Effects of COVID-19 on EMS Refresher Course Completion and Delivery.

Introduction: The COVID pandemic has significantly impacted educational development and delivery, yet there is little quantitative research on this topic. The primary objective of this study was to compare the total number of Emergency Medical Service (EMS) Refresher (ER) course completions during 2020 versus prior years. Secondary outcomes examined in person versus on-line/distributive learning during the study period. Methods: The Commission on Accreditation for Prehospital Continuing Education (CAPCE) is the only national organization that accredits continuing education (CE) for paramedics and EMTs and currently has a database with over 14 million CE records. The total number of ER course completions each month in 2020 were compared to 2019 and 2018. We also compared the different educational format types: live in-person (LIP), asynchronous on-line distributive learning (DL), and virtual instructor lead training (VILT) synchronous DL courses. Data was analyzed using descriptive and two-way ANOVA statistics. Results: There were 1,922,783 ER course completions in 2020 versus 1,166,335 in 2019 and 1,074,636 in 2018, representing a 179% increase during the study period. Asynchronous DL course completions in 2020 were 1,830,513 EMS versus 1,078,580 in 2019 and 987,749 in 2018 a 185% increase over the three-year study period. Asynchronous DL monthly means by year was statistically significant, F(2, 99) = 95.632, p < .001. Mean monthly LIP and VLIT educational deliveries by year were not significantly different, p = .802, p = .754, respectively. Total LIP course completions in 2020 were 20,045 versus 51,552 in 2019 and 63,058 in 2018. In 2020 LIP courses made up only 1.0% (20,045/1,922,783) of all ER completions. This study was limited to only EMS professionals taking ER course completions in the CAPCE database. However EMS is not unique, since previous research has suggested that DL has flourished in other health care disciplines while LIP courses have continued to decrease. Conclusion: This large nationwide study of EMS profession has shown the trend toward DL education and a trend away from LIP courses. Future studies should examine the advantages and disadvantages of DL education.

Retention of cricothyrotomy skills by paramedics using a wire guided technique.

INTRODUCTION: Cricothyrotomy may be necessary for airway management when a patient's airway cannot be maintained through standard techniques such as oral airway placement, blind insertion airway device, or endotracheal intubation. Wire-guided cricothyrotomy is one of many techniques used to perform a cricothyrotomy. Although there is some controversy over which cricothyrotomy technique is superior, there is no published data regarding long term retention rates. The purpose of this study is to determine whether ground based paramedics can be taught and are able to retain the skills necessary to successfully perform a wire-guided cricothyrotomy. METHODS: This retrospective study was performed in a suburban county with a population of 160,000 with 23,000 EMS calls per year. Participants were ground-based paramedics who were taught wire-guided cricothyrotomy as part of a standardized paramedic educational update program. After viewing an instructional video, the paramedics were shown each the steps of the procedure on a simulation model, using a low fidelity task trainer previously developed to train emergency medicine residents. Using a 16 step procedural checklist, participants were allowed open-ended practice using the task trainer. Critical steps in the checklist were marked in bold lettering indicating automatic failure. Each paramedic was then individually supervised performing a minimum of 5 successful simulations. Retention was assessed using the same 16 step checklist 6 to 12 weeks following the initial training. RESULTS: A total of 55 paramedics completed both the initial training and reassessment during the time period studied. During the initial training phase 100% (55 of 55) of the paramedics were successful in performing all 16 steps of the wire-guided cricothyrotomy. During the retention phase, 87.3% (48 of 55) of paramedics retained the skills necessary to successfully perform the wire-guided cricothyrotomy. On the 16 step checklist, most steps were performed successfully by all the paramedics or missed by only 1 of the 55 paramedics. The step involving removal of the needle prior to advancing the airway device over the guide wire was missed by 34.5% (19 of 55) of the participants. This was not an automatic failure since most participants immediately self-corrected and completed the procedure successfully. CONCLUSION: Paramedics can be taught and can retain the skills necessary to successfully perform a wire-guided cricothyrotomy on a simulator. Future research is necessary to determine if paramedics can successfully transfer these skills to real patients.

Tratamiento combinado con radioterapia externa y hormonoterapia en los pacientes con cáncer de próstata localmente avanzado: factores predictivos de toxicidad genitourinaria / Combined External Radiotherapy and Hormone Therapy in Patients with Locally Advanced Prostate Cancer: Predictive Factors of Genitourinary Toxicity

Introducción: una opción de tratamiento del cáncer de próstata localmente avanzado es la radioterapia combinada con la ablación androgénica. Revisamos los resultados de eficacia y toxicidad del tratamiento combinado en un grupo de pacientes tratados con esta terapia combinada en nuestra institución. Material y método: estudio retrospectivo de 80 pacientes con cáncer prostático localmente avanzado tratados con radioterapia externa y hormonoterapia neoadyuvante (dos meses) y adyuvante (24 meses). Se realiza un estudio descriptivo de las variables clínico-patológicas y de los efectos secundarios. Evaluamos la respuesta al tratamiento mediante el PSA nadir y recidiva bioquímica. Analizamos la toxicidad aguda y crónica genitourinaria, intentando establecer qué factores influyen en su aparición mediante análisis uni y multivariante (regresión logística múltiple). Resultados: la media de edad fue 68 ± 5,81 años, el PSA inicial 20,05 ±1 6,27 ng/ ml y el volumen prostático medio 43,7 ± 27,57 cc. El 33% fueron estadio T3a y el 66% T3b. El Gleason fue < 7 en el 39%, 7 en el 46% y ≥ 8 en el 15%. Tras un seguimiento medio de 44,4 meses se detectó recidiva bioquímica en tres casos. La toxicidad aguda postirradiación genitourinaria apareció en el 90% (35% tardía) y gastrointestinal en el 75% (32% tardía). El análisis univariante muestra relación entre el volumen prostático y los síntomas urinarios previos con la toxicidad genitourinaria aguda y crónica. Estos se confirman como factores predictivos independientes de toxicidad geniturinaria en el análisis de regresión logística. Conclusiones: la hormono-radioterapia es una opción válida para el tratamiento del cáncer localmente avanzado con resultados óptimos a corto plazo, aunque no está exenta de efectos secundarios. La sintomatología urinaria previa y el volumen prostático pueden predecir la toxicidad genitourinaria (AU)

Introduction: Radiotherapy and androgen deprivation are an established treatment option for locally advanced prostate cancer. We evaluate outcomes in efficacy and toxicity for patients treated with this combined therapy at our institution. Methods: A retrospective study of 80 patients with locally advanced prostate cancer treated with radiotherapy combined with neo-adjuvant (2 months) and adjuvant (24 months) androgen deprivation. We studied the clinical variables and side effects. We evaluated treatment outcomes using PSA nadir and biochemical failure, and recorded acute and late gastrointestinal and urinary toxicity. We assessed the correlation between clinical variables and urinary toxicity by means of univariate and multivariate analyses (multiple logistic regression). Results: The mean patient age was 68 ± 5.81 years; the initial PSA was 20.05 ± 16.27 ng/ ml and the mean prostate volume 43.7 ± 27.57 cc. The clinical stage was T3a in 33% and T3b in 66%. The Gleason score was <7 in 39%, 7 in 46% and ≥8 in 15%. The mean follow-up was 44.4 months and biochemical failure was observed in 3 cases. Acute urinary toxicity was recorded in 90% of the patients (chronic in 35%) and acute gastrointestinal toxicity in 75% (late in 32%). In a univariate analysis, prostate volume and urinary symptoms were statistically correlated to acute and late urinary toxicity. Both prostate volume and urinary symptoms were independently associated with an increase in urinary toxicity in the logistic regression analysis. Conclusions: Hormone-radiotherapy is a valid option to locally treat advanced prostate cancer with optimal short-term outcomes, although it is not devoid of side effects. Prostate volume and urinary symptoms before treatment can predict genitourinary toxicity (AU)

[Combined external radiotherapy and hormone therapy in patients with locally advanced prostate cancer: predictive factors of genitourinary toxicity]. / Tratamiento combinado con radioterapia externa y hormonoterapia en los pacientes con cáncer de próstata localmente avanzado: factores predictivos de toxicidad genitourinaria.

INTRODUCTION: Radiotherapy and androgen deprivation are an established treatment option for locally advanced prostate cancer. We evaluate outcomes in efficacy and toxicity for patients treated with this combined therapy at our institution. METHODS: A retrospective study of 80 patients with locally advanced prostate cancer treated with radiotherapy combined with neo-adjuvant (2 months) and adjuvant (24 months) androgen deprivation. We studied the clinical variables and side effects. We evaluated treatment outcomes using PSA nadir and biochemical failure, and recorded acute and late gastrointestinal and urinary toxicity. We assessed the correlation between clinical variables and urinary toxicity by means of univariate and multivariate analyses (multiple logistic regression). RESULTS: The mean patient age was 68 ± 5.81 years; the initial PSA was 20.05 ± 16.27 ng/ ml and the mean prostate volume 43.7 ± 27.57 cc. The clinical stage was T3a in 33% and T3b in 66%. The Gleason score was <7 in 39%, 7 in 46% and ≥8 in 15%. The mean follow-up was 44.4 months and biochemical failure was observed in 3 cases. Acute urinary toxicity was recorded in 90% of the patients (chronic in 35%) and acute gastrointestinal toxicity in 75% (late in 32%). In a univariate analysis, prostate volume and urinary symptoms were statistically correlated to acute and late urinary toxicity. Both prostate volume and urinary symptoms were independently associated with an increase in urinary toxicity in the logistic regression analysis. CONCLUSIONS: Hormone-radiotherapy is a valid option to locally treat advanced prostate cancer with optimal short-term outcomes, although it is not devoid of side effects. Prostate volume and urinary symptoms before treatment can predict genitourinary toxicity.

Real-time quantification of human telomerase reverse transcriptase mRNA in the plasma of patients with prostate cancer.

The aim of this study was to evaluate the potential diagnostic value of quantitative analysis of human telomerase reverse transcriptase (hTERT) mRNA in plasma for noninvasive diagnosis of prostate cancer (PCa). Expression levels of hTERT were analyzed by real-time quantitative RT-PCR in 68 patients showing elevated prostate-specific antigen (PSA) levels and a control group of 44 healthy volunteers. Sensitivity and specificity were determined and compared to the corresponding PSA values. Median values for hTERT gene expression in the PCa patients (0.72 ng; range 0.01-12.86) were statistically significantly higher (P < 0.001) than in the control group (0.13 ng; 0.02-0.35). Patients with clinically confirmed prostatitis showed lower plasma hTERT expression than PCa patients (0.29; 0.01-66.07). At a cutoff value of 0.35 sensitivity and specificity for the diagnosis of PCa were 81% and 60%, respectively. We suggest that hTERT mRNA in plasma is a very specific and sensitive method that may aid to differentiate between malignant and nonmalignant prostate tissue and may be a useful marker (in combination with PSA) for early PCa diagnosis.

Cirugía Radioguiada de lesiones no palpables de mama / Radio-guided surgery in non palpable breast lesions

Introducción: La cirugía de lesiones no palpables de mama va en aumento y han aparecido nuevas técnicas de localización preoperatoria. Presentamos nuestra experiencia con la cirugía radioguiada (ROLL, radioguided occult lesion localisation), los aspectos técnicos y los resultados de nuestra serie de pacientes.Matarial y métodos: Estudiamos un total de 144 pacientes con lesiones no palpables de mama que sean visibles por ecografía, divididas en dos grupos. Un primer grupo de 44 pacientes que corresponden a lesiones benignas y probablemente benignas para exéresis radioguiada de la lesión únicamente; se inyectan macroagregados de albúmina marcados con 99mTecnecio por vía intralesional. Un segundo grupo de 100 pacientes que son lesiones probablemente malignas y con diagnóstico preoperatorio de malignidad para exéresis radioguiada de la lesión y biopsia del ganglio centinela en el mismo acto quirúrgico (SNOLL: sentinel node and occult lesion localisation), en las cuales se inyecta 99mTecnecio-coloide de albúmina por vía perilesional. Gammagrafía preoperatoria en todos los casos. La cirugía se realiza bajo anestesia general y la detección con sonda modelo Navigator GPS® (Tyco).Resultados: En todas las 144 pacientes se ha podido localizar el punto de máxima captación con facilidad y rapidez. En el grupo de lesiones probablemente benignas el resultado definitivo ha sido 93,2% patología benigna y 6,8% patología maligna. En el grupo de lesiones con sospecha moderada o alta de malignidad el resultado ha sido 9% patología benigna y 91% patología maligna, en las cuales la biopsia del ganglio centinela se realizó con éxito en 85 pacientes (93,4%). Resultado global patología benigna/maligna de 1/ 1,9. Porcentaje de reintervenciones por márgenes afectos o insuficientes en patología maligna de 14,9%. Conclusiones: La cirugía radioguiada ROLL de lesiones no palpables de mama marcadas bajo control ecográfico es una técnica sencilla y rápida que permite la exéresis de las lesiones con seguridad y menores índices de márgenes afectos que los métodos tradicionales (arpón). En patología maligna se puede realizar de forma adecuada tanto la ROLL como la biopsia del ganglio centinela con una sola inyección de radiotrazador

Background: Occult breast lesions surgery are in increasing frecuency and new preoperative localization techniques have been reported. We present our experience in radioguided surgery (ROLL, radioguided occult lesion localisation), technical aspects and our results.Methods: 144 patients of occult breast lesions detected by ultrasounography were included in two groups. First group of 44 patients with benign or probably benign lesions for excision biopsy only; using macroaggregates of 99mTechnecium labelled human serum albumin injected into the center of the lesion. A second group of 100 patients with suspicious abnormalities suggestive of malignancy and preoperative diagnosed breast cancer were enrolled for simultaneous performance of ROLL and sentinel node identification (SNOLL: sentinel node and occult lesion localisation), with peritumoral injection of 99mTechnecium labelled human albumin microcolloid. Lymphoscintigraphy was always performed. General anesthesia was used in all patients and excision was performed using a gamma-detecting probe Navigator GPS® (Tyco).Results: In all 144 patients, the "hot spot" was located easily and quickly. In probably benign lesions, pathologic examination revealed 93,2% benign lesions and 6,8% breast cancer. In diagnosed breast cancers and moderate or high suspicious lesions, the histology revealed 9% benign lesions and 91% breast cancers, in which sentinel node biopsy was succesfull in 85 patinets (93,4%). Global histologic results revealed benign/ malignant ratio 1/1,9. In breast cancers additional excisions to ensure free margins were performed in 14,9%. Conclusions: Radioguided surgery ROLL for nonpalpable breast lesions labelled with ultrasonographic guidance is a feasible and quickly method that allows more accurate removal of nonpalpable breast lesions and a lower rate of insufficient margins than conventional localization techniques (wire). In breast cancer simultaneous performance of ROLL and sentinel lymph node biopsy are possible with a single radiotracer injection

Heat transfer properties, moisture loss, product yield, and soluble proteins in chicken breast patties during air convection cooking.

Chicken breast patties were processed in an air convection oven at air temperatures of 149 to 218 C, air velocities of 7.1 to 12.7 m3/min, and air relative humidities of 40 to 95%. The air humidity was controlled via introducing steam into the oven. The patties were processed to a final center temperature of 50 to 80 C. Heat flux, heat transfer coefficient, moisture loss in the cooked chicken patties, the product yield, and the changes of soluble proteins in the product were evaluated for the cooking system. During cooking, heat flux varied with the processing time. Heat flux increased with increasing air humidity. The effective heat transfer coefficient was obtained for different cooking conditions. Air humidity in the oven affected the heat transfer coefficient. The moisture loss in the cooked products increased with increasing the final product temperature and the oven air temperature. The soluble proteins in the cooked patties decreased with increasing the final product temperature. Increasing humidity increased heat transfer coefficient and therefore reduced cooking time. Reducing oven temperature, reducing internal temperature, and increasing air humidity increased the product yield. Soluble proteins might be used as an indicator for the degree of cooking. The results from this study are important for evaluating commercial thermal processes and improving product yields.

EMT knowledge of ambulance traffic laws.

OBJECTIVE: The safe operation of ambulances using warning lights and siren requires both the public and emergency medical technician (EMT) drivers to understand and obey relevant traffic laws. However, EMTs may be unfamiliar with these laws. The purpose of this study was to evaluate EMTs' knowledge of traffic laws related to the operation of ambulances with warning lights and sirens. METHODS: North Carolina EMTs participating in a statewide EMS conference October 6-8, 1995, completed a five-question survey. Knowledge of ambulance speed limits, yielding at intersections, yielding in roadways, and following distances was assessed using a multiple-choice format. Demographic data pertaining to EMT age, years of experience, paid vs volunteer status, driver's education courses, and past accident involvement were also obtained. Proportions were compared using chi-square analysis, alpha = 0.05. RESULTS: Two-hundred ninety-three of 308 (95%) EMTs attending the conference completed questionnaires. The median number of correct responses to the five knowledge questions was 1 (range 0-4). Thirty-three percent of the EMTs knew that other vehicles are required by law to yield while either approaching or being overtaken by an ambulance with warning lights and sirens; 2% knew that due regard for safety is the only requirement of an ambulance approaching a red light at an intersection; 14% knew that the minimum following distance behind an ambulance is one city block; and 28% knew that there is no speed limit on ambulances with warning lights and sirens. Respondents were more likely to score above the median if they had taken one or more emergency driver's education courses or had nine years or more of EMS experience. CONCLUSION: In this sample, EMT knowledge of basic traffic laws pertaining to ambulance operation is poor. Emergency driver's education courses and increased experience appear to be related to increased knowledge scores. Increased training for EMTs about traffic laws may improve the safe operation of ambulances.

Intravenous ketorolac vs intravenous prochlorperazine for the treatment of migraine headaches.

OBJECTIVE: To compare i.v. ketorolac with i.v. prochlorperazine as the initial treatment of migraine headaches in the ED. METHODS: A prospective, double-blind comparison study was performed, using a convenience sample of 64 patients suffering from migraine headaches presenting to the ED at a tertiary care university teaching hospital. Patients were randomly assigned to receive either 10 mg of prochlorperazine i.v. or 30 mg of ketorolac i.v.. Patients scored the severity of their headaches using a 10-cm visual analog pain scale. An initial mark was made on the scale at the time of entry into the study and later another mark was made on a new unmarked pain scale 1 hour after medication administration. Changes in pain scores within each treatment group and between groups were analyzed using the Wilcoxon rank sum test. RESULTS: Prior to treatment, the patients assigned to receive prochlorperazine had a median score of 9.2 cm (mean +/- SD pain score of 8.3 cm +/- 2.1 cm), while the patients receiving ketorolac had a median score of 9.0 (mean pain score of 8.4 cm +/- 1.7 cm). There was no significant difference between the pain scores of the participants in the 2 groups prior to treatment (p = 0.80). One hour after medication administration, the patients in the prochlorperazine group had a median score of 0.5 cm (mean 2.1 +/- 3.2 cm), while those patients receiving ketorolac had a median pain score of 3.9 (mean 4.0 +/- 3.3 cm). The decrease in pain score was significant for both groups of patients (p = 0.0001). The change in pain score for the patients in the prochlorperazine group (median 7.1) was significantly greater than the change in pain score for the patients in the ketorolac group (median 4.0; p = 0.04). CONCLUSION: Although both drugs were associated with a significant reduction in pain scores, benefit over a placebo agent was not tested. Furthermore, the patients who received prochlorperazine i.v. for migraine headaches had a statistically significant greater decrease in their pain scores than did those receiving ketorolac i.v.

Do training programs help AFDC recipients leave the welfare rolls? An evaluation of New York City's BEGIN (Begin Employment Gain Independence Now) program.

Guided by the Federal Family Support Act of 1988 and the Job Opportunity and Basic Skills Program (JOBS), welfare reform initiatives on state and local levels were designed to foster employability among the public assistance population. Reform has focused on enhancing the supply of labor rather than the demand for labor as a route to labor force participation for the public assistance population. Program reforms assume that, by providing job training, educational services, and training-related expenses, labor market entry of the participating clientele would be facilitated while caseloads and public expenditures would decline. To date, analysis of similar programs in many states indicates that the impact of such programs in reducing public assistance caseloads is marginal. In New York City, despite the large investment of public funds in such programs, prior to this study the outcome of program implementation remained largely unknown. This study evaluates New York City's BEGIN program outcome target defined as the ability of the program to move welfare clients off public assistance and into the labor market. While the results of the study indicate that New York City's BEGIN program does not improve client's odds of leaving welfare, when compared to the odds of a non-participation client, there are several significant findings. The impact of program participation can be distinguished among distinct age groups. While older clients responded positively to BEGIN participation, access to day care was the only factor that significantly improved the probability that clients younger than 36 years of age would leave the welfare rolls within a two-year period. In response to the findings, the researchers suggest that future welfare reform efforts should grant localities broader flexibility to determine their own target population so that resources can be allocated to those groups that are most likely to benefit from specific programs.

Campho-Phenique ingestion: an intentional overdose.

We report a suicide attempt with the camphorated phenol preparation Campho-Phenique. The total dose ingested was 68 mg/kg of camphor and 28.9 mg/kg of phenol. The patient had grand mal seizures minutes after ingestion. Supportive medical care and intubation resulted in full recovery within 12 hours. Although Campho-Phenique has been discussed extensively in the pediatric literature and its accidental ingestion by adults has occasionally been reported, intentional ingestion of the preparation has not been reported. We discuss our unusual case and review the literature.

A breathing manikin model for teaching nasotracheal intubation to EMS professionals.

OBJECTIVE: The widespread use of orotracheal intubation with rapid-sequence induction has made it difficult for emergency medical services (EMS) professionals to gain experience in nasotracheal intubation (NTI) in a controlled and supervised setting. The purpose of this study was to determine whether a training session on NTI with a breathing manikin can be used to improve the self-assessed skill level and comfort of EMS professionals. METHODS: A prospective trial was conducted with a convenience sample of 33 EMS professionals, previously trained in NTI techniques. For the training session, a Laerdal airway manikin was modified by replacing the lungs with self-inflating resuscitation bag. The bag could then be squeezed to simulate breathing, with an inspiratory and expiratory phase. Following didactic instruction, and with direct supervision, each participant practiced NTI using this breathing manikin. Each participant completed a questionnaire, both before and after the training session, to determine self-assessed comfort and skill level for both oral and nasal intubations (0 = lowest, 10 = highest). The pre- and postintervention scores were compared using the Wilcoxon signed-rank test, alpha = 0.01. RESULTS: Following the training session, the comfort level for NTI by the participants increased significantly from a median value of 2 to 7 (p = 0.001). Furthermore, the self-assessed skill level for NTI following the training session increased significantly from a median value of 4 to 8 (p = 0.0001). As expected, there were no significant differences noted in self-assessed skill level for orotracheal intubation following the training session. However, there was statistically significant improvement in self-assessed comfort levels for orotracheal intubation after the skills laboratory, p = 0.0001. CONCLUSION: For EMS professionals, a training session for NTI using a relatively inexpensive and easily assembled breathing manikin model increases both comfort and self-assessed skill level.

Does ambulance crew size affect on-scene time or number of prehospital interventions?

INTRODUCTION: While large cities typically staff ambulances with two emergency medical services (EMS) professionals, some EMS agencies use three people for ambulance crews. The Greenville, North Carolina, EMS agency converted from three-person to two-person EMS crews in July 1993. There are no published reports investigating the best crew size for out-of-hospital emergency care. HYPOTHESIS: Two-person EMS crews perform the same number and types of interventions as three-person EMS crews. Two-person EMS crews do not have longer on-scene times than do three-person EMS crews. METHODS: Data for the two most common advanced life support calls in this system--seizures and chest pains--were collected for the months of June and August 1993. Three-person EMS crews responded to both types of calls in June. In August, two-person EMS crews responded to seizure calls; two-person EMS crews accompanied by a fire department engine (pumper) with additional manpower responded to chest pain calls. The frequency of specific interventions, number of total interventions, and scene times for the August calls were compared to their historical control groups, the June calls. RESULTS: One hundred twenty-six patient contacts were included in the study. There were no significant differences in total number or types of procedures performed for the two patient groups. Mean on-scene time for patients with seizures was 11.0 +/- 4.2 minutes for three-person crews and 19.4 +/- 8.3 minutes for two-person crews (p < 0.001). Mean on-scene time for patients with chest pain was 13.6 +/- 4.9 minutes for three-person crews, and 15.4 +/- 3.2 minutes for two-person crews assisted by fire department personnel (p > 0.05). CONCLUSION: Two-person EMS crews perform the same number of procedures as do three-person EMS crews. However, without the assistance of additional responders, two-person EMS crews may have statistically significantly longer on-scene times than three-person EMS crews.

Decay in quality of closed-chest compressions over time.

STUDY OBJECTIVE: To characterize fatigue-induced deterioration in the adequacy of closed-chest compressions performed over a period of 5 minutes and to determine whether CPR providers can recognize the effects of fatigue on compression adequacy. DESIGN: Prospective evaluation of study subjects performing closed-chest compressions on an electronic mannequin that assesses compression placement and depth. SETTING: Major resuscitation room in rural university hospital emergency department. PARTICIPANTS: Eleven experienced nursing assistants who regularly provide CPR in the ED. RESULTS: Each study participant performed 5 minutes of closed-chest compressions. Compression adequacy (for placement and depth) was assessed with the mannequin and reported on an attached monitor out of view of the study subjects. Subjects were asked to verbally indicate the point during their 5-minute compression period at which they felt too fatigued to provide effective compressions (arbitrarily defined as a minimum of 90% of all compressions being judged correct by the mannequin). We used one-way repeated-measures ANOVA and regression analysis to determine whether compression adequacy diminished over time. ANOVA was also used to determine whether the total compressions performed per minute diminished over time. The percentage of correct chest compressions decreased significantly after 1 minute of compressions (P = .0001). We found 92.9% of compressions performed during minute 1 to be correct. The percentages for minutes 2 through 5 were as follows: 67.1%, 39.2%, 31.2%, and 18.0%. Regression analysis revealed a decrement in compression adequacy of 18.6% per minute after the first minute of compressions. The number of total compressions attempted per minute did not decrease (P = .98). Study subjects did not accurately identify the point during their 5-minute sessions at which their fatigue caused compressions to become impaired. Whereas mean compression adequacy declined below 90% after only 1 minute, the time of indicated fatigue was 253 +/- 40 seconds (mean +/- SD). CONCLUSION: Although compression rate was maintained over time, chest compression quality declined significantly over the study period. Because CPR providers could not recognize their inability to provide proper compressions, cardiac arrest team leaders should carefully monitor compression adequacy during CPR to assure maximally effective care for patients receiving CPR.

Utilization of a pressure-sensing monitor to improve in-flight chest compressions.

Previous research at the Division of Air Medical Services at East Carolina University School of Medicine has demonstrated impairment of chest compression efficacy in the setting of an airborne BO-105 helicopter. This study was undertaken to determine whether in-flight compression efficacy could be improved with utilization of a pressure-sensing monitor providing real-time feedback during cardiopulmonary resuscitation (CPR). Ten flight nurses each performed two minutes of in-flight chest compressions on a mannequin that electronically assessed compression depth and hand placement. The session was then repeated using the pressure-sensing device. The mean proportion of correct compressions (95.7 +/- 3.2%) achieved with utilization of the pressure-sensing monitor was significantly higher (P < .01) than the corresponding proportion for the control group (33.4 +/- 12.1%). This study demonstrated that the difficulties of performing effective in-flight chest compressions are largely overcome with utilization of a pressure-sensing device providing real-time feedback on compression efficacy.