Absent Pulmonary Artery Presenting as High-Altitude Pulmonary Edema.

CASE PRESENTATION: A 22-year-old male with no known past medical history presented to our emergency department complaining of difficulty breathing. A plain film chest radiograph revealed findings consistent with a tension pneumothorax. DISCUSSION: However, due to physical examination findings inconsistent with the imaging report, a computed tomography of the chest was ordered which revealed an absent right pulmonary artery.The patient was ultimately treated for high altitude pulmonary edema and discharged on nifedipine and supplementary oxygen.

Operational Readiness: Redesigning Advanced Practice Registered Nurse (APRN) Curriculum for an Evolving Battlefield.

INTRODUCTION: The Global War on Terror and the ensuing Overseas Contingency Operations has rapidly transformed the U.S. military's strategic philosophy for warfare. The paradigm shift to unconventional warfare has forced military medicine to adapt with the rapidly evolving battle space. To this end, large fixed facility hospitals are being replaced with highly mobile and austere medical platforms that serve farther forward. The transition in operational health care has challenged the role of all health care team members.Through the evolution of the modern battlefield, nursing roles have grown and expanded beyond the traditional roles and peacetime practice. Nurses are seeing greater autonomy and scope of practice in operational settings while caring for patient pathologies that are often different than at home. The expansion of practice extends beyond the registered nurse at the bedside to the Advanced Practice Registered Nurse (APRN) that serves in the provider role. Through anecdotal reports, and a growing body of literature, that APRN operational practice is different than in the traditional health care setting. MATERIALS AND METHODS: Although a variety of organizations have codified knowledge, skills and attitudes (KSAs) relevant to operational practice, no formal APRN operational curriculum currently exists. Using an adaptation of Kern's Six-Step Model of curriculum design, we describe a curriculum development process used to improve and focus educational experiences to better prepare APRNs for evolving operational roles. RESULTS: Through deliberate approaches the GSN has reimagined its operational readiness curriculum for the preparation of the military APRN on the evolving battlefield. The GSN has operationalized APRN operational readiness through the integration of operationally relevant curriculum designed around interprofessional education experiences. Through this curricular design, GSN APRN students are provided with operationally relevant experiences in the context of authentic military scenarios. Through these encounters, we believe, allows our students to successfully develop the clinical, operational and teamwork skills to successfully perform care in austere and operational settings. CONCLUSIONS: This manuscript describes a novel approach to provide operational readiness education to military APRN students. Through an evaluation of the current literature, expert reports and information of the current operational requirements, the USU GSN has developed a model and curricula for APRN operational readiness that lie beyond the traditional skills in the peacetime setting. Through this plan of instruction, USU GSN APRN students will have the requisite skills to meet the evolving operational needs of the Department of Defense.

The prevalence and impact of defensive medicine in the radiographic workup of the trauma patient: a pilot study.

BACKGROUND: Defensive medicine is estimated to cost the United States $210 billion annually. Trauma surgeons are at risk of practicing defensive medicine in the form of reflexively ordering computed tomography (CT) scans. The aim of this study is to quantify the monetary impact and radiation exposure related to the radiographic workup of trauma patients. METHODS: We conducted a prospective, observational study involving 295 trauma patients at Level I trauma center. Physicians were surveyed regarding specific CT scans ordered, likelihood of significant injuries found on scans, and which scans would have been ordered in a hypothetical, litigation-free environment. RESULTS: Four hundred sixteen of 1,097 CT scans (38%) were ordered out of defensive purposes. Nine CT scans (2.2%) that would not have been ordered resulted in a change in management. Defensively ordered CT scans resulted in nearly $120,000 in excess charges and 8.8 mSv of unnecessary radiation per patient. CONCLUSION: Defensively ordered CT scan in the workup of trauma patients is a prevalent and costly practice that exposes patients to potentially unnecessary and harmful radiation.

Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?

OBJECTIVES: The value of ventilation monitoring with end-tidal carbon dioxide (ETCO2) to anticipate acute respiratory events during emergency department (ED) procedural sedation and analgesia (PSA) is unclear. The authors sought to determine if ETCO2 monitoring would reveal findings indicating an acute respiratory event earlier than indicated by current monitoring practices. METHODS: The study included a prospective convenience sample of ED patients undergoing PSA. Clinicians performed ED PSA procedures with generally accepted patient monitoring, including oxygen saturation (SpO2), and clinical ventilation assessment. A study investigator recorded ETCO2 levels and respiratory events during each PSA procedure, with clinical providers blinded to ETCO(2) levels. Acute respiratory events were defined as SpO2 < or =92%, increases in the amount of supplemental oxygen provided, use of bag-valve mask or oral/nasal airway for ventilatory assistance, repositioning or airway alignment maneuvers, and use of physical or verbal means to stimulate patients with depressed ventilation or apnea, and reversal agent administration. RESULTS: Enrollment was stopped after independent review of 20 acute respiratory events in 60 patient sedation encounters (33%). Abnormal ETCO2 findings were documented in 36 patients (60%). Seventeen patients (85%) with acute respiratory events demonstrated ETCO2 findings indicative of hypoventilation or apnea during PSA. Abnormal ETCO2 findings were documented before changes in SpO2 or clinically observed hypoventilation in 14 patients (70%) with acute respiratory events. CONCLUSIONS: Abnormal ETCO2 findings were observed with many acute respiratory events. A majority of patients with acute respiratory events had ETCO2 abnormalities that occurred before oxygen desaturation or observed hypoventilation.