Medic and Portable Pulse Oximeter Respiratory Rate Measurement Comparison to Waveform Capnography: A Prospective, Observational Study.

BACKGROUND: The second leading cause of preventable battlefield death involves airway management. Tactical combat casualty care (TCCC) guidelines emphasize combat casualty airway, breathing and respiratory evaluation, including respiratory rate (RR) measurement. The current standard of practice for the US Army medics is to measure the RR by manual counting. Manual counting methods are operator-dependent, and medics face situational stressors limiting accurate measurement of RR in combat settings. To date, no published studies evaluate alternate methods of RR measurement by medics. The purpose of this study is to compare RR assessment by medics against waveform capnography and commercial finger pulse oximeters with continuous plethysmography. MATERIALS AND METHODS: We conducted a prospective, observational study to compare Army medic RR assessments against plethysmography and waveform capnography RR. Assessments were performed prior to and following exertion at 30 and 60 seconds with both the pulse oximeter (NSN 6515-01-655-9412) and defibrillator monitor (NSN 6515-01-607-8629), followed by end-user surveys. RESULTS: Of the 40 medics enrolled over a 4-month period, most were male (85%), and reported between less than 5 years of military and medical experience. The mean manual RR reported by medics at rest did not significantly differ from waveform capnography (14.05 versus 13.98, p is equal to 0.523); however, mean manual RR reported by medics on post-exertional subjects was significantly lower than waveform capnography (25.62 versus 29.77, p is less than 0.001). Time to medic-obtained RR was slower than the pulse oximeter (NSN 6515-01-655-9412) both at rest (-7.37 seconds, p is less than 0.001) and at exertion (-6.50 seconds, p is less than 0.001). While the mean difference in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at rest at 30 seconds was statistically significant (-1.38, p is less than 0.001). There was no overall statistically significant differences in RR between the pulse oximeter (NSN 6515-01-655-9412) and waveform capnography in models at exertion at 30 seconds and at rest and exertion at 60 seconds. CONCLUSION: Resting RR measurement did not differ significantly; however, medic-obtained RR considerably deviated from both pulse oximeters and waveform capnography at elevated rates. Existing commercial pulse oximeters with RR plethysmography do not differ significantly from waveform capnography and should be investigated further for consideration in fielding across the force for RR assessment.

Comparing two doses of intramuscular ketorolac for treatment of acute musculoskeletal pain in a military emergency department.

STUDY OBJECTIVE: The goal of the study was to assess a low-dose versus a high-dose of intramuscular (IM) ketorolac for non-inferiority in adults with acute MSK pain in an emergency department (ED). METHODS: This was a single-blinded, randomized controlled, non-inferiority trial of adults presenting to an ED with a chief complaint of acute MSK pain. Patients were randomized to either a 15 mg or a 60 mg IM ketorolac dose. The primary outcome was the mean difference of change in pain from baseline to 60-min between the two groups as reported on a 100-mm (mm) visual analog scale (VAS). Secondary outcomes included the mean difference of change in VAS scores at 30-min and the incidence of reported adverse effects associated with the administration of ketorolac. RESULTS: One hundred ten patients were randomized with 55 in each group. The mean difference in pain between groups at 60-min (0.2 mm [95% CI -8.5-8.7]; p = .98) and 30 min (-1.7 mm [95% CI -8.5-5.1; p = .63) was less than the predetermined non-inferiority margin of 13 mm. There were no major adverse effects reported. Minor adverse effects were more frequent in the 60 mg group (n = 9; 16.4% vs. n = 1; 1.8%; p = .016) with burning at the injection site being the most commonly reported. CONCLUSIONS: A 15 mg dose of IM ketorolac was found to be non-inferior to a 60 mg dose for acute MSK pain in adults presenting to the ED. Discontinuing the practice of ordering 60 mg doses of IM ketorolac in place of a lower dose for acute MSK pain should be considered.

Improving vaccination uptake in pediatric Cochlear implant recipients.

BACKGROUND: An Infectious Disease vaccine specialist joined our institution's Cochlear Implant Team in 2010 in order to address the high percentage of non-compliance to immunization prior to surgery identified previously from an internal review. The purpose of this study was to (1) review the immunization status of cochlear implant recipients in 2010-2014, (2) assess if introducing a vaccine specialist made a significant change in vaccination compliance and (3) elucidate any barriers to vaccination compliance. METHODS: Retrospective chart review and a telephone survey. Medical records of 116 cochlear implant recipients between 2010 and 2014 were reviewed. A telephone survey was conducted to obtain the current vaccination status in children who required post-operative vaccinations with incomplete records on chart review and, if applicable, the reason for non-compliance. RESULTS: Between 2010 and 2014, 98% of children were up-to-date at the time of surgery, compared to 67% up-to-date at the time of surgery between 2002 and 2007. 27 children were included in our post-operative immunization analysis. 29.6% (8/27) failed to receive necessary vaccinations post-surgery. Pneumovax-23, a vaccine for high-risk patients (such as cochlear implant candidates) was missed in all cases. CONCLUSION: Pre-operative vaccination for cochlear implant recipients improved dramatically with the addition of a vaccine specialist. However, a significant proportion of patients requiring vaccinations post-surgery did not receive them. The main reason for non-compliance was due to parents being unaware that their children required this vaccine postoperatively by being "high-risk". Although improvement was demonstrated, a communication gap continued to impede the adequacy of vaccination uptake in pediatric cochlear implant recipients following surgery at age 2 when the high-risk vaccine was due.

Detection of abnormally shaped ears by a trained non-specialist allows for early non-surgical intervention.

INTRODUCTION: Many children are born with abnormally-shaped ears, including protruding ears or unusually-shaped outer ears. While the majority are benign, these may cause significant issues with self-esteem and bullying in childhood. Early molding can resolve some of these abnormalities, avoiding the need for future corrective surgery. However, newborns with these abnormalities are rarely identified early, within the first few days of life, when molding is most effective. In this study, we investigate whether a trained non-specialist can correctly identify ear shape abnormalities in newborns. METHODS: A non-specialist (medical student) was trained on normal and abnormal ear anatomy using photographs and descriptions. Newborns <72 h of age were recruited from maternity wards. Newborns' ears were photographed and these images were assessed independently by two specialists and the non-specialist. External ear shape was classified as either normal or abnormal based on pre-determined criteria. RESULTS: A total of 661 ears of 334 newborns were photographed and assessed. High inter-rater agreement was achieved with a kappa statistic of 0.863 (SE 0.078). The non-specialist detected abnormally-shaped ears with a sensitivity and specificity of 90.9% and 91.1% respectively. CONCLUSIONS: Our study illustrates that non-specialist can be trained to accurately detect newborn ear abnormalities, providing a cost-effective means of ensuring that these children's health care needs are met in a timely fashion. Specifically, we recommend the integration of ear shape assessment into currently established programs such as the newborn hearing screening program.

"Guidewire Intravenous Catheter Systems Do Not Improve First-Pass Success Rates for Peripheral Access When Placed By Army Combat Medics (68W) in a Pre-hospital Setting." A Prospective, Randomized Controlled Trial with Crossover Study Design.

Introduction: This study was completed to determine if guidewire catheters improve first-pass success and time of placement for peripheral intravenous access. In the military, 21% of casualties from the battlefield arrive to a medical facility in hemorrhagic shock. The importance of successful and timely intravenous placement is crucial in the initial steps of preventing this condition. Multiple studies and reviews have shown that initial first-pass success rates for pre-hospital intravenous placement have been as low as 40%, and an average success rate of 81% when completed by paramedics or similarly skilled personnel. In an attempt to replicate or improve these rates, we proposed to study placement success rates by active duty military combat medics. We hypothesized that there would be no difference in first-pass success rates when using either a standard or guidewire catheter. Materials and Methods: This study was a prospective, randomized, controlled trial with a crossover study design comparing the Accucath 18-gauge guidewire catheter to the standard 18-gauge peripheral intravenous catheter. The study included 93 1st Cavalry Division Army Combat Medics. Participants were voluntarily enrolled and consented on an individual basis. Each participant paired with a partner of their choice and acted as their own control. All supplies were laid out for the participants with the catheters randomly selected for either arm of the patient. The subjects were allowed to choose which catheter they would be tested on first. Times were recorded for only successful attempts. Results: The guidewire catheter was not proven to have a higher cannulation rate, achieving only a 44% success rate versus 66% in the standard catheter group, as well as averaging 42 seconds longer to obtain successful cannulation versus the standard catheter. Interestingly, it was observed that the greater the time in service, there was an increased success rate with the guidewire catheter that was not noted with the standard catheter. Conclusions: There was not a statistically significant improvement in the first-pass success rate of intravenous placement with the use of the guidewire catheter when compared with the standard-issue catheter. With these results, we cannot recommend the guidewire catheter to be used in leu of the standard catheter. Further studies might show improvement if subjects are allotted increased practice and familiarity with the new guidewire device.

Fracture of the inferior pole of the patella.

The patient was a 19-year-old woman serving in the military at a remote location. She presented to a medical aid station with a chief complaint of right anterior knee pain after falling 3 hours prior from a height of 3 m and landing directly on the anterior aspect of her right knee.

Peri-implant bone regeneration using recombinant human bone morphogenetic protein-2 in a canine model: a dose-response study.

The objective of this study was to evaluate the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) dose on alveolar ridge augmentation and dental implant osseointegration. Bilateral, 5 mm supraalveolar, peri-implant defects were surgically created in 6 beagle dogs. rhBMP-2 (0.05, 0.1 or 0.2 mg/ml) in an absorbable collagen sponge (ACS) carrier was molded around the fixtures and wounds were closed. Treatment variations were alternated between animals (incomplete block design). Animals were sacrificed at week 8 postsurgery. Nine of twelve jaw quadrants healed uneventfully. Two jaw quadrants exhibited wound failure by week 4 and one by week 8 postsurgery. Radiographic bone regeneration was observed in defects without wound failure from week 4 postsurgery. Radiolucent voids of variable size and shape were observed and regressed over time. In weeks 6 through 8, there was an apparent increase in bone density and trabecular structure, while bone height and volume decreased. Histometric analysis revealed limited differences in bone regeneration between experimental conditions. Bone regeneration area averaged (+/- SD) 1.0 +/- 0.5, 3.5 +/- 1.4 and 2.3 +/- 0.4 mm2 for the 0.05, 0.1 and 0.2 mg/ml dose, respectively. There were no significant differences in osseointegration. Osseointegration in newly formed bone averaged 19 +/- 4%, 18 +/- 10% and 21 +/- 6% for the 0.05, 0.1 and 0.2 mg/ml rhBMP-2 sites, respectively. Collectively, the data suggest that there are no dramatic differences in bone induction and osseointegration within the selected dose and observation interval.