Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study.

BACKGROUND: Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS: We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS: A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS: Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.

An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference.

BACKGROUND: Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered. OBJECTIVE: To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference. METHODS: We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016-May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported. RESULTS: During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3-48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57-100.0]) and glucagon (3/4 or 75% [95% CI 32.57-100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04-91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47-76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36-60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19-67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19-67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64-36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31-5.98]). CONCLUSIONS: Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

Describing Prehospital Deliveries in the State of Michigan.

Introduction We observed clinically that prehospital deliveries locally appeared to have a high rate of complications and appeared associated with midwife deliveries. There is scant literature that addresses prehospital deliveries across a state. We set out to describe utilization, complications, and short-term outcomes of EMS-attended prehospital deliveries in Michigan in 2015, and to describe the relationship between prehospital delivery and socioeconomic status (SES). Methods We identified candidate cases for prehospital deliveries through the Michigan EMS Information System (MI-EMSIS). To assess the relationship of SES with the frequency of EMS delivery, we utilized the mean income of the patient residences' zip codes. Results We identified 223 EMS-attended deliveries from 1.6 million MI-EMSIS records. Most births were normal vaginal deliveries on the scene or en route to the hospital (92, 40.0%) or delivered prior to EMS arrival (58, 25.4%). Maternal or fetal complications were identified in 69 (32.0%) deliveries. We identified a few midwife-attended deliveries (31), but these had a high rate of complications (19, 61.3%). The frequency of prehospital delivery was inversely related to estimated patient income (Pearson=-0.85). Conclusions EMS deliveries were rare and most were normal vaginal deliveries, but almost a third had complications. Midwife and EMS-attended deliveries were rare, but when they occurred, had high rates of complications. Although an imperfect measure of patient SES, frequency of delivery was inversely related to patient income, and agencies that provide care in these communities should have focused training.

Comparison of Four Methods of Paramedic Continuing Education in the Management of Pediatric Emergencies.

Introduction: Finite resources limit the amount of time EMS agencies can dedicate to continuing education in pediatric emergencies. EMS instructors need effective, efficient, and affordable educational strategies for these high-risk, low frequency events.Objective: To compare the effectiveness of four training methods in management of pediatric emergencies for paramedics.Methods: A validated, performance-based, simulated clinical assessment module was used to provide a baseline measurement of paramedics' resuscitation skills during three simulated pediatric emergencies. Educational modules were developed that targeted deficiencies identified by the baseline assessment, including advanced pediatric life support skills, airway management, use of the Broselow-Luten Tape®, pediatric drug dose calculations and drug delivery, seizure management, and trauma assessment. Paramedics from five EMS agencies in Michigan were randomized to four education intervention groups. The control group used an existing, online, continuing education course. Three experimental groups were exposed to the same content during five, one-hour sessions conducted over 2.5 years. Instruction was delivered using high-fidelity, simulated case-based training, low-fidelity simulation training, or lecture with procedural skills lab, based on group assignment. After the training, all groups were tested within 4-6 months using methods identical to baseline testing.Results: One hundred forty-seven subjects completed the study. There were no differences in baseline skill levels among the four groups. Only the low fidelity simulation training group demonstrated improvement of combined scenario scores (p = 0.0008). Scores for targeted skills improved in one scenario in the high-fidelity group, two in the low-fidelity group, one in the lecture/lab group, and none in the control group.Conclusions: Although improvements in those skills included in the training were found in three groups, two hours of training in pediatric emergencies per year was insufficient to produce a substantial improvement overall. Expensive, high-fidelity simulators were not necessary for teaching pediatric resuscitation skills to paramedics; instructive scenarios using low-fidelity manikins and debriefings appear to be adequate. The content delivered by an online refresher course did not provide any improvement in performance as measured by simulated, case-based assessments.

Evaluation of Basic Life Support First Responder Naloxone Administration Protocol Adherence.

OBJECTIVES: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted. METHODS: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence. RESULTS: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30). CONCLUSION: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols.

Novel Penicillium species causing disseminated disease in a Labrador Retriever dog.

This report describes the phenotypic characteristics of a novel Penicillium species, Penicillium labradorum, isolated from a 3-year-old male, castrated, Labrador retriever with disseminated fungal disease. The dog's presenting clinical signs included lethargy, lymphadenopathy, tachypnea, moderate pitting edema, and nonweight bearing lameness associated with the right hind limb. Fine-needle aspirate biopsies from the sublumbar and prescapular lymph nodes were initially examined. The cytologic findings were consistent with pyogranulomatous inflammation with abundant extracellular and phagocytized fungal fragments and hyphae. Based on the morphology of the organisms and lack of endogenous pigment, hyalohyphomycosis was considered most likely, with Fusarium, Penicillium, and Paecilomyces species being considerations. Fungal isolates were obtained via culture of samples from the lymph nodes, and molecular identification testing originally identified an undescribed Penicillium species belonging to the Penicillium section Exilicaulis. BLAST searches and phylogenetic analyses performed approximately 1 year and 9 months after the isolation date revealed an isolate within the Penicillium parvum clade in the Penicillium section Exilicaulis but phylogenetically distant from the other species in the section, thus representing a new species, Penicillium labradorum. Antifungal susceptibility testing was also performed on the isolate and low minimum inhibitory concentrations were observed with terbinafine, voriconazole, and posaconazole, while in vitro resistance was observed with fluconazole. The dog had been previously treated with fluconazole, itraconazole, amphotericin B lipid complex, voriconazole, and terbinafine. Approximately 587 days after the initial diagnosis, the dog was euthanized due to worsening of clinical signs and concerns for quality of life.

An Innovative Inexpensive Portable Pulmonary Edema Intubation Simulator.

Audience: This pulmonary edema intubation simulator is designed to instruct paramedics, medical students, emergency medicine residents, emergency medical services fellows, and attending physicians. Introduction: Acute pulmonary edema results in respiratory distress and may require endotracheal intubation. On occasion, pulmonary edema can result in copious amounts of pink, frothy sputum in the airway, complicating intubation by hindering the intubator's view. Although airway management skills are frequently taught in a simulation setting, the frothy sputum seen in acute pulmonary edema is not easily replicated. Several articles have been published in reference to simulation model development for difficult airway management due to emesis obscuring the view of the glottic opening.1,2 There is, however, a scarcity of literature describing pulmonary edema airway management simulator construction, with only one other model identified on our review of the literature, which utilized cadavers, baking soda, vinegar, and red food coloring.3In our simulation center, we teach a variety of learners who may be called upon to care for patients in acute pulmonary edema in their clinical practice, including medical students, residents from various specialties, practicing physicians and pre-hospital personnel. We wished to familiarize these trainees with the challenges associated with intubating patients with significant frothy secretions within the hypopharynx by developing a dynamic, realistic, portable and inexpensive model to simulate the airway manifestations associated with acute pulmonary edema. Educational Objectives: By the end of the session, learners will be able to: 1. Discuss the pathophysiology of, and immediate stabilization management steps for, acute cardiogenic pulmonary edema. 2. List the indications, contraindications, and risks associated with intubating a patient with acute cardiogenic pulmonary edema. 3. Demonstrate effective communication and teamwork skills to manage the airway of a simulated patient in respiratory distress due to acute cardiogenic pulmonary edema. 4. Successfully and safely intubate a simulated patient with a difficult airway due to visual obstruction from frothy pulmonary edema secretions. Educational Methods: We adapted a previously owned commercial airway task trainer simulator using an aquarium pump, tubing, an air stone, and an endotracheal tube. Pulmonary edema solution was created with glycerin, dish soap, (distilled) water and simulated blood. The solution and air stone are placed in one of the simulator's lungs. Subsequently, turning on the aquarium air pump generates simulated pulmonary edema within the lung itself, which froths up and out of the trachea and into the hypopharynx, mimicking the gross pathophysiological process.Learners complete pre-reading assignments prior to attending a small group didactic-practical session. Following a brief case discussion, led by the instructor, about the management of a patient in respiratory distress due to acute pulmonary edema, learners transition to a hands-on experience intubating the pulmonary edema manikin with the use of direct and video laryngoscopy, aided by a large bore Yankauer for suction and a bougie. Depending on the training level of the learners, the instructor will use judgment and may elect to demonstrate intubating the manikin using video laryngoscopy before the learners attempt the procedure. The authors recommend that the instructor use video laryngoscopy for teaching purposes so that all learners can visualize the intubation techniques (Yankauer, bougie) in the context of copious pulmonary edema fluid obscuring the glottis and surrounding airway structures.The practical portion is dedicated solely to intubation, with one learner assuming the role of the intubator and another assuming the role of a respiratory therapist, while the other leaners observe and/or provide real-time feedback. Learners rotate through these aforementioned roles. To maintain efficiency of the simulation session and maximize the number of intubation attempts each learner receives, the session is designed to begin with a case discussion about the management of a patient with acute pulmonary edema up through the timepoint of successful intubation, followed by a practical portion where the learners perform multiple intubations on the innovative pulmonary edema airway management task trainer. During the practical portion, real-time constructive feedback is given to each learner. At the end of the simulation session, a debriefing is completed.This model can be used to address several ACGME Emergency Medicine Milestones,4 specifically Milestone 9 (General Approach to Procedures - PC9), Level 4 (Performs indicated procedures on any patients with challenging features [eg, poorly identifiable landmarks, at extremes of age or with comorbid conditions], and also Milestone 10 (Airway Management - PC10), Level 4 (Performs airway management in any circumstance taking steps to avoid potential complications). This model can also be used to address ACGME Emergency Medical Services Milestones,5 specifically "Procedures Performed in the Pre-hospital Environment - Patient Care," Level 4 (Performs indicated procedures on any patients, including those with challenging features (eg, poorly identifiable landmarks, at extremes of age or with co-morbid conditions). Research Methods: At the conclusion of the session, verbal feedback is sought from each participant by the instructor: How helpful did you find this simulation experience for learning about airway management in patients with acute pulmonary edema? Did you find the pulmonary edema intubation model to be realistic? Following this simulation experience, how would you rate your personal confidence in terms of managing an airway complicated by acute pulmonary edema? Results: For under fifty dollars, we have been able to adapt one of our previously owned airway management task trainers to build a pulmonary edema intubation simulator. It has been used in a wide variety of settings for different learners, including medical students, residents, fellows and pre-hospital providers. Since the 2016-2017 academic year, two hundred and twenty-six emergency medicine residents (PGY1, PGY2, and PGY3) have successfully used our innovative pulmonary edema airway management task trainer. Qualitatively it has been well-received and felt to be realistic by both our learners and instructors based on verbal feedback received following the simulation sessions. Discussion: We are aware of only one prior report attempting to simulate the frothy sputum seen in acute pulmonary edema. Lipe, et al., described mixing baking soda, vinegar and red food coloring in a cadaver hypopharynx just prior to an intubation attempt.3 This combination creates a fizzy frothy solution that fills the hypopharynx and pushes proximally into the mouth. This model is limited by design, however, in that it was unable to mimic a true in vivo appearance of a continuous flow of pulmonary edema-like fluid from the glottic opening. We feel we were able to overcome this limitation and also believe it is important for the leaner to experience the challenges of intubation when faced with copious secretions originating from within the lower airways. Our model generates the froth from within the lung itself, and it migrates proximally, similar to the dynamic pathophysiological process that occurs in vivo. Since we did not compare these two techniques, it is unknown which is more realistic. Neither the Lipe cadaver model nor our manikin model has been validated in terms of the realistic nature of the simulated pulmonary edema fluid. This would be ripe for future investigation. Nonetheless, informal qualitative feedback from our learners and instructors has been positive.Resident use of our innovative dynamic pulmonary edema airway management task trainer has been incorporated into our Emergency Medicine residency and Emergency Medical Services fellowship Clinical Competency Committee discussions with respect to ACGME Milestone satisfaction. Our model addresses level 4 of Emergency Medicine Milestone 9 (General Approach to Procedures) and Milestone 10 (Airway Management). Additionally, level 4 of Emergency Medical Services Milestone 2 (Procedures Performed in the Pre-hospital Environment - Patient Care) is addressed. Incorporating successful intubation of the dynamic pulmonary edema airway management task trainer has provided the EM and EMS faculty with a more objective measure by which to score the aforementioned milestones during the mid-year and year-end Clinical Competency Committee meetings.Overall, this innovation has met our objectives well. We have added this model to our library of more complicated airway management scenarios, such as vomitus and aspiration. Our emergency medicine residency program hosts a version of the difficult airway course and includes this pulmonary edema simulation station as part of that course. The model is very portable, allowing us to transport it to different sites for use. It is inexpensive, costing less than $50 to construct. Finally, the design is readily adaptable to any standard airway training manikin that has a simulated hollow lung with a detachable connection to a conduit representing a bronchus, which has a direct connection with a simulated trachea into which an endotracheal tube can physically be passed. Topics: Airway management, difficult airway, intubation, obstructed airway, pulmonary edema, video laryngoscopy, visual obstruction.

An outbreak of Mycoplasma mycoides subspecies capri arthritis in young goats: a case study.

Mycoplasmosis is a well-known cause of morbidity and mortality in small ruminants. Previously recognized outbreaks have involved arthritis, and pneumonia or pleuropneumonia. Modern bacteriology procedures rely less on isolation techniques that require special media for mollicutes given that these species are notoriously difficult to isolate, and rely more on PCR tests. We report an outbreak of arthritis, pleuropneumonia, and mild meningitis affecting dairy goat kids, spanning a period of 3 y, which had unusual epidemiologic characteristics related to husbandry practices. Lesions were characterized by polyarthritis of the appendicular joints, with copious joint fluid and extension of arthritic exudate beyond the joint itself. The cause remained unknown until serendipitous isolation of a mycoplasma on blood agar. Mycoplasmosis was not detected from synovial samples by a general mycoplasma PCR, despite multiple attempts. Isolated colonies were also negative by this general PCR assay. The isolate was identified as Mycoplasma mycoides subspecies capri, using universal 16S primers and amplicon sequencing. Testing of additional isolates from other diseased goats in the herd confirmed that this was the cause of illness. A failure to recognize the distinct nature of organisms of the M. mycoides group of mycoplasmas meant that a PCR test that cannot detect this group of organisms was utilized at first, and the etiology of the illness was overlooked for a period of time. Veterinary pathologists and microbiologists must be aware of the limitations of some PCR assays when confronted with joint disease and pleuropneumonia in small ruminants.

Challenges of Using Probabilistic Linkage Methodology to Characterize Post-Cardiac Arrest Care in Michigan.

BACKGROUND: To improve survival of patients resuscitated from out of hospital cardiac arrest (OCHA), data is needed to assess and improve inpatient post-resuscitation care. Our objective was to apply probabilistic linkage methodology to link EMS and inpatient databases and evaluate whether it may be used to describe post-arrest care in Michigan. METHODS: We performed a retrospective study to describe post-cardiac arrest care in adult OHCA patients who were transported to Michigan hospitals from July 1, 2010, to June 30, 2013. Using probabilistic linkage methodology we linked two databases, the Michigan EMS Information System (MI_EMSIS) and the Michigan Inpatient Database (MIDB), which describes inpatient care and outcome of all admissions. Rates of case incidence and survival were compared to published literature. We compared the linked dataset to existing cardiac arrest databases from three counties to evaluate the quality of this linkage. RESULTS: Multiple iterations of match strategies were used to create a linked EMS-inpatient dataset. There were 12,838 MI_EMSIS cardiac arrest records of which 1,977 were matched with MIDB records, identifying them as surviving to hospital admission. Of these 590 (30.0%) survived to hospital discharge. The annual survival incidence/100,000 population to admission was 6.93/100,000 and survival incidence to discharge was 2.1/100,000. The matched dataset was compared to county databases identified a limited sensitivity [48.2%, 95% CI 42.1%-55.3%)] and positive predictive value [64.4%, 95% CI 56.8%-71.3%)]. CONCLUSION: Use of the MI_EMSISEMS database and the Michigan Inpatient database was feasible and produced rates of cardiac arrest admission and survival rates similar to published literature. This process yielded a limited match compared to existing county cardiac arrest databases. We conclude that such a linked dataset is useful for descriptive purposes but not as a population based dataset to evaluate statewide post-cardiac arrest care.

Pilot Study of Antimicrobial Resistance in Northern Bobwhites (Colinus virginianus).

Antimicrobial resistance (AMR) is an important issue for both wildlife conservation and public health. The purpose of this study was to screen for AMR in fecal bacteria isolated from northern bobwhite (Colinus virginianus), a species that is an ecologically and economically important natural resource in the southern United States. The antimicrobial susceptibility profiles of 45 Escherichia coli isolates, 20 Enterococcus faecalis isolates, and 10 Enterococcus faecium isolates were determined using the SensititerTM microbroth dilution minimum inhibitory concentration (MIC) plate, AVIAN1F. Overall, E. coli isolates had high MIC values for the following classes of antimicrobials: aminocoumarins, beta-lactams, lincosamides, macrolides, florfenicol, and sulfonamides. Enterococcus faecalis and E. faecium isolates had high MICs for aminocyclitols, aminoglycosides, beta-lactams, lincosamides, and sulfonamides. Enterococcus faecalis isolates also showed high MICs for aminocoumarins, while E. faecium isolates had high MICs for trimethoprim/sulfamethoxazole and tetracycline. Based on available veterinary interpretive criteria, 15% and 33% of E. coli isolates were resistant to sulphathiazole and sulphadimethoxine, respectively. Intermediate susceptibility to florfenicol was seen with 17.8% of E. coli isolates. Twenty percent of E. faecalis and 80% of E. faecium isolates were resistant to high-concentration streptomycin. One third of E. faecalis and 70% of E. faecium isolates were intermediately susceptible to erythromycin. Ten percent of E. faecium isolates were resistant to tetracycline and oxytetracycline. A comparison of available MIC suggests that AMR in wild bobwhite is less severe than in domestic poultry. Further investigation is needed to determine the source of AMR in wild bobwhite.

Evaluating the Cost and Utility of Mandating Schools to Stock Epinephrine Auto-injectors.

BACKGROUND: The Michigan Legislature mandated that all public schools stock epinephrine auto-injectors (EAIs). A minimal amount is known regarding the incremental value of EAIs in schools. Our primary objective was to describe the frequency of administration of epinephrine for EMS patients with acute allergic reactions in public schools. Our secondary objective was to estimate the cost of mandating public schools to stock EAIs. METHODS: We performed a retrospective cohort study of EMS cases with an impression of allergic reaction and who received epinephrine recorded in the 2014 Michigan EMS Information System (MI-EMSIS). We abstracted patient demographics, incident location by address to identify public schools, source of epinephrine given, and suspected allergen if known. We calculated advanced life support (ALS) response times to assess temporal impact of school EAIs in communities with ALS systems. We estimated the unsubsidized annual procurement cost of this mandate for Michigan public schools (N = 4,039), using range of costs for the required 2 EAIs (adult and pediatric) as estimated by the legislature ($140/each) and recently reported costs for commercial sources ($1,200). Training costs were not included. Descriptive statistics are reported. RESULTS: During this period, there were 1,550,009 EMS cases in the state with 631 receiving non-cardiac arrest epinephrine for presumed anaphylaxis, of which 23 cases were in public schools. Reported allergens were most often food 12 (51.2%), insect stings 4(22.2%) or unknown 7(30.4%). Among these patients, the source for epinephrine used was from the student, 7 (30.4%), EMS 7 (30.4%), school 7(30.4%), and unknown 2(8.7%). A majority (21, 91.3%) of the public school cases occurred in communities with ALS systems and ALS response was relatively rapid (median response 6 minutes, 90 percentile, 13 minutes). The unsubsidized annual cost of Michigan public schools to stock EAIs ranges from $565,460 to $4,846,800. CONCLUSION: In this study, few public school patients received epinephrine for anaphylaxis and the vast majority occurred in communities with rapid ALS response. The direct annual supply cost of the school EAI mandate is substantial.

Pediatric Prehospital Medication Dosing Errors: A National Survey of Paramedics.

BACKGROUND: Pediatric drug dosing errors occur at a high rate in the prehospital environment. OBJECTIVE: To describe paramedic training and practice regarding pediatric drug administration, exposure to pediatric drug dose errors and safety culture among paramedics and EMS agencies in a national sample. METHODS: An electronic questionnaire was sent to a random sample of 10,530 nationally certified paramedics. Descriptive statistics were calculated. RESULTS: There were 1,043 (9.9%) responses and 1,014 paramedics met inclusion criteria. Nearly half (43.0%) were familiar with a case where EMS personnel delivered an incorrect pediatric drug dose. Over half (58.5%) believed their initial paramedic program did not include enough pediatric training. Two-thirds (66.0%) administered a pediatric drug dose within the past year. When estimating the weight of a pediatric patient, 54.2% used a length-based tape, while 35.8% asked the parent or guardian, and 2.5% relied on a smart phone application. Only 19.8% said their agency had an anonymous error-reporting system and 50.7% believed they could report an error without fear of disciplinary action. For solutions, 89.0% believed an EMS-specific Broselow-Luten Tape would be helpful, followed by drug dosing cards in milliliters (83.0%) and changing content of standardized pediatric courses to be more relevant (77.7%). CONCLUSION: This national survey demonstrated a significant number of paramedics are aware of a pediatric dosing error, safety systems specific to pediatric patients are lacking, and that paramedics view pediatric drug cards and eliminating drug calculations as helpful. Pediatric drug-dosing safety in the prehospital environment can be improved.

Pharmacokinetics of Ceftiofur Crystalline-Free Acid in Clinically Healthy Dogs (Canis lupus familiaris).

Economical, injectable antibiotics are beneficial when clinical manifestations of an animal model prevent the use of oral antibiotics. Ceftiofur crystalline-free acid (CCFA) is an injectable, sustained-release form of ceftiofur, a third-generation cephalosporin that is labeled for use in swine, cattle, and horses. Because CCFA is an economical, injectable antibiotic that could be of value for use in research dogs, the objective of this study was to determine the pharmacokinetic properties of CCFA in apparently healthy dogs and to determine the minimal inhibitory concentrations of ceftiofur for veterinary pathogens cultured during 2011 through 2014 from the respiratory system, integumentary system, and urinary system of dogs. The study population comprised of 5 dogs (age, 1 y; weight, 24.7 to 26.9 kg) that were deemed healthy after no abnormalities were found on physical exam, CBC analysis, and clinical chemistry panel. Each dog received CCFA at 5.0 mg/kg SC, and blood samples were collected before administration of CCFA and at 1, 4, 8, 12, 24, 36, 48, 72, 96, 120, 144, 168, 192, 216, and 240 h after injection. The maximal plasma concentration (mean ± 1 SD) of CCFA was 1.98 ± 0.40 µ g/mL, time to reach maximal concentration was 22.3 ± 8.9 h, half-life was 56.6 ± 16.9 h, and AUC0-last was 124.98 ± 18.45 µ g-h/mL. The minimal inhibitory concentrations of ceftiofur ranged from ≤ 0.25 to ≥ 8.0 µ g/mL; ceftiofur was most effective against Pasteurella spp., Proteus spp., and Escherichia coli haemolytica and least effective against Bordatella bronchiseptica, Enterococcus spp., and Pseudomonas aeruginosa.

Care for Cardiac Arrest on Golf Courses: Still Not up to Par?

Abstract Introduction. Early CPR and use of automated external defibrillators (AEDs) have been shown to improve cardiac arrest (CA) outcomes. Placement of AEDs on golf courses has been advocated for more than a decade, with many trade golf publications calling for their use. Objective. To describe the incidence and treatment of CAs at Michigan golf courses and assess the response readiness of their staff. Methods. We performed a retrospective study of CA on Michigan golf courses from 2010 to 2012. Cases were identified from the Michigan EMS Information (MI-EMSIS) database. Cases with "golf" or "country club" were manually reviewed and location type was confirmed using Google Maps. We conducted a structured telephone survey capturing demographics, course preparedness, including CPR training and AED placement, and a description of events, including whether CPR was performed and if an AED was used. Our primary area of interest was the process of care. We also recorded return of spontaneous circulation (ROSC) as an outcome measure. EMS Utstein data were collected from MI-EMSIS. Descriptive data are presented. Results. During the study period, there were 14,666 CAs, of which 40 (0.18%) occurred on 39 golf courses (1 arrest/64 courses/year). Of these, 38 occurred between May and October, yielding a rate of 1 arrest/33.5 courses/golf season. Almost all (96.2%) patients were male, mean age 66.3 (range 45-85), 68% had VT/VF, and 7 arrested after EMS arrival. Mean interval from 9-1-1 call to EMS arrival at the patient was 9:45 minutes (range 3-20). Of all cases, 24 (72.3%) patients received CPR with 2 patients having CPR performed by course staff. Although AEDs were available at 9 (22.5%) courses, they were only placed on 2 patients prior to EMS arrival. Sustained ROSC was obtained in 12 (30.0%) patients. Only 7, (17.9%) courses required CPR/AED training of staff. Conclusion. When seasonally adjusted, the rate of cardiac arrest on Michigan golf courses is similar to that of other public locations. AED use was rare even when available. Preparedness for and response during a CA is suboptimal. Despite more than a decade of advocacy, response to golf course cardiac arrest is still not up to par.

Isolation of Aureimonas altamirensis, a Brucella canis-like bacterium, from an edematous canine testicle.

Microbiological and histological analysis of a sample from a swollen testicle of a 2-year-old Border Collie dog revealed a mixed infection of the fungus Blastomyces dermatitidis and the Gram-negative bacterium Aureimonas altamirensis. When subjected to an automated microbial identification system, the latter isolate was provisionally identified as Psychrobacter phenylpyruvicus, but the organism shared several biochemical features with Brucella canis and exhibited agglutination, albeit weakly, with anti-B. canis antiserum. Unequivocal identification of the organism was only achieved by 16S ribosomal RNA gene sequencing, ultimately establishing the identity as A. altamirensis. Since its first description in 2006, this organism has been isolated infrequently from human clinical samples, but, to the authors' knowledge, has not been reported from a veterinary clinical sample. While of unknown clinical significance with respect to the pathology observed for the polymicrobial infection described herein, it highlights the critical importance to unambiguously identify the microbe for diagnostic, epidemiological, infection control, and public health purposes.

Errors and error-producing conditions during a simulated, prehospital, pediatric cardiopulmonary arrest.

INTRODUCTION: Management of pediatric cardiac arrest challenges the skills of prehospital care providers. Errors and error-producing conditions are difficult to identify from retrospective records. The objective of this study was to identify errors committed by prehospital care providers and the underlying causes of those errors during a simulated pediatric cardiopulmonary arrest followed by a structured debriefing. METHODS: Performance criteria were defined prospectively by an advisory panel. Prehospital care providers from 6 emergency medical service agencies in Michigan participated in a simulation of an infant cardiopulmonary arrest using their own drugs, equipment, and protocols in a mobile trailer. Simulations were video recorded and played back during debriefings that were conducted immediately after the event to facilitate error analysis. Observed errors and subjects' explanations were analyzed by thematic qualitative assessment methods and descriptive statistics. RESULTS: One hundred ninety-four subjects, including paramedics, emergency medical technicians, and emergency medical responders in various crew configurations, participated in 60 simulation sessions during a 5-month period (April to August of 2010). Error types were classified into 4 clinically important themes as follows: failure to provide adequate ventilation, failure to provide effective circulation, failure to achieve vascular access rapidly, and medication errors. Multiple underlying causes of medication dosing and other errors were identified, including cognitive, procedural, communication, teamwork, and systems factors. CONCLUSIONS: We systematically observed many types of errors and identified some of the underlying causes during a simulated, prehospital, pediatric cardiopulmonary arrest. There were numerous, multifactorial, and sometimes, synergistic causes of medication dosing errors. Emergency medical service officials can use these findings to prevent future errors.

Medication errors in prehospital management of simulated pediatric anaphylaxis.

BACKGROUND: Systematic evaluation of the performances of prehospital providers during actual pediatric anaphylaxis cases has never been reported. Epinephrine medication errors in pediatric resuscitation are common, but the root causes of these errors are not fully understood. OBJECTIVE: The primary objective of this study was to identify underlying causes of prehospital medication errors that were observed during a simulated pediatric anaphylaxis reaction. METHODS: Two- and 4-person emergency medical services crews from eight geographically diverse agencies participated in a 20-minute simulation of a 5-year old child with progressive respiratory distress and hypotension from an anaphylactic reaction. Crews used their own equipment and drugs. A checklist-based scoring protocol was developed to help identify errors. A trained facilitator conducted a structured debriefing, supplemented by playback of video recordings, immediately after the simulated event to elicit underlying causes of errors. Errors were analyzed with mixed quantitative and qualitative methods. RESULTS: One hundred forty-two subjects participated in 62 simulation sessions. Ninety-five percent of crews (59/62) gave epinephrine, but 27 of those crews (46%) delivered the correct dose of epinephrine in an appropriate concentration and route. Twelve crews (20%) gave a dose that was ≥5 times the correct dose; 8 crews (14%) bolused epinephrine intravenously. Among the 55 crews who gave diphenhydramine, 4 delivered the protocol-based dose. Three crews provided an intravenous steroid, and 1 used the protocol-based dose. Underlying causes of errors were categorized into eight themes: faulty reasoning, weight estimation errors, faulty recall of medication dosages, problematic references, calculation errors, dose estimation, communication errors, and medication delivery errors. CONCLUSION: Simulation, followed by a structured debriefing, identified multiple, underlying causes of medication errors in the prehospital management of pediatric anaphylactic reactions. Sequential and synergistic errors were observed with epinephrine delivery.

Root causes of errors in a simulated prehospital pediatric emergency.

OBJECTIVES: Systematic evaluation of prehospital provider performance during actual resuscitations is difficult. Although prior studies reported pediatric drug-dosing mistakes and other types of management errors, the underlying causes of those errors were not investigated. The objective of this study was to identify causes of errors during a simulated, prehospital pediatric emergency. METHODS: Two-person emergency medical services (EMS) crews from five geographically diverse agencies participated in a validated simulation of an infant with altered mental status, seizures, and respiratory arrest using their own equipment and drugs. A scoring protocol was used to identify errors. A debriefing conducted by a trained facilitator immediately after the simulated event elicited root causes of active and latent errors, which were analyzed by thematic qualitative assessment methods. RESULTS: Forty-five crews completed the study. Clinically important themes that emerged from the data included oxygen delivery, equipment organization and use, glucose measurement, drug administration, and inappropriate cardiopulmonary resuscitation. Delay in delivery of supplemental oxygen resulted from two different automaticity errors and a 54% failure rate in using an oropharyngeal airway (OPA). Most crews struggled to locate essential pediatric equipment. Three found broken or inoperable bag/valve/masks (BVMs), resulting in delayed ventilation. Some mistrusted their intraosseous (IO) injection gun device; others used it incorrectly. Only 51% of crews measured blood glucose; some discovered that glucometers were not stored in their sealed pediatric bags. The error rate for diazepam dosing was 47%; for midazolam, it was 60%. Underlying causes of dosing errors were found in four domains (cognitive, procedural, affective, and teamwork), and they included incorrect estimates of weight, incorrect use of the Broselow pediatric emergency tape, faulty recollection of doses, difficulty with calculations under stress, mg/kg to mg to mL conversion errors, inaccurate measurement of volumes, use of the wrong end of prefilled syringes, and failure to crosscheck doses with partners. CONCLUSIONS: Simulation, followed immediately by facilitated debriefing, uncovered underlying causes of active cognitive, procedural, affective, and teamwork errors, latent errors, and error-producing conditions in EMS pediatric care.

Medication dosing errors in pediatric patients treated by emergency medical services.

BACKGROUND: Medication dosing errors occur in up to 17.8% of hospitalized children. There are limited data to describe pediatric medication errors by emergency medical services (EMS) paramedics. It has been shown that paramedics have infrequent encounters with pediatric patients. OBJECTIVE: To characterize medication dosing errors in children treated by EMS. METHODS: We studied patients aged ≤11 years who were treated by paramedics from eight Michigan EMS agencies from January 2004 through March 2006. We defined a medication dosing error as ≥20% deviation from the weight-appropriate dose, as determined by the patient's reported weight in the prehospital medical record or by use of the Broselow-Luten tape (BLT). We studied errors in administering six EMS medications commonly given to children: albuterol, atropine, dextrose, diphenhydramine, epinephrine, and naloxone. RESULTS: There were 5,547 children aged ≤11 years who were treated during the study period, of whom 230 (4.1%) received drugs and had a documented weight. These patients received a total of 360 medication administrations. Multiple drug administrations occurred in 73 cases. Medication dosing errors occurred in 125 of the 360 drug administrations (34.7%; 95% confidence interval [CI] 30.0, 39.8). Relative drug dosage errors (with 95% CI) were as follows: albuterol 23.3% (18.4, 29.1), atropine 48.8% (34.3, 63.5), diphenhydramine 53.8% (29.1, 76.8), and epinephrine 60.9% (49.9, 73.9). The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine overdoses was 808% ± 428%. The mean error (± standard deviation) for intravenous/intraosseous 1:1000 epinephrine underdoses was 35.5% ± 27.4%. CONCLUSIONS: Medications delivered in the prehospital care of children were frequently administered outside of the proper dose range when compared with patient weights recorded in the prehospital medical record. EMS systems should develop strategies to reduce pediatric medication dosing errors.