Telemedicine in a box: overcoming complexity and high-cost telemedicine barriers using self-contained videoconferencing units.

This report describes our experience using low-and moderate-cost videoconferencing systems for telemedicine. After determining that low-cost systems using a standard personal computer and personal computer camera were unsatisfactory, a demonstration project was carried out using a $4000 self-contained videoconferencing unit (telemedicine in a box), using eight simulated telemedicine consultation scenarios. The quality of the videoconferencing was good for all eight scenarios. All eight consultation simulations demonstrated different ways of improving patient care. Two of the major problems hindering the broad proliferation of telemedicine (high cost and high complexity) are solved by the telemedicine in a box concept. Focussing on the telemedicine in a box concept when planning a telemedicine system will improve its feasibility in the real world of health care.

Injury reduction and bounce characteristics of safety baseballs and acceptability by youth leagues.

The only reasonable way to reduce the potential for ball-related youth baseball injuries sustained by the defensive players (the majority of ball-related injuries) is to make the ball less injurious. The American Academy of Pediatrics' 1994 statement on youth baseball injuries in this regard reads, "Consideration should be given to utilizing low-impact NOCSAE-approved baseballs and softballs for children 5 to 14 years of age, if these balls demonstrate satisfactory playing characteristics and reduce injury risk. A variety of studies should be undertaken to determine the efficacy of low-impact balls in reducing serious impact injuries." The purpose of this study, in accordance with this AAP policy, is to investigate the following: A) injury reduction potential of softer baseballs, B) their bounce characteristics, and C) their acceptability by youth leagues. Six simple injury models were studied, baseball bounce characteristics were analyzed, and attitudes of safety baseballs among statewide Little League district presidents were surveyed. Injury models demonstrated less injury potential with safety baseballs compared to that with standard hard baseballs. Safety baseballs bounced higher after vertical drops and slow throws, but during fast throws (with the greatest injury potential), the bounce heights were similar for all ball types. Of 27 survey cards sent out, 13 were returned. While 9 respondents indicated that they were already using safety baseballs for the younger players, none of the 13 respondents indicated that they were planning to expand the use of safety baseballs in their leagues. In conclusion, safety baseballs are less injurious in these models. The bounce characteristics of safety baseballs are satisfactory. Youth baseball league officials are not very willing to expand the use of safety baseballs. We recommend using safety baseballs as a standard for all youth baseball leagues because these balls are safer.

GPS computer navigators to shorten EMS response and transport times.

GPS (global positioning satellite system to determine one's position on earth) units have become inexpensive and compact. The purpose of this study is to assess the effectiveness of a GPS enhanced computer street map navigator to improve the ability of EMS drivers in an urban setting to locate their destination and shorten response times. For part I, residential addresses in the city were randomly selected from a telephone directory. Two driver/navigator teams were assigned to drive to the address adhering to speed limits. One team used a standard street map, whereas the other team used a GPS computer navigator. The travel time and distance of the runs were compared. For part II, the computer GPS navigator was placed on an ambulance to supplement their normal methods of navigation to find the address requesting EMS. After the run was completed, EMS providers were interviewed to determine their opinion of whether the GPS navigator was helpful. For part I the results showed that in the 29 initial test runs, comparing the GPS team versus the standard map team, the mean distances traveled were 8.7 versus 9.0 kilometers (not significant) and the mean travel times were 13.5 versus 14.6 minutes (P=.02), respectively. The GPS team arrived faster in 72% runs. For part II the results showed that most EMS providers surveyed noted that the GPS computer navigator enhanced their ability to find the destination and all EMS providers acknowledged that it would enhance their ability to find a destination in an area in which they were unfamiliar. These results suggest that a portable GPS computer navigator system is helpful and can enhance the ability of prehospital care providers to locate their destination. Because these units are accurate and inexpensive, GPS computer navigators may be a valuable tool in reducing pre-hospital transport times.

Child literacy promotion in the emergency department.

INTRODUCTION: Studies using primary health care settings to promote literacy have demonstrated success. Since socioeconomically disadvantaged children have less access to primary care, obtaining much of their medical care episodically in emergency departments (ED), the purpose of this study is to investigate the effectiveness of a simple literacy promotion program conducted in the ED and to determine its efficacy and if there is a difference in promoting literacy with a brochure alone versus a brochure plus a children's book. METHODS: Medical student study investigators enrolled patients aged 20 months to 7 years undergoing acute care treatment and evaluation in an ED. Subjects were randomized to a literacy promotion brochure versus a brochure plus a children's book. Phone follow-up interviews were conducted to survey the degree of parental reading taking place at home. RESULTS: Fifty-one families were enrolled, 8 could not be contacted for follow-up, which left 43 families. Twenty-eight were randomized to book + handout and 15 were randomized to handout alone. On follow-up phone interviews, no significant change in reading was demonstrated regardless of whether a brochure alone was given or a book was given with the brochure. CONCLUSION: Literacy promotion in the ED was not associated with any measurable improvement in parent-child reading. This could mean that the ED is not an effective place to promote literacy or confounding factors in this study are responsible for failing to demonstrate a measurable benefit.

Parental pediatric corticosteroid preferences.

Corticosteroids are often prescribed in the acute care management of asthma. Prednisolone can be administered intramuscularly (IM) or orally in 2 different concentrations. This study evaluated parental preference for three prednisolone preparations based on the route of administration, taste, and volume required. Accompanying adults (AAs) of pediatric patients were interviewed about their preferences based on the 3 factors. Those AAs who passed the health screen (51 of 214) were asked to taste 2 oral prednisolone preparations and reinterviewed about their corticosteroid preferences. Of the 214 AAs, 96% were parents. Of the group, 43% preferred IM corticosteroids whereas 40% preferred oral corticosteroids. Without considering taste as a factor for oral corticosteroids, 94% preferred the more concentrated syrup compared with the less concentrated one. When told that the less concentrated syrup tasted better, 58% preferred the less concentrated/better tasting syrup. After the 51 taste test subcohort subjects tasted the syrups, 96% preferred the less concentrated/ better tasting syrup over the more concentrated/poorer tasting syrup. Taste is more important than volume of administration for this particular corticosteroid comparison. Simply asking parents about their IM/oral and syrup formulation preferences may be the easiest way of optimizing their treatment plan.

Revising the decision analysis for febrile children at risk for occult bacteremia in a future era of widespread pneumococcal immunization.

Previous decision analyses (DA), which have attempted to determine a superior management option for febrile children at risk for occult bacteremia, have come to different conclusions based on their underlying assumptions. Most DAs have recommended a laboratory evaluation with antibiotic treatment or have concluded that all management options are roughly the same. The purpose of this revised DA is to determine which management strategy will be superior in an anticipated era of widespread pneumococcal immunization. Decision analysis methodology comparing the following 3 management options: Obs: observation, no tests, no antibiotics; CBC+: Complete blood count (CBC) first; if the white blood cell count (WBC) >15,000, then blood culture (BC) plus antibiotics (Abx); BC+Abx: BC+Abx for all patients. Assumptions include a current bacteremia rate of 2% to 4%, and 95% of this bacteremia is caused by S. pneumococcus (which has a 15% persistent bacteremia rate) with the remainder caused by virulent bacteria (which has a 100% persistent bacteremia rate), and other assumptions made by previous decision analysis publications. Pneumococcal vaccine efficacy rates of 0%, 50%, 75%, and 100% in preventing pneumococcal bacteremia were analyzed. Overall death and neurologic sequelae rates are lower with efficacious pneumococcal vaccine. The Obs strategy is superior for all efficacy rates (including 0%) if the negative consequences of treatment are high. If the negative consequences of treatment are low, the CBC+ strategy is superior at pneumococcal vaccine efficacy rates of 50% or greater. The absolute differences between the outcomes of the 3 strategies are small, making them similar. This decision analysis indicates that widespread efficacious pneumococcal vaccine will reduce the overall morbidity and mortality associated with pneumococcal bacteremia. This favors the Obs strategy, but the superior management strategy is still dependent on an assumption of the negative consequences of treatment. Since the outcome measures for each of the management strategies are similar numerically, the strategy chosen in clinical practice may consider other factors associated with the clinical encounter such as those described.

Malpractice risk assessment among different approaches for informed consent.

INTRODUCTION: The standards for obtaining informed consent, set forth by the Hawaii Revised Statutes, establish that it is the physician's duty to disclose what a reasonable person objectively needs to hear in order to make an informed decision. It is the purpose of this study to report the opinions of medical malpractice attorneys to survey their opinion whether full or limited disclosure of alternative treatments in informed consent is viewed as having a lower malpractice risk. METHODS: Hawaii medical malpractice attorneys viewed a compilation of arguments for and against both full and limited disclosure, and completed an opinion survey after reading samples of disclosure statements in two different case scenarios: 1) a pediatric emergency department case involving a febrile child at risk for occult bacteremia, and 2) an obstetrics case involving a woman with a postdate pregnancy. RESULTS: A vast majority of respondents believe that, in general and in the obstetrics case, full disclosure results in less liability. In the pediatrics ED case, 46% chose full disclosure as having less liability, 38% believe that the same liability exists with both full and limited disclosure, and 15% believe that limited disclosure is associated with less liability in this case. CONCLUSIONS: Hawaii attorneys with medical malpractice experience overwhelmingly agree that, in general, full disclosure is associated will less medical legal liability. Full disclosure was also the option selected as associated with less liability by a majority of attorneys in a sample obstetrical case. Opinions were more diverse in the pediatrics ED case. Many attorneys stressed that judging the risk of liability in general is difficult, and should be done on a case by case basis.

The role of intravenous valproic acid in status epilepticus.

Valproic acid (VA) has been reported to be effective in status epilepticus (SE) when given rectally. More recently, intravenous (IV) VA has been demonstrated to be effective and safe. Pharmacokinetic studies and initial clinical experience with IV valproic acid suggest that it may have a useful role in the management of refractory status epilepticus, but the magnitude of its utility is not possible to quantify or compare with phenytoin and phenobarbital. In simple SE, IV VA provides less additional benefit, since standard therapy usually works well. IV VA may be useful as a substitute for standard simple SE therapy, but this is difficult to justify unless adverse reactions to standard therapy are anticipated. The published pediatric experience with IV VA for SE is scant.

A demonstration of instant pocket wireless CT teleradiology to facilitate stat neurosurgical consultation and future telemedicine implications.

To show the feasibility of wireless pocket teleradiology, brain computed tomography scan images of five neurosurgical emergency cases were received on a pocket computer via a wireless modem link. Viewing times from turning on the pocket computer to viewing the entire image ranged from 4 to 6 minutes. The quality of the images was satisfactory. Reliability in obtaining a wireless internet connection was good, but not perfect. Wireless pocket telemedicine devices carried by specialists may improve the ability of telemedicine systems to gain access to the expertise of specialists.

Intraosseous is faster and easier than umbilical venous catheterization in newborn emergency vascular access models.

The purpose of this study is to compare the speed and ease of establishing newborn emergency vascular access using intraosseous (IO) versus umbilical venous catheterization (UVC). The study is an experimental design. A total of 42 medical students, without prior IO and UVC experience, were recruited as study subjects. All subjects performed the UVC procedure and were randomized (by a coin flip) to perform the IO procedure in one of two models: (1) turkey bone or (2) plastic infant leg. Each subject performed an initial trial for both the IO and UVC procedures without practice ("Inexperienced attempt") and a second trial in both procedures after practice ("Experienced attempt"), such that in total, each subject completed four attempts (two IO and two UVC). IO and UVC placement times were measured, and placement difficulty scores for IO and UVC were measured using a 10 cm visual analog scale (VAS). The averaged elapsed time to successful access was significantly shorter for the IO procedure on both the initial "inexperienced" attempt (52 versus 134 seconds, P < .001) as well as the "experienced" attempt (45 versus 95 seconds, P = .011). Procedure difficulty scores were lower in the IO procedure for both "inexperienced" and "experienced" attempts (3.5 versus 5.5, P = .001 and 2.6 versus 4.7, P < .001) as measured on a 10 cm VAS. Although UVC may be preferred by neonatologists, this model suggests that IO results in easier and more rapid vascular access in those who do not frequently perform newborn resuscitation. As such, the benefit of teaching UVC in pediatric resuscitation courses should be reconsidered. The recommended method of emergency newborn vascular access should be reconsidered pending further studies on this subject.

Comparison of a new screw-tipped intraosseous needle versus a standard bone marrow aspiration needle for infusion.

The purpose of this study is to compare the speed and ease of establishing intraosseous infusion using a standard bone marrow needle (SBMN; $8) and a new screw-tipped intraosseous needle (Sur-Fast; $42). The study is an experimental design. A total of 42 medical students, without prior IO experience, were recruited as study subjects. Subjects were randomized to perform the IO procedures in one of two models: (1) turkey femur or (2) pork ribs. Each subject performed an initial trial using both IO needles without practice (inexperienced) and a second trial using both IO needles after practice (experienced attempt), such that in total, each subject completed four attempts (two with each needle type). IO placement times were measured, and placement difficulty scores were measured using a 10 cm visual analog scale (VAS). The averaged elapsed time to successful IO completion was significantly shorter for the SBMN in the initial "inexperienced" attempt (33 versus 54 seconds, P = .019), but there was no significant difference in the postpractice "experienced" attempt. VAS difficulty scores were lower (easier) for the SBMN for both inexperienced and experienced trials. Success rates were significantly higher for the Sur-Fast needle during the experienced attempt (95% versus 79%, P < .05), but there was no significant difference in success rates during the inexperienced attempt. The Sur-Fast screw-tipped intraosseous needle does not show superiority over the SBMN in this intraosseous model, therefore its higher cost is difficult to justify based on this study.

Dispensing home nebulizers for acute wheezing from the hospital is cost-effective.

The objective was to investigate the use characteristics of home nebulizers and to measure the benefit gained from dispensing home nebulizers (compared with their cost) to patients from the hospital. During the study period, August 28,1996 to May 17,1997, a sample of 232 of the 291 entries from a log of home nebulizers dispensed by the hospital respiratory care department were surveyed over the telephone. Of the 232 study subjects under the age of 21, a telephone interview of a guardian or supervising adult was completed in 106 subjects (46%) a mean of 43 weeks after the home nebulizer was prescribed (47% of the cohort received their home nebulizers from the inpatient service and another 47% were discharged with home nebulizers from the emergency department (ED)). An average of 3.6 estimated additional ED visits and 5.4 office/clinic visits for each patient were prevented by the home nebulizer. The benefit (savings from reduced ED and office visits alone) to cost ratio estimates range from $855:$90 to $1710:$90 or more. The overwhelming majority of the patients felt that the home nebulizer was a good idea, it was easy to use, they had no problems with the nebulizer and they received adequate training for home nebulizer use. Home nebulizers are a cost-effective means of providing home nebulized albuterol for selected outpatients. Hospital inpatient units and EDs which have the ability to dispense a home nebulizer, have an additional therapeutic option available for selected patients who may benefit from it. Medical insurance companies should fully support (ie, pay for) home nebulizers because it is cost effective. If there is any concern about the reliability of the patient to follow-up with their primary physician, the patient's primary physician should be contacted to discuss the feasibility of discharging the patient with a home nebulizer.

Emergency department presentations of cerebrovascular disease in children.

Five cases of children with cerebrovascular disease presentations to the emergency department (ED) were selected as a series to illustrate the variety of presentation of cerebrovascular disease in children. This series shows that although cerebrovascular disease in children is uncommon, it is likely that cases will occasionally present acutely to an ED. The emergency physician's role in the management of suspected acute strokes in children is that of immediate stabilization, imaging to rule out hemorrhage, other studies to rule out emergent acute disease, and timely consultation for further management. Computed tomography (CT) is useful to detect an acute hemorrhage or old ischemic lesion. Magnetic resonance imaging has superior image resolution over CT, but CT may be more practical initially. Magnetic resonance angiography is a useful part of the stroke workup in children.

A blinded, randomized, paired, placebo-controlled trial of 20-minute EMLA cream to reduce the pain of peripheral i.v. cannulation in the ED.

A eutectic mixture of local anesthetics (EMLA) in cream form has been used as a topical anesthetic to reduce the pain of procedures penetrating the skin. It is generally applied for 45 to 60 minutes before the painful procedure. The purpose of this study was to determine whether a 20-minute application of EMLA is useful in reducing the pain of routine peripheral intravenous cannulation in the emergency department (ED). A blinded, randomized, placebo-controlled, paired trial compared the pain of intravenous cannulation in both hands of study subjects: one hand was treated with 20-minute EMLA cream and the other hand was treated with 20-minute placebo cream. Forty subjects identified the more painful hand and scored pain measurements of each hand using a 10-cm visual analog scale. These data failed to demonstrate any significant benefit of EMLA compared with placebo. EMLA is not useful for intravenous cannulation when used for 20-minute application times. There may be more effective and less costly ways of reducing the pain of intravenous cannulation that patients would prefer.

Comparing ease of intraosseous needle placement: Jamshidi versus cook.

In a sample of 34 study subjects, Cook and Jamshidi intraosseous (IO) needles were compared for ease of insertion into turkey bones. The averaged lapsed time of insertion was significantly shorter using the Jamshidi needle (25.5 v 56.2 seconds, P < .0001). The mean difficulty of insertion score was lower using the Jamshidi needle (3.0 v 7.1 on a 10-cm visual analog scale, P < .0001). The less costly Jamshidi needle is easier to use in IO insertion in this turkey bone model.

A revised decision analysis of strategies in the management of febrile children at risk for occult bacteremia.

Two decision analysis reports published in 1991 concluded that the strategy of routine blood culture and empiric antibiotics was the superior strategy for febrile children at risk for occult bacteremia. This report describes a decision analysis of treatment strategies for these children considering the following changes that have occurred since then: (1) Hemophilus influenzae B incidence is low because of widespread vaccine use; (2) the emergence of resistant Streptococcus pneumoniae may affect the clinical effectiveness of empiric antibiotics in the future; and (3) the negative consequences of unnecessary antibiotic treatment have yet to be well defined. A decision analysis approach, modifying the original assumptions, was carried out. Sensitivity analyses were conducted on all assumption variables. Strategies employing empiric antibiotics were found to have the best outcomes, assuming low negative treatment consequences. If a high level of negative treatment consequences is assumed, strategies using a white blood cell count (WBC) are superior. If a very high level of negative treatment consequences is assumed, the strategy of no tests and no empiric antibiotic treatment is usually superior, unless the frequency of bacteremia is 10% or higher and empiric antibiotic efficacy is high, in which case a WBC strategy is superior. This information can be used to select a treatment strategy based largely on the estimation of the negative consequences of treatment.