. Also included in this paper are the consensus statements developed from small discussion groups held after the main presentation. These comments provide another perspective to the problems and to possible approaches to deal with them.
Subject(s)
Emergency Medical Services/statistics & numerical data , Evidence-Based Medicine , Heart Arrest/therapy , Practice Guidelines as Topic , Advanced Cardiac Life Support/methods , Advanced Cardiac Life Support/standards , American Heart Association , Cardiopulmonary Resuscitation/methods , Cardiopulmonary Resuscitation/standards , Electric Countershock/methods , Electric Countershock/standards , Health Services Accessibility/standards , Heart Arrest/epidemiology , Humans , Outcome and Process Assessment, Health Care , Survival Analysis , Time Factors , United States/epidemiologyABSTRACT
The acute coronary syndrome (ACS) is now used to describe a spectrum of clinical presentations that share an underlying pathophysiology, replacing the previous nomenclature of ischemic chest pain. The accurate diagnosis and proper management of patients with these entities require the emergency medicine physician to consider the entire spectrum of ACS, with emphasis placed on early diagnosis and rapid treatment. Each of these syndromes has its own prognosis, pathophysiology, and specific management strategy.
Subject(s)
Angina, Unstable/classification , Myocardial Infarction/classification , Myocardial Infarction/physiopathology , Angina, Unstable/diagnosis , Angina, Unstable/physiopathology , Chest Pain/etiology , Diagnosis, Differential , Emergency Medical Services , Humans , Myocardial Infarction/diagnosisABSTRACT
The use of ionizing radiation and radioactive materials continues to increase worldwide in industry, medicine, agriculture, research, electrical power generation, and nuclear weaponry. The risk of terrorism using weapons of mass destruction or simple radiological devices also has increased, leading to heightened concerns. Radiation accidents occur as a consequence of errors in transportation of radionuclides, use of radiation in medical diagnosis and therapy, industrial monitoring and sterilization procedures, and rarely, nuclear power generation. Compared to other industries, a small number of serious radiation accidents have occurred over the last six decades with recent cases in the Republic of Georgia, Peru, Japan, and Thailand. The medical, psychological, and political consequences of such accidents can be considerable. A number of programs designed to train medical responders in the techniques of radiation accident management have been developed and delivered in many countries. The low frequency of serious radiation accidents requires constant re-training, as skills are lost and medical staff turnover occurs. Not all of the training involves drills or exercises in which responders demonstrate learning or communication over the broad spectrum of medical response capabilities. Medical preparedness within the context of a total emergency response program is lacking in many parts of the world, particularly in Central and Eastern Europe and the Newly Independent States. This paper describes an effort to enhance medical preparedness in the context of a total program of international cooperation and conventions facilitated by the International Atomic Energy Agency. The paper concludes that novel application of telecommunications technology as part of a training activity in radiation accident preparedness can help address gaps in training in this field in which preparedness is essential but experience and practical field exercises are lacking.
Subject(s)
Computer-Assisted Instruction/methods , Emergency Medical Technicians/education , Inservice Training/organization & administration , Internet/organization & administration , Radiation Injuries/diagnosis , Radiation Injuries/therapy , Attitude of Health Personnel , Curriculum , Disaster Planning , Emergencies , Emergency Medical Technicians/psychology , Europe , Global Health , Humans , International Cooperation , Organizational Objectives , Program Development , Program Evaluation , Radiation Injuries/etiology , Radioactive Hazard Release , Telecommunications , Terrorism , United StatesABSTRACT
An ongoing collaborative partnership between the University of Massachusetts Medical Center, Boston University Medical Center, the Armenian Ministry of Health, and the Emergency Hospital of Yerevan, Armenia has been established since 1993. The primary goal of this partnership is to reform and improve the delivery of emergency medical care through a process of education and training that is reproducible, practical, and self-sustaining for the advancement of health care into the future. A six-step educational process was developed, using Armenia as the initial model site for this format. Through the development of a regional training center and two emergency medicine training curricula, the partnership has trained over 1800 health care workers and first responders. Preliminary results from pre- and post-course examinations show a significant overall improvement in scores. An ongoing trauma database collection also shows significant improvement in the number of advanced life support measures being implemented since the inception of this educational training programme. This educational strategy has subsequently been replicated in nine similar partnerships in other countries of the New Independent States, formed after the dissolution of the former Soviet Union in 1990. We believe this six-step educational format is effective for the development and improvement of emergency medical systems in developing countries worldwide.
Subject(s)
Emergency Medical Services , Emergency Medicine/education , International Cooperation , Armenia , Curriculum , Developing Countries , Educational Measurement , United States , WorkforceABSTRACT
The purpose of this study was to determine if emergency medical service (EMS) personnel could take instant photographs of motor vehicle damage at crash scenes depicting the area and severity of damage of the crash under adverse weather conditions, in different lighting, and quickly enough so as not to interfere with patient care. This prospective multicenter trial involved 35 ambulances responding to motor vehicle crash scenes in rural, suburban, and urban areas in five centers in four states. Emergency medical technicians (EMTs) reported their experience implementing a protocol for use of an instant camera to photograph vehicle damage at crash scenes. Time reported by EMTs to take the photographs was 1 minute or less in 204 of 288 (70.9%) of motor vehicle crashes and 2 minutes or longer in 12 of 288 (4.2%) of motor vehicle crashes. From one EMS agency in the study, 48 scene times during which photographs were taken were, on average, 1.5 minutes shorter than 48 scene times immediately before implementation of on-scene crash photography. Photographs were taken in different weather and lighting conditions. EMTs reported they were able to determine both area and severity of damage in 260 of 290 (92.5%) crash photographs, but they were unable to determine area and severity of damage in only 2 of 290 (0.7%) crash photographs.
Subject(s)
Accidents, Traffic , Emergency Medical Technicians , Photography , Documentation/methods , Emergency Medical Services , Humans , Prospective Studies , Time Factors , United States , Wounds and Injuries/therapyABSTRACT
The goal of emergency medicine is to improve health while preventing and treating disease and illness in patients seeking emergency medical care. Improvements in emergency medical care and the delivery of this care can be achieved through credible and meaningful research efforts. Improved delivery of emergency medical care through research requires careful planning and the wise use of limited resources. To achieve this goal, emergency medicine must provide appropriate training of young investigators and attract support for their work. Promotion of multidisciplinary research teams will help the specialty fulfill its goals. The result will be the improvement of emergency medical care which will benefit not only the patients emergency physicians serve but also, ultimately, the nation's health.
Subject(s)
Emergency Medicine , Research , Emergency Medicine/trends , Emergency Service, Hospital , HumansABSTRACT
Correct decision making may have far-reaching consequences. Triage is an area in which decision-makers must know what they are doing, why they are doing it, and which actions to take to achieve a satisfactory outcome. Triage has its origins in military history and today is used in a variety of medical settings. In this article we focus on the role of triage in disaster situations, its application in military settings, and its use in disaster medicine. Useful concepts enabling correct decision making by the triage officer include the application of computer technology and a review of methods of patient categorization. The dynamic nature of triage and the role of the triage officer as part of a team approach to disaster patient management are highlighted. We explore techniques for the successful training and education of triage officers and investigate a model of the emergency physician as the triage officer.
Subject(s)
Decision Making , Triage/methods , Disasters , Emergencies , Humans , Military Medicine , Triage/trends , Wounds and Injuries/diagnosisABSTRACT
The definition and causes for internal and external disasters are discussed in this article. Features of a hospital disaster plan are outlined with special reference to the role of the emergency department. Examples of previous disasters involving hospitals are presented to demonstrate problems that disaster planners should anticipate.
Subject(s)
Disaster Planning , Emergency Medicine , Emergency Service, Hospital/organization & administration , Disasters/classification , HumansABSTRACT
STUDY OBJECTIVE: To compare oxygen administration by means of an inflatable portable hyperbaric chamber with that through a nonrebreather mask for the elimination of carboxyhemoglobin (COHb). DESIGN: Double-crossover prospective analysis. SETTING: University emergency department, Level I trauma center. PARTICIPANTS: Twelve healthy paid adult volunteers, all smokers. INTERVENTIONS: Each subject smoked five cigarettes within 60 minutes. COHb levels were measured before and after smoking by means of cooximetry. Subjects then breathed hyperbaric and normobaric oxygen in separate trials for 40 minutes. Normobaric oxygen was administered through a nonrebreather face mask at 15 L/minute outside the Gamow bag. Hyperbaric oxygen was delivered inside the Gamow bag with a demand valve regulator mask at a pressure of 1.58 atmospheres absolute pressure (8.5 psi). Venous blood (.5 mL) was sampled every 5 minutes. The specimens were iced and assayed for COHb in triplicate. RESULTS: A significant increase in the elimination of COHb was observed for each subject in the Gamow bag (P < .05, repeated-measures ANOVA). The average half-life for COHb elimination was 27.5 +/- 1.08 minutes (mean +/- SE) (n = 10). IV access failure occurred in two patients, with incomplete data as a result. CONCLUSION: The modified Gamow bag eliminated COHb more quickly than did nonrebreather mask oxygen and proved simple to operate and maintain. No complications were noted for any of the subjects. One subject experienced claustrophobia, but it abated after the bag was inflated.
Subject(s)
Carboxyhemoglobin/metabolism , Hyperbaric Oxygenation/instrumentation , Adult , Cross-Over Studies , Equipment Design , Female , Half-Life , Humans , Male , Masks , Prospective Studies , Smoking/metabolism , Trauma CentersABSTRACT
At this writing, a collaborative partnership has been in place for 30 months between the Boston University Medical Center, the University of Massachusetts Medical Center, the Armenian Ministry of Health, and the Emergency Hospital of Yerevan, Armenia, to improve emergency and trauma care in that city. Fifty-five individuals have traveled to and from the Emergency Hospital, the partner hospital. The collaboration has led to the creation of the Emergency Medical Services Institute (EMSI) at Emergency Hospital, an 800-bed facility that serves as a trauma center and as base for the Yerevan ambulance system. A curriculum (text and slides) has been developed and translated into Armenian and Russian. To date, the Armenian EMSI has trained nearly 300 emergency medical personnel: physicians, nurses, drivers, and first responders. The Armenian EMSI faculty have received training in directing instruction of emergency care providers. Plans are in place to begin training in Armenian cities outside of Yerevan and in neighboring republics. An emergency medicine residency program received ministry approval and was begun with six resident physicians in January 1995. To date, 45 nurses have graduated from a 400-hour training program. This partnership program chose an education initiative as the vehicle for interaction between the United States and the formerly Soviet-directed Armenian health care system. Officials of the partner hospital requested assistance in upgrading the skills of its abundant emergency care workforce, citing cardiovascular disease, trauma, and accidents as leading causes of death and disability in Armenia.(ABSTRACT TRUNCATED AT 250 WORDS)
Subject(s)
Emergency Medical Services/organization & administration , Emergency Medicine/education , Health Personnel/education , International Educational Exchange , Armenia , Curriculum , Emergency Medicine/organization & administration , Feasibility Studies , Health Services Needs and Demand , Humans , Program Development , United StatesSubject(s)
Chest Pain/etiology , Emergency Service, Hospital/standards , Patient Care Team , Humans , United StatesABSTRACT
All patients with symptoms and ECG findings suggestive of acute myocardial infarction (AMI) should be considered for treatment with thrombolytic agents. The decision to use thrombolytic therapy is a clinical judgment based upon a weighing of the potential benefits versus the possible risks. The physician must take into account relative contraindications, age of the patient, area of jeopardized myocardium, and duration of symptoms. Health professionals involved in the care of AMI patients should develop written plans and protocols addressing the following matters: identification of patients with chest pain in the prehospital setting (this applies to hospitals that receive patients from emergency medical services systems), triage of patients in the emergency department, obtaining the 12-lead electrocardiogram, determination of contraindications, authority for ordering thrombolytic therapy, and consultation for atypical cases. There also should be agreed standards for the time interval from arrival in the ED to administration of the thrombolytic agent, as well as a commitment to the prospective monitoring of procedures and times to assure continuous improvement. A time interval for treatment (arrival in ED to administration of drug) of 30 to 60 minutes should be achievable for patients who present with typical symptoms and ECG findings.
Subject(s)
Cardiopulmonary Resuscitation/methods , Fibrinolytic Agents/therapeutic use , Myocardial Infarction/drug therapy , Acute Disease , Electrocardiography , Emergencies , Fibrinolytic Agents/adverse effects , Humans , Myocardial Infarction/diagnosisABSTRACT
The computer is rapidly becoming an essential tool for the physician. Proper use of computers in practice will help physicians achieve both higher levels of quality and greater consistency in patient care. Only with computers can physicians rapidly access and process all the data now needed to best address the needs of their patients. As computer use in practice becomes the standard, the inability to use these tools will be incompatible with quality care. The computer is rapidly becoming essential to modern medical management strategies that demand efficiency, accuracy, and cost effectiveness in response to patient demands for assurance that quality care is being delivered.
Subject(s)
Emergency Service, Hospital/standards , Hospital Information Systems , Quality Assurance, Health Care , Computer Systems/economics , Hospital Information Systems/economics , Humans , Medical RecordsABSTRACT
STUDY OBJECTIVES: This study tested the hypothesis that serial creatine phosphokinase (CK)-MB sampling in the emergency department can identify acute myocardial infarction (AMI) in patients presenting to the ED with chest pain and nondiagnostic ECGs. DESIGN: Patients more than 30 years old who were evaluated initially in the ED and hospitalized for chest pain were studied. Serial CK-MB levels were analyzed prospectively using a rapid serum immunochemical assay for identification of AMI patients in the ED. Presenting ECGs showing new, greater than 1-mm ST elevation in two or more contiguous leads were considered diagnostic for AMI. All other ECGs were considered nondiagnostic ECGs. CK-MB levels were determined at ED presentation and hourly for three hours (total of four levels). Patients with at least one level of more than 7 ng/mL were considered to have a positive enzyme study. The in-hospital diagnosis of AMI was determined by the development of typical serial ECG changes or separate standard cardiac enzyme changes after admission. SETTING: Eight tertiary-care medical center hospitals. METHODS AND MAIN RESULTS: Of the 616 study patients, 108 (17.5%) were diagnosed in the hospital as AMI; 69 of these AMI patients (63.9%) had nondiagnostic ECGs in the ED. Of the patients with nondiagnostic ECGs, 55 (sensitivity, 79.7%) had a positive ED serial CK-MB enzyme study within three hours after presentation. Combining serial ED CK-MB assay results with diagnostic ECGs yielded an 88.4% sensitivity for AMI detection within three hours of ED presentation. The predictive value of a negative serial ED enzyme study for no AMI was 96.2% (specificity, 93.7%). CONCLUSION: Serial CK-MB determination in the ED can help identify AMI patients with initial nondiagnostic ECGs. Use of serial CK-MB analysis may facilitate optimal in-hospital disposition and help guide therapeutic interventions in patients with suspected AMI despite a nondiagnostic ECG.
Subject(s)
Chest Pain/etiology , Creatine Kinase/blood , Electrocardiography , Myocardial Infarction/diagnosis , Adult , Female , Humans , Isoenzymes , Male , Myocardial Infarction/enzymology , Predictive Value of Tests , ROC Curve , Reproducibility of Results , Sensitivity and SpecificityABSTRACT
A recent surge in the general awareness of the extent of disasters has increased concern over the adequacy of our state of preparedness for these events. Outbreaks of infectious disease after a disaster may have significant societal impacts. In preparation, rescuers must anticipate and identify infectious risks, isolate and treat the individuals with infections, and institute measures that will prevent the further spread of infectious diseases. Epidemiological factors may contribute to the spread of infectious disease after a given disaster. A simple microbiological laboratory in the field may be helpful in attempting to direct therapy at specific infectious etiologies. Prior post-disaster experience suggests that mass immunization may not always be valuable in protecting against disease spread acutely, although immunizations may be considered in a limited number of situations. Disaster medical personnel should prepare themselves with appropriate vaccinations and remain in good health; new pathogens must not be brought in by well-meaning relief personnel. Disasters often occur in a Third-World setting where resources are limited and often compromised. Complete recovery from infectious disease outbreaks and restoration of infection control practices may take years when a Third-World population has suffered a major disaster.
Subject(s)
Communicable Disease Control/methods , Communicable Diseases/epidemiology , Disaster Planning , Disease Outbreaks/prevention & control , Emergency Medical Services/organization & administration , Communicable Diseases/etiology , HumansABSTRACT
Traditionally, the autopsy is viewed as the ultimate quality assurance indicator in clinical medicine, yet very few clinical departments actually incorporate autopsy results in their formal quality assurance plans. Consequently, to investigate how autopsy results can be included on our emergency department plan, the clinical and autopsy diagnoses of 244 patients were reviewed retrospectively and compared to identify conditions that were unapparent or misdiagnosed at the time of death. The study period was from January 1984 through June 1988. The average yearly ED census was 33,266. Differences between clinical and autopsy diagnoses were categorized as class 1, 2, 3, or 4 findings. Major unexpected findings (classes 1 and 2) were found in ten patients (4%); the most common missed diagnoses were aortic dissection 3 (1.2%) and pulmonary embolus 2 (0.8%). Minor unexpected findings (classes 3 and 4) were discovered in 14 patients (5.8%). The results clearly identify unexpected findings and point to the need for more aggressive evaluations of certain conditions. Systematic review of autopsy data as presented has led to meaningful changes and delivery of care to emergency patients. Autopsies are a vital source of outcome-based information that should be part of every ED's quality assurance and risk management plan.