Implementation of a low titer group O whole blood program for a law enforcement tactical team.

The Texas Ranger Special Operations Group (SOG) performs high-risk warrant service and responds to callouts for evolving kinetic situations and special missions as required. These operations may occur many hours from a trauma center. Fresh whole blood (FWB) transfusions may offer a stopgap for those who are critically injured. To make FWB transfusions a viable option, several steps must be implemented. The following lays out how the Texas Ranger SOG will implement and conduct FWB transfusions using low titer group O whole blood. The techniques outlined may be useful for communities that may face critical blood shortage in disasters.

Training in the Management of Psychobehavioral Conditions: A Needs Assessment Survey of Emergency Medicine Residents.

OBJECTIVE: Mental health-related ED visits are increasing. Despite this trend, most emergency medicine (EM) residency programs devote little time to psychiatry education. This study aimed to identify EM residents' perceptions of training needs in emergency psychiatry and self-confidence in managing patients with psychobehavioral conditions. METHODS: A needs assessment survey was distributed to residents at 15 Accreditation Council for Graduate Medical Education-accredited EM programs spanning the U.S. Survey items addressed amount and type of training in psychiatry during residency, perceived training needs in psychiatry, and self-confidence performing various clinical skills related to emergency psychiatric care. Residents used a 5-point scale (1 = nothing; 5 = very large amount) to rate their learning needs in a variety of topic areas related to behavioral emergencies (e.g., medically clearing patients, substance use disorders). Using a scale from 0 to 100, residents rated their confidence in their ability to independently perform various clinical skills related to emergency psychiatric care (e.g., differentiating a psychiatric presentation from delirium). RESULTS: Of the 632 residents invited to participate, 396 (63%) responded. Twelve percent of respondents reported completing a psychiatry rotation during EM residency. One of the 15 participating programs had a required psychiatry rotation. Residents reported that their program used lectures (56%) and/or supervised training in the ED (35%) to teach residents about psychiatric emergencies. Most residents reported minimal involvement in the treatment of patients with psychiatric concerns. The majority of residents (59%) believed that their program should offer more education on managing psychiatric emergencies. Only 14% of residents felt "quite" or "extremely" prepared to treat psychiatric patients. Overall, residents reported the lowest levels of confidence and highest need for more training related to counseling suicidal patients and treating psychiatric issues in special populations (e.g., pregnant women, elderly, and children). CONCLUSIONS: Most EM residents desire more training in managing psychiatric emergencies than is currently provided.

Prolonged Field Care of a Casualty With Penetrating Chest Trauma.

As Special Operations mission sets shift to regions with less coalition medical infrastructure, the need for quality long-term field care has increased. More and more, Special Operations Medics will be expected to maintain casualties in the field well past the "golden hour" with limited resources and other tactical limitations. This case report describes an extended-care scenario (>12 hours) of a casualty with a chest wound, from point of injury to eventual casualty evacuation and hand off at a Role II facility. This case demonstrates the importance of long-term tactical medical considerations and the effectiveness of minimal fluid resuscitation in treating penetrating thoracic trauma.

Apoptosis-related proteins and proliferation markers in the orbitofrontal cortex in major depressive disorder.

BACKGROUND: In major depressive disorder (MDD), lowered neural activity and significant reductions of markers of cell resiliency to degeneration occur in the prefrontal cortex (PFC). It is still unclear whether changes in other relevant markers of cell vulnerability to degeneration and markers of cell proliferation are associated with MDD. METHODS: Levels of caspase 8 (C8), X-linked inhibitor of apoptosis protein (XIAP), direct IAP binding protein with low pI (DIABLO), proliferating cell nuclear antigen (PCNA) and density of cells immunoreactive (-IR) for proliferation marker Ki-67 were measured in postmortem samples of the left orbitofrontal cortex (OFC) of subjects with MDD, and psychiatrically-normal comparison subjects. RESULTS: There was significant increase in C8, a higher ratio of DIABLO to XIAP, lower packing density of Ki-67-IR cells, and an unexpected age-dependent increase in PCNA in subjects with MDD vs. controls. PCNA levels were significantly higher in MDD subjects unresponsive to antidepressants or untreated with antidepressants. The DIABLO/XIAP ratio was higher in MDD subjects without antidepressants than in comparison subjects. LIMITATIONS: Qualitative nature of responsiveness assessments; definition of resistance to antidepressant treatment is still controversial; and unclear role of PCNA. CONCLUSIONS: Markers of cell vulnerability to degeneration are increased and density of Ki67-positive cells is low MDD, but accompanied by normal XIAP levels. The results suggest increased vulnerability to cell pathology in depression that is insufficient to cause morphologically conspicuous cell death. Persistent but low-grade vulnerability to cell degeneration coexisting with reduced proliferation readiness may explain age-dependent reductions in neuronal densities in the OFC of depressed subjects.

Dealing with DIG. A comprehensive review of digoxin and its therapeutic and toxic effects.

Toxicity due to cardiac glycosides is a common and potentially life-threatening problem. Treatment of such toxicity presents unique challenges to the pre-hospital provider, because many of the tools commonly used to treat patients in the field may lead to disaster if inappropriately applied. But with better understanding of the mechanism of digitalis toxicity, prehospital providers can avoid pitfalls of treatment and render lifesaving care.