Integrating population- and individual-level information in a movement model of Yellowstone bison.

Throughout the world, fragmentation of landscapes by human activities has constrained the opportunity for large herbivores to migrate. Conflict between people and wildlife results when migrating animals transmit disease to livestock, damage property, and threaten human safety. Mitigating this conflict requires understanding the forces that shape migration patterns. Bison Bos bison migrating from Yellowstone National Park into the state of Montana during winter and spring concern ranchers on lands surrounding the park because bison can transmit brucellosis (Brucella abortus) to cattle. Migrations have been constrained, with bison being lethally removed or moved back into the park. We developed a state-space model to support decisions on bison management aimed at mitigating conflict with landowners outside the park. The model integrated recent GPS observations with 22 years (1990-2012) of aerial counts to forecast monthly distributions and identify factors driving migration. Wintering areas were located along decreasing elevation gradients, and bison accumulated in wintering areas prior to moving to areas progressively lower in elevation. Bison movements were affected by time since the onset of snowpack, snowpack magnitude, standing crop, and herd size. Migration pathways were increasingly used over time, suggesting that experience or learning influenced movements. To support adaptive management of Yellowstone bison, we forecast future movements to evaluate alternatives. Our approach of developing models capable of making explicit probabilistic forecasts of large herbivore movements and seasonal distributions is applicable to managing the migratory movements of large herbivores worldwide. These forecasts allow managers to develop and refine strategies in advance, and promote sound decision-making that reduces conflict as migratory animals come into contact with people.

Bovine brucellosis in wildlife: using adaptive management to improve understanding, technology and suppression.

Eradication of brucellosis from bison (Bison bison) and elk (Cervus elaphus) populations in the Greater Yellowstone Area is not possible with current technology. There are considerable uncertainties regarding the effectiveness of management techniques and unintended effects on wildlife behaviour and demography. However, adaptive management provides a framework for learning about the disease, improving suppression techniques, and lowering brucellosis transmission among wildlife and to cattle. Since it takes approximately three years after birth for female bison to become reproductively active and contribute to brucellosis transmission, there is an opportunity to implement actions such as vaccination and the selective removal of infectious bison based on age and assay results to reduce the potential for transmission. Older adult bison that have been exposed to the bacteria, but recovered from acute infection, could be retained in the population to provide some immunity (resistance) against future transmission. Through careful predictions, research, and monitoring, our understanding and technology will be improved and management actions can be adjusted to better achieve desired outcomes.

Resuscitation in the out-of-hospital setting: medical futility criteria for on-scene pronouncement of death.

The complete and irreversible cessation of life is often difficult to determine with complete confidence in the dynamic environment of out-of-hospital emergency care. As a result, resuscitation efforts often are initiated and maintained by emergency medical services (EMS) providers in many hopeless situations. Medical guidelines are reviewed here to aid EMS organizations with respect to decisions about: 1) initiating or waiving resuscitation efforts; 2) the appropriate duration of resuscitation efforts; and 3) recommended procedures for on-scene or prehospital pronouncement of death (termination of resuscitation). In cases of nontraumatic cardiac arrest, few unassailable criteria, other than certain physical signs of irreversible tissue deterioration, exist for determining medical futility at the initial encounter with the patient. Thus, the general medical recommendation is to attempt to resuscitate all patients, adult or child, in the absence of rigor mortis or dependent lividity. Conversely, wellfounded guidelines now are available for decisions regarding termination of resuscitation in such patients once they have received a trial of advanced cardiac life support. In practice, however, the final decision to proceed with on-scene pronouncement of death for these patients may be determined more by family and provider comfort levels and the specific on-scene environment. For patients with posttraumatic circulatory arrest, the type of injury (blunt or penetrating), the presence of vital signs, and the electrocardiographic findings are used to determine the futility of initiating or continuing resuscitation efforts. In general, patients who are asystolic on-scene are candidates for on-scene pronouncement, regardless of mechanism. With a few exceptions, blunt trauma patients with a clearly associated mechanism of lethal injury are generally candidates for immediate cessation of efforts once they lose their pulses and respirations. Regardless of the medical futility criteria, specialized training of EMS providers and targeted related testing of operational issues need to precede field implementation of on-scene pronouncement policies. Such policies also must be modified and adapted for local issues and resources. In addition, although the current determinations of medical futility, as delineated here, are important to establish for societal needs, the individual patient's right to live must be kept in mind always as new medical advances are developed.

EMT domestic violence knowledge and the results of an educational intervention.

The objective of this study was to determine levels of knowledge regarding domestic violence (DV), and the effectiveness of formal instruction about DV. A general knowledge survey of DV was given before and approximately 4 to 6 months after 3 hours of instruction given by Emergency Medicine and Law Enforcement faculty. A Emergency medical service (EMS) consisting of 73% paramedic-level providers in a metropolitan urban/suburban area. Differences in DV knowledge before and after the instruction were the main outcome measures. In the preinstruction series, 46 emergency medical technicians (EMTs) participated. After the instruction 19 EMTs participated (42%). Thirty-five percent of EMTs before instruction and 37% after instruction correctly identified the prevalence of DV against women as 15% to 30%. Thirty-five percent of EMTs before instruction and 63% after instruction (P < .05) correctly identified the prevalence of DV against men as 0% to 15%. Before instruction 54% knew that DV is equal among races, and 79% after instruction (P < .05). Before instruction 37% of EMTs knew that DV is equal in different socioeconomic groups and 68% after instruction (P < .05). The percent of EMTs who knew that the victim is not responsible for the abuse was 50% before instruction and 89% after instruction (P < .05). Before instruction, the results on a knowledge questionnaire were 54% correct, after instruction, results improved to 71% correct. Improvement in understanding of DV was shown for 4 of 11 questions after 3 hours of instruction. These results indicate the need for more instruction on DV for EMTs.

A culture apparatus for maintaining H2 at sub-nanomolar concentrations.

We devised a microbial culture apparatus capable of maintaining sub-nanomolar H2 concentrations. This apparatus provides a method for study of interspecies hydrogen transfer by externally fulfilling the thermodynamic requirement for low H2 concentrations, thereby obviating the need for use of cocultures to study some forms of metabolism. The culture vessel is constructed of glass and operates by sparging a liquid culture with purified gases, thereby removing H2 as it is produced. We used the culture apparatus to decouple a syntrophic association in an ethanol-consuming, methanogenic enrichment culture, allowing ethanol oxidation to dominate methane production. We also used the culture apparatus to grow pure cultures of the ethanol-oxidizing, proton-reducing Pelobacter acetylenicus (WoAcy 1), and to study the bioenergetics of growth.

Injury prevention and emergency medical services for children in a managed care environment.

Each year, 1 in 5 US children receives medical care as a result of injury. Injuries are the leading cause of medical spending for children ages 5 to 21 years, accounting for more than 20% of hospital admissions and days spent in the hospital. Pediatric injuries become an important issue for managed care organizations because of concern for member safety and increasing medical costs related to treatment. Because effective prevention decreases health care consumption, injury prevention often costs less than treating injuries. Simple devices, such as bicycle helmets, smoke detectors, and child safety seats, help keep children safe and save money. Appropriate emergency care at the scene of an injury, poison control centers that dispense expert advice over the telephone, and triaged regional trauma systems improve the outcome and save money at the same time. This article continues the white paper series by the Emergency Medical Services for Children Managed Care Task Force.

The out-of-hospital use of a domestic violence screen for assessing patient risk.

OBJECTIVES: To determine the following: 1) whether a Domestic Violence Scene Assessment Screen (DVSAS) is accurate at predicting domestic violence (DV) when compared with results on the validated Abuse Assessment Screen (AAS), and 2) whether EMTs can perform accurately on a DVSAS after they have finished a transport so as not to interfere with routine care. METHODS: All patients transported by ambulance from domestic environments (i.e., home) by an urban EMS system were included in the study. A ten-question screen was developed to assess whether a domestic environment had a high risk of having DV (DVSAS). A positive answer to any of the questions was considered to be a positive result on the screen. A trained observer with no clinical duties rode on the ambulance for randomized shifts during a two-month period. The observer completed the DVSAS while at the scene, then the patient, if able, completed the AAS. After finishing the transport, the EMT completed the DVSAS based on his or her memory of the scene. Results of the observer DVSAS were compared with the results of the EMT DVSAS and with the AAS. RESULTS: A total of 43 transports from domestic scenes were included in the study. The observer DVSAS alone was positive in five cases (12%), the EMT DVSAS alone was positive in five cases (12%), and both were positive in seven cases (17%). Agreement between the EMT and the observer yielded a kappa of 0.56 adjusted for chance. Of 15 (42%) patients able to complete the AAS, one (7%) was positive on the AAS alone, four (27%) were positive on the observer DVSAS alone, and three (29%) were positive on both. The observer DVSAS agreed with the AAS results in ten of 15 (66%) of cases. When compared with the AAS, the observer DVSAS had a sensitivity of 75%, specificity of 55%, positive predictive value of 38%, and negative predictive value of 86%. CONCLUSION: Emergency medical technicians can complete the DVSAS at the end of a transport with good agreement with results obtained by an independent observer at the scene. The DVSAS is able to reflect the results of the AAS with moderate to good agreement.

Hydrogen production by methanogens under low-hydrogen conditions.

Hydrogen production was studied in four species of methanogens (Methanothermobacter marburgensis, Methanosaeta thermophila, Methanosarcina barkeri, and Methanosaeta concilii) under conditions of low (sub-nanomolar) ambient hydrogen concentration using a specially designed culture apparatus. Transient hydrogen production was observed and quantified for each species studied. Methane was excluded as the electron source, as was all organic material added during growth of the cultures (acetate, yeast extract, peptone). Hydrogen production showed a strong temperature dependence, and production ceased at temperatures below the growth range of the organisms. Addition of polysulfides to the cultures greatly decreased hydrogen production. The addition of bromoethanesulfonic acid had little influence on hydrogen production. These experiments demonstrate that some methanogens produce excess reducing equivalents during growth and convert them to hydrogen when the ambient hydrogen concentration becomes low. The lack of sustained hydrogen production by the cultures in the presence of methane provides evidence against "reverse methanogenesis" as the mechanism for anaerobic methane oxidation.

Biphasic truncated exponential waveform defibrillation.

This paper presents data from studies that have compared the efficacies of biphasic truncated exponential (BTE) and monophasic damped sine (MDS) waveform defibrillation in patients with out-of-hospital cardiac arrest and in in-hospital defibrillation. When a shock is delivered, rhythms evolve rapidly in a variety of directions and take different courses, even over a short time. When defibrillation is defined as termination of ventricular fibrillation at 5 seconds postshock, whether to an organized rhythm or asystole, low-energy BTE shocks appear to be more effective than high-energy MDS shocks in out-of-hospital arrest. For future research, the terms associated with defibrillation should be standardized and used uniformly by all investi-gators. In particular, there should be an agreed-upon definition of shock efficacy.

The Lost Colony and Jamestown droughts.

Tree-ring data from Virginia indicate that the Lost Colony of Roanoke Island disappeared during the most extreme drought in 800 years (1587-1589) and that the alarming mortality and the near abandonment of Jamestown Colony occurred during the driest 7-year episode in 770 years (1606-1612). These extraordinary droughts can now be implicated in the fate of the Lost Colony and in the appalling death rate during the early occupations at Jamestown, the first permanent English settlement in America.

Comparison of midazolam and diazepam for conscious sedation in the emergency department.

STUDY OBJECTIVE: To compare the efficacy of diazepam and midazolam when used for conscious sedation in emergency department patients. DESIGN: Prospective, randomized, double-blind, multicenter trial. SETTING: Three university EDs. TYPE OF PARTICIPANTS: Patients requiring one of the following procedures: abscess drainage, joint reduction, extensive suturing, chest tube insertion, or lumbar puncture. INTERVENTIONS: Diazepam (2.5 mg/mL) or midazolam (1 mg/mL) was administered until the desired level of sedation was achieved to a maximum of 5 mL. Fentanyl citrate was administered if needed for pain. MEASUREMENTS AND MAIN RESULTS: Thirty-three patients received diazepam and 36 received midazolam. Patients receiving midazolam had a greater degree of early sedation (P < .05), a higher 90-minute alertness scale score (P < .05), more patients ready for discharge at 90 minutes (P = .05), significantly less recall for the procedure (P < .02), and less pain on injection (P < .01) than patients who were given diazepam. CONCLUSIONS: Diazepam and midazolam are both effective for conscious sedation in ED patients. Midazolam causes less pain on injection, a significantly greater degree of early sedation, and a more rapid return to baseline function.

Fast Track in the emergency department: a one-year experience with nurse practitioners.

The use of a Fast Track system in the emergency department is becoming increasingly popular in order to provide fast and efficient service to patients with minor emergencies. In this paper we describe the one-year results of our system staffed by nurse practitioners. During the first year of operation, a total of 4468 patients were seen in Fast Track. Approximately 28% of patients are triaged to Fast Track during its hours of operation. The average patient seen in Fast Track was ready for discharge 94.4 minutes after presentation. Fewer than 1% of patients required admission to the hospital. Overall, patients and medical staff were highly satisfied with the Fast Track system. Our experience demonstrates that nurse practitioners can effectively and efficiently staff a Fast Track in an academic emergency department.

Prehospital diagnosis and treatment of acute myocardial infarction: a north-south perspective. The Cincinnati Heart Project and the Nashville Prehospital TPA Trial.

Intravenous thrombolytic therapy improves left ventricular function and reduces mortality in patients with acute myocardial infarction (AMI). In European and Middle Eastern trials, prehospital delivery of thrombolytic agents by physician-directed mobile intensive care units has been successful. This report describes two independently conceived and performed trials that used cellular telephone transmission of 12-lead ECGs to deliver recombinant tissue plasminogen activator (r-tPA) in the field to patients with AMI. In the Nashville Prehospital TPA Trial, 85 patients with chest pain were evaluated in the field for possible administration of r-tPA over a 6-month period. Three of 85 patients (3.5%) were found to be actual candidates for r-tPA treatment in the field. In phase II (dry-run phase) of the Cincinnati Heart Project, 374 patients were evaluated in the field with 14 documented cases of AMI (3.7%) before r-tPA was placed in ambulances for administration by paramedics. In phase III (active with r-TPA in ambulances), over a 1-year period 103 patients were evaluated with six (5.8%) documented cases of AMI. Three of five r-tPA field treatment decisions by emergency physicians using transmitted 12-lead ECGs were accurate (60%). When patients in phases II and III were combined, only 20 of 477 total patients (4.2%) were documented to have AMI. A decline in paramedic skills was noted because of the infrequent administration of the thrombolytic agent. Combining the Nashville and Cincinnati experiences, only 27 of 562 total patients with chest pain (4.8%) were candidates for prehospital thrombolysis. We conclude that few patients evaluated in the prehospital setting are actual candidates for thrombolytic therapy. Substantial allocation of financial and human resources for prehospital delivery of intravenous thrombolytic therapy does not appear warranted.