Calcium-alkali syndrome as a rare cause of severe hypercalcemia requiring dialysis in early twin gestation.

Hypercalcemia is rare in women of child-bearing age, and most cases are due to primary hyperparathyroidism. A 28-year-old woman, 14 weeks pregnant with dichorionic diamniotic twins, presented to hospital with vomiting, muscle cramps, and weakness. She had been taking calcium carbonate for gastric reflux and nausea from 5 weeks of gestation. Investigations revealed severe hypercalcemia, metabolic alkalosis, and renal injury. She was transferred to intensive care, receiving fluid resuscitation and subcutaneous calcitonin followed by dialysis. Investigations revealed suppressed PTH and PTH-related peptide, negative malignancy screening and low vitamin D level. Calcium and renal function quickly normalized and with cessation of calcium carbonate remained normal throughout the rest of pregnancy. Reports of calcium-alkali syndrome causing severe hypercalcemia are scarce, with most cases occurring later in gestation. This case represents a dramatic presentation requiring renal replacement therapy early in twin gestation.

Comparison of malleable stylet and reusable and disposable bougies by paramedics in a simulated difficult intubation.

In a randomised crossover study, 60 ambulance paramedics attempted tracheal intubation of a manikin model of a Cormack and Lehane grade 3/4 view using a Portex stylet, Portex and Frova single-use bougies, and a Portex reusable bougie. Tracheal intubation within 30 s was achieved by 34/60 (57%) using the stylet, 18/60 (30%) using a Portex single-use bougie, 16/60 (27%) using a Frova single-use bougie and 5/60 (8%) using a Portex reusable bougie. The proportion intubating within 30 s was significantly higher with the stylet compared with any bougie (p < 0.001), but significantly lower with a Portex reusable bougie than any other device (p < 0.004). Participants rated the Portex reusable bougie as significantly more difficult to use than the other devices (p < 0.001). There was no evidence of a relationship between previous experience and success rate for any device.

Can undergraduate paramedic students accurately identify lung sounds?

INTRODUCTION: The accurate identification of lung sounds during chest auscultation is a skill commonly used by healthcare clinicians, including paramedics, when assessing a patient's respiratory status. It is a necessary skill as it enables confirmation of a patient's respiratory condition and guides the paramedic to a provisional diagnosis and the implementation of appropriate management. The object of this study was to identify if undergraduate paramedic students from two Australian universities were able to interpret a variety of lung sounds accurately. METHODS: A prospective single-blinded observational study requiring 96 undergraduate paramedic students from two Australian universities to estimate the lung sounds of six audio files. RESULTS: The findings demonstrated variable accuracy in lung sound interpretation of the six audio files. The lung sound that contained a wheeze was most accurately interpreted, whereas coarse crackles were the least accurately interpreted. Monash University undergraduate paramedic students displayed similar lung sound interpretations to Charles Sturt University undergraduate paramedic students. CONCLUSION: In this study undergraduate paramedic students from two Australian universities were found to be inaccurate at interpreting a variety of common lung sounds. The study has highlighted that a greater emphasis needs to be given to lung sound interpretation in undergraduate paramedic education programmes.

Airtraq vs standard laryngoscopy by student paramedics and experienced prehospital laryngoscopists managing a model of difficult intubation.

Two consecutive, randomised, cross-over trials compared intubation success rates in third-year paramedic students and experienced prehospital practitioners using the Airtraq or a Macintosh laryngoscope with flexible stylet in a manikin model of a Cormack and Lehane grade III/IV laryngoscopic view. First-time intubation rates for the Macintosh and Airtraq for students were 0/23 (0%) vs 10/23 (44%) (44% difference, 95% CI 26-63%, p < 0.001) and for experienced laryngoscopists were 14/56 (25%) vs 47/56 (84%) (59% difference, 95% CI 42-72%, p < 0.0001), respectively. First-time oesophageal intubation rates for students were 15/23 (65%) vs 3/23 (13%) (-52% difference, 95% CI -25 to -72%, p < 0.001) and for experienced practitioners 9/56 (16%) vs 0/56 (0%) (-16% difference, 95% CI -9 to -28%, p = 0.0014). Student paramedics and experienced prehospital laryngoscopists managing a manikin model of a grade III/IV view had increased first-time intubation rates and had lower rates of oesophageal intubation with the Airtraq compared with a standard laryngoscope.

Use of the Airtraq laryngoscope in a model of difficult intubation by prehospital providers not previously trained in laryngoscopy.

This study evaluated the ability of prehospital providers who had no previous training in intubation, to use an Airtraq laryngoscope to intubate a manikin model of a Cormack and Lehane grade III/IV view. Volunteers attending the Australian College of Ambulance Professionals conference, Adelaide, in November 2006 received approximately 5 min of Airtraq training. First-time intubation success rate was 26/33 (79%) (95% CI 61-91%); oesophageal intubation rate was 0/33 (0%) (95% CI 0-11%); median time to intubation was 17 s (IQR 10-25 s (range 5-30 s)); and median subject-rated difficulty of use score was 21 out of a maximum of 100 (IQR 7.5-35.5 (range 1-65)). Pre-hospital providers without previous laryngoscopy training achieved high first-time intubation success rates when managing a model of a grade III/IV difficult intubation with an Airtraq laryngoscope. Users evaluated it as easy to use and achieved intubation within an acceptable breath-to-breath interval.

Working together for a sustainable urgent care system: a case study from south eastern Australia.

CONTEXT: A small, isolated community in the south east of Australia, Malacoota, had a long-standing concern about the adequacy of their emergency medical systems. There was no hospital, the local medical practitioners were under stress and their ambulance services were limited. Following an approach through the local Division of General Practice in August 2002, the School of Rural Health at Monash University was invited to assist. ISSUES: A policy development toolkit was used to improve the rural urgent care systems through engagement with community members. The process involved community consultation, a meeting of key stakeholders, and the formation of a representative Steering Committee to oversee the local management of the project. Project officers worked with a university facilitator and other stakeholders to implement the Transforming Rural Urgent Care Systems (TrUCs) process from August 2002 to June 2003. A proposal of recommendations was put to the Victorian State Minister of Health and this was accompanied by a degree of political action. The submission raised the issues of poor interstate communications, ambulance staffing, support for medical practitioners, facilities for the stabilisation of patients, and access to air ambulance services. Funding was obtained for the implementation of a community paramedic model. Ambulance service communications systems improved and an innovative model of ambulance service delivery for isolated communities was implemented. LESSONS: A number of lessons have been identified, including the crucial role of the project officers, and communication within the community and among specific stakeholders. The approach used could be adopted in other rural locations hoping to improve their emergency health services.

Would a prehospital practitioner model improve patient care in rural Australia?

BACKGROUND: Existing rural prehospital models have been criticised for being isolated from the healthcare system, and for following inflexible clinical protocols. Greater reliance on clinical judgement and informed decision making in the prehospital setting offer the potential to improve patient care. METHODS: Soft systems methodology was used to develop and critically appraise the prehospital practitioner model as an alternative to existing models. This approach started from the philosophical viewpoint that prehospital services should be patient centred. Soft systems methodology was used to structure the elements of prehospital systems and the relations between them into metaphors and pictures that could be analysed. RESULTS: This analysis showed that the most powerful reason for advocating the prehospital practitioner model is that it places prehospital systems within a symbiotic relationship with the healthcare system. Unlike the existing emergency service models or the "chain of survival" model, it is an integrated system that provides a range of services at multiple points during the patient care cycle. Thus, the prehospital practitioner would have roles in the prevention of injury and illness, responding to emergencies, facilitating recovery, and planning future strategies for a healthy community. CONCLUSIONS: Implementing this new model would see the prehospital system using its available capacity more effectively to fulfill broader public health and primary care outreach roles than is currently the case. Patients would be referred or transported to the most appropriate and cost effective facility as part of a seamless system that provides patients with well organised and high quality care.

Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference?

OBJECTIVE: To evaluate whether evidence based clinical pathways for acute management of hip fracture have an effect on patient care, short term mortality, or residential status. METHODS: Observational cohort study comparing management, as determined by medical record review, and outcomes, as determined by telephone followup 4 months post-fracture, before (n = 455) and after (n = 481) clinical pathway implementation within pathway hospitals as well as between patients admitted to hospitals with (n = 2) and without (n = 4) pathways. RESULTS: Mean age was 82 years, 80% were women and 30% were admitted from nursing homes. Significant improvement in best practice as recommended by evidence based clinical guidelines was evident in pathway hospitals for most components of care. However, compliance was variable and nonpathway hospitals performed better for some (use of spinal anesthesia, avoidance of urinary catheters). After adjusting for potential confounders, no difference was found in 4 month mortality between the pathway (17.6%) and non-pathway (16.8%) patients (OR 0.8, 95% CI 0.5-1.5). There was a nonsignificant reduction in median acute care hospital length of stay of 1 day (p = 0.200) for non-nursing home patients and a significant reduction of 1 day (p = 0.038) for nursing home patients in the pathway hospitals. There was a nonsignificant decrease in admission rates for new patients to nursing homes in pathway hospitals (18.5%) compared to non-pathway hospitals (24.3%) (OR 0.5, 95% CI 0.3-1.1). CONCLUSION: Clinical pathways were associated with increased use of evidence based best practice, some reduction in acute hospital length of stay, but no significant effect on 4 month mortality or residential status. Their development and maintenance were resource intensive and further work on the implementation of evidence based guidelines is needed to determine whether they can influence patient outcomes.

Developing a funding model for an after-hours primary medical care service in a rural town.

The study described in this paper aimed to determine a funding model for an after-hours primary medical care service in the rural town of Moe, a socioeconomically disadvantaged area of Victoria suffering the rigours of industry restructuring and privatisation. It has 12.5 equivalent full-time general practitioners servicing 21,966 persons. A break-even analysis of the financial viability compared the expected costs of providing the service with the anticipated income. A mixed funding model is recommended. This would incorporate a general practitioner incentive scheme and State Government underwriting of infrastructure and basic non-medical staffing costs during the business development phase to supplement the income from the Health Insurance Commission.

Comparison of a once-a-day sustained-release morphine formulation with standard oral morphine treatment for cancer pain.

Kadian/Kapanol (K) is a capsule formulation of morphine designed for 12- or 24-hourly dosing. This double-blind study compared the efficacy and safety of K every 24 hr to K every 12 hr and MS Contin tablets (MSC) every 12 hr. One hundred fifty-two patients with cancer pain were titrated to adequate analgesia with immediate-release morphine (IRM) solution. Stabilized patients were randonized to one of the three treatments for 7 +/- 1 days. Rescue medication was IRM tablets. Efficacy and safety were assessed by time to first remedication and total dose of rescue medication, pain scores, global assessments, and incidence of morphine-related side effects. Fifty-four patients were treated with K every 24 hr. 45 with K every 12 hr. and 53 with MSC every 12 hr. Mean age was 61 years and mean total daily dose of morphine was 138 mg. Forty-six percent of the K every 24 hr patients, 51% of the K every 12 hr patients, and 55% of the MSC every 12 hr patients required rescue medication on the final day. Time to remedication was 16.0 hr for K every 24 hr, 9.1 hr for K every 12 hr and 8.7 hr for MSC every 12 hr (P = 0.0010). Patient global assessment significantly favored K every 24 hr over MSC every 12 hr (P = 0.018). There were no statistically significant differences among the treatments for any morphine-related side effects when adjusted for baseline. K had efficacy and safety profiles similar to MSC every 12 hr but had the advantage of 12- or 24-hourly administration.

Surgical techniques for arthroscopic meniscal repair.

Meniscus repair surgery should involve: (1) concomitant anterior cruciate ligament (ACL) reconstruction in ACL-deficient knees, (2) rasping of the perimeniscal synovium and both tear surfaces, (3) the use of a posterior incision and popliteal retractor, (4) closely spaced, vertically placed suture repair with good coaptation of the tear surfaces, (5) the implantation of an exogenous fibrin clot in the defect, and (6) a well-supervised rehabilitation program. This article reviews the different surgical techniques for arthroscopic meniscal repair.

The basic science of meniscus repair.

The meniscus transmits load and reduces stress and compression of the articular cartilage and subchondral bone of the knee during weight bearing. Removal of even small portions of the meniscus may increase joint contact forces dramatically and lead to early degenerative changes in the knee. The goal of meniscus surgery is to preserve as much functional meniscus tissue as possible in the hope of decreasing the risk of late degenerative sequelae and still relieve the symptoms associated with the tear. The indication for repair of any meniscus tear should depend solely on the ability to technically stabilize and coaptate the tear. This article reviews the basic treatment principles of meniscal tears.

Rehabilitation following reconstruction of the anterior cruciate ligament.

A closely supervised rehabilitation program is mandatory if maximum benefit is to be derived from anterior cruciate ligament (ACL) reconstruction. The author describes a postoperative rehabilitation protocol based on kinesiologic, histologic, and biomechanical factors affecting the ACL.

Management of open fractures.

An open fracture is an orthopaedic emergency that can lead to devastating complications and prolonged rehabilitation. The goals of treatment are to prevent infection, achieve bone union, and restore function. The treatment should involve the use of antibiotics, repeated thorough irrigation and debridement, early fracture stabilization, early wound closure, and aggressive rehabilitation. The result of treatment is largely affected by the initial soft-tissue loss, wound contamination, fracture stability, and neurovascular status.

Is syncope related to moderate altitude exposure?

STUDY OBJECTIVE: To investigate factors related to syncope occurring on recent ascent to moderate altitude. DESIGN: A 1-year retrospective case-control study, using local acclimatized residents as a control group. SETTING: The two main ambulance destinations for Summit County, Colorado (elevation, 2770 m). PATIENTS: All patients with a diagnosis of syncope, near-syncope, or fainting whose medical records were available for review. RESULTS: There was a significant relationship (P less than .05) between syncope of unknown origin and recent arrival at altitude (less than 24 hours), and a significant inverse relationship (P less than .05) between syncope of unknown origin and arterial oxygen saturation as measured by pulse oximetry. CONCLUSIONS: Short-term exposure to moderate altitude may be related to otherwise unexplained syncope in healthy young adults. We suggest the name high-altitude syncope for this entity and encourage further research in this area.

Anterior cruciate ligament reconstruction stability with continuous passive motion. The role of isometric graft placement.

A comparison was made of the stability of isometric versus nonisometric anterior cruciate ligament (ACL) reconstructions when subjected to immediate postoperative continuous passive motion (CPM). Anterior cruciate ligament reconstructions were performed on 13 anatomic specimen knees using bone/patellar tendon/bone grafts. Nine ACL substitutions were considered isometric with maximum graft length changes of less than 1 mm. Four ACL substitutions were nonisometric with graft length changes of 3 mm or greater resulting from tightening in flexion. The specimens were subjected to CPM through 0 degrees-95 degrees knee flexion. Knee stability was remeasured with a knee arthrometer at three and 14 days after beginning CPM. All four nonisometric specimens had failed within three days, with increased anterior laxity of 2-9 mm in both the Lachman (20 degrees) and anterior drawer (90 degrees) positions. All nine isometric reconstructions successfully retained pre-CPM anterior stability within 1 mm after 14 days of CPM. This investigation illustrates the importance of isometric graft placement for ACL reconstruction success. Continuous passive motion does not appear to adversely affect immediate ACL-substitute integrity or fixation if graft placement is isometric (less than 1 mm of graft excursion through 0 degrees-110 degrees of knee motion). Continuous passive motion may cause graft deformation, fixation failure, or both, with resultant loss of knee stability if the graft is not isometrically positioned (greater than 3 mm of graft excursion resulting from tightening in flexion).