Elevated blood lead levels in urban moonshine drinkers.

STUDY OBJECTIVE: During a study of problem drinking, we found that surprisingly large numbers of emergency department patients reported moonshine consumption. Because of sporadic reports of moonshine-associated lead toxicity in rural areas, we suspected that urban ED patients might have previously unidentified elevated blood lead levels caused by moonshine consumption. We initiated an active screening program to identify patients with moonshine-associated elevated blood lead levels. METHODS: We performed a prospective case-finding effort at a large urban ED in Atlanta, GA, screening all patients admitted to the ED for a 6-month period during times when study personnel were available. Patients reporting moonshine consumption within the preceding 5 years were asked to participate. After written informed consent, subjects completed a structured interview administered by one of the investigators, and blood was obtained for determination of a whole blood lead level. We recorded the numbers of patients reporting moonshine consumption, time of most recent consumption, other potential sources of lead exposures, and whole blood lead levels. RESULTS: Of 49 patients reporting consumption of moonshine within the past 5 years, 25 (51%) of 49 had elevated blood lead levels (>15 microg/dL), with 15 (31%) of 49 having extremely elevated blood lead levels (>50 microg/dL). Recent moonshine consumption (within the past month) was reported by 38 (78%) of 49 patients. Of these 38 recent consumers, 23 (61%) had elevated lead levels compared with only 2 (18%) of 11 of those reporting more remote consumption (risk difference 42%; 95% confidence interval 15% to 70%). CONCLUSION: A high percentage of patients who reported moonshine consumption had elevated blood lead levels. Emergency physicians should consider screening to determine the prevalence of moonshine consumption in their practice settings, as well as the possibility of lead intoxication among patients with suggestive symptoms. All patients reporting moonshine consumption within the past 5 years should be tested for lead exposure.

Acceptability of emergency department-based screening and brief intervention for alcohol problems.

OBJECTIVES: To adapt screening and brief intervention for alcohol problems (SBI) to a high-volume emergency department (ED) setting and evaluate its acceptability to patients. METHODS: Patients at a large public-hospital ED were screened with the Alcohol Use Disorders Identification Test (AUDIT). Screen-positive drinkers (AUDIT score >/= 6) were provided brief, on-site counseling and referral as needed. Three months later, project staff blinded to baseline measures reassessed alcohol intake, alcohol-related harm, alcohol dependence symptoms, and readiness to change. RESULTS: Of 1, 034 patients approached, 78.3% (810) consented to participate (95% CI = 75.5% to 81.2%), and 21.2% (172) screened positive (95% CI = 18.4% to 24.0%). Of 88 patients with complete intervention data, 94.3% (83) accepted an intervention (95% CI = 89.5% to 99.2%), with acceptance rates ranging from 93% to 100% across four alcohol-problem-severity levels (p = 0.7). A majority (59.0%) set goals to decrease or stop drinking (95% CI = 48.4% to 69.6%). The group recontacted (n = 23) experienced statistically significant decreases in alcohol intake, alcohol-related harm, and dependence symptoms, with measures decreasing for 68%, 52%, and 61% of the patients. Readiness to change also showed statistically significant improvement, with scores increasing for 43% of the patients. Moreover, two-thirds of the patients (15/23) reported at follow-up that SBI was a helpful part of their ED visit. CONCLUSIONS: High rates of consent and acceptance of counseling for alcohol problems by patients across a wide range of problem severity indicate that this protocol was acceptable to at-risk patients in a public-hospital ED. Improvements in alcohol-related outcome measures at follow-up were strong enough to warrant controlled studies of intervention efficacy.

Injury control in Honduras: a survey of injury mortality.

STUDY OBJECTIVE: We sought to evaluate the methods and accuracy of mortality data collection and summarize the injury mortality rate in one sector of the State of Olancho, Honduras, with the intent to establish a baseline of injury mortality that will identify potential areas of intervention and serve as a comparison after subsequent interventions. METHODS: Mortality data were collected from a rural, regional, health center database containing age, sex, and cause of death for one geographic sector in the State of Olancho, Honduras. Causes of death were classified as medical or intentional versus nonintentional injury. RESULTS: Accurate mortality data were difficult to obtain for several reasons: (1) deaths are often recorded by untrained health care workers, (2) causes of death are not coded in a standard manner, and (3) infant mortality is underreported. We found 132 recorded noninfant deaths. A disproportionate number of these resulted from injury, especially from intentional injury, particularly among male subjects aged 12 to 49 years. Eighty-two percent of male subjects aged 12 to 49 years who died did so from injuries, and 52% died from intentional injuries. Overall, 48% of all male deaths were injury related. The estimated male mortality rate (age 12 to 49 years) from injuries was 4.5 times that of the United States. CONCLUSION: Injury, particularly intentional injury, is an important cause of mortality in rural Honduras, particularly among male subjects aged 12 to 49 years. This suggests a fertile opportunity for intervention. More reliable data collection will be necessary to accurately target which specific causes of injury death are most amenable to interventions and to monitor the effect of injury control programs.

Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group.

BACKGROUND: Because clinicians fear missing occult cervical-spine injuries, they obtain cervical radiographs for nearly all patients who present with blunt trauma. Previous research suggests that a set of clinical criteria (decision instrument) can identify patients who have an extremely low probability of injury and who consequently have no need for imaging studies. METHODS: We conducted a prospective, observational study of such a decision instrument at 21 centers across the United States. The decision instrument required patients to meet five criteria in order to be classified as having a low probability of injury: no midline cervical tenderness, no focal neurologic deficit, normal alertness, no intoxication, and no painful, distracting injury. We examined the performance of the decision rule in 34,069 patients who underwent radiography of the cervical spine after blunt trauma. RESULTS: The decision instrument identified all but 8 of the 818 patients who had cervical-spine injury (sensitivity, 99.0 percent [95 percent confidence interval, 98.0 to 99.6 percent]). The negative predictive value was 99.8 percent (95 percent confidence interval, 99.6 to 100 percent), the specificity was 12.9 percent, and the positive predictive value was 2.7 percent. Only two of the patients classified as unlikely to have an injury according to the decision instrument met the preset definition of a clinically significant injury (sensitivity, 99.6 percent [95 percent confidence interval, 98.6 to 100 percent]; negative predictive value, 99.9 percent [95 percent confidence interval, 99.8 to 100 percent]; specificity, 12.9 percent; positive predictive value, 1.9 percent), and only one of these two patients received surgical treatment. According to the results of assessment with the decision instrument, radiographic imaging could have been avoided in the cases of 4309 (12.6 percent) of the 34,069 evaluated patients. CONCLUSIONS: A simple decision instrument based on clinical criteria can help physicians to identify reliably the patients who need radiography of the cervical spine after blunt trauma. Application of this instrument could reduce the use of imaging in such patients.

Ethnicity and analgesic practice.

STUDY OBJECTIVE: We previously reported that Hispanic ethnicity was an independent risk factor for inadequate analgesic administration among patients presenting to a single emergency department. We then attempted to generalize these findings to other ethnic groups and EDs. Our current study objective is to determine whether black patients with extremity fractures are less likely to receive ED analgesics than similarly injured white patients. METHODS: We conducted the following retrospective cohort study at an urban ED in Atlanta, GA. All black and white patients presenting with new, isolated long-bone fractures over a 40-month period were studied. After abstracting demographic information from the medical record and subsequently removing ethnic identifiers, we submitted the medical record to a physician who recorded characteristics of the patients' injury and treatment. We then submitted the records to a nurse, again blinded to ethnicity, who recorded analgesic administration. We used multiple logistic regression to determine the independent effect of ethnicity on analgesic use while controlling for multiple potential confounders. Our main outcome measure was the proportion of black versus white patients receiving ED analgesics. RESULTS: The study group consisted of 217 patients, of whom 127 were black and 90 were white. White patients were significantly more likely than black patients to receive ED analgesics (74% versus 57%, P =.01) despite similar records of pain complaints in the medical record. The risk of receiving no analgesic while in the ED was 66% greater for black patients than for white patients (relative risk 1.66, 95% confidence interval, 1.11 to 2.50). This effect persisted after controlling for multiple potential confounders. CONCLUSION: Black patients with isolated long-bone fractures were less likely than white patients to receive analgesics in this ED. No covariate measured in this study could account for this effect. Our findings have implications for efforts to improve analgesic practices for all patients.

Simple CPR: A randomized, controlled trial of video self-instructional cardiopulmonary resuscitation training in an African American church congregation.

STUDY OBJECTIVE: Despite the proven efficacy of cardiopulmonary resuscitation (CPR), only a small fraction of the population knows how to perform it. As a result, rates of bystander CPR and rates of survival from cardiac arrest are low. Bystander CPR is particularly uncommon in the African American community. Successful development of a simplified approach to CPR training could boost rates of bystander CPR and save lives. We conducted the following randomized, controlled study to determine whether video self-instruction (VSI) in CPR results in comparable or better performance than traditional CPR training. METHODS: This randomized, controlled trial was conducted among congregational volunteers in an African American church in Atlanta, GA. Subjects were randomly assigned to receive either 34 minutes of VSI or the 4-hour American Heart Association "Heartsaver" CPR course. Two months after training, blinded observers used explicit criteria to assess CPR performance in a simulated cardiac arrest setting. A recording manikin was used to measure ventilation and chest compression characteristics. Participants also completed a written test of CPR-related knowledge and attitudes. RESULTS: VSI trainees displayed a comparable level of performance to that achieved by traditional trainees. Observers scored 40% of VSI trainees competent or better in performing CPR, compared with only 16% of traditional trainees (absolute difference 24%, 95% confidence interval 8% to 40%). Data from the recording manikin confirmed these observations. VSI trainees and traditional trainees achieved comparable scores on tests of CPR-related knowledge and attitudes. CONCLUSION: Thirty-four minutes of VSI can produce CPR of comparable quality to that achieved by traditional training methods. VSI provides a simple, quick, consistent, and inexpensive alternative to traditional CPR instruction, and may be used to extend CPR training to historically underserved populations.

Job stressors and job satisfaction in a major metropolitan public EMS service.

INTRODUCTION: Behavioral and social science research suggests that job satisfaction and job performance are positively correlated. It is important that EMS managers identify predictors of job satisfaction in order to maximize job performance among prehospital personnel. PURPOSE: Identify job stressors that predict the level of job satisfaction among prehospital personnel. METHODS: The study was conducted within a large, urban Emergency Medical Services (EMS) service performing approximately 60,000 Advanced Life Support (ALS) responses annually. Using focus groups and informal interviews, potential predictors of global job satisfaction were identified. These factors included: interactions with hospital nurses and physicians; on-line communications; dispatching; training provided by the ambulance service; relationship with supervisors and; standing orders as presently employed by the ambulance service. These factors were incorporated into a 21 item questionnaire including one item measuring global job satisfaction, 14 items measuring potential predictors of satisfaction, and seven questions exploring demographic information such as age, gender, race, years of experience, and years with the company. The survey was administered to all paramedics and Emergency Medical Technicians (EMTs) Results of the survey were analyzed using univariate and multivariate techniques to identify predictors of global job satisfaction. RESULTS: Ninety paramedics and EMT participated in the study, a response rate of 57.3%. Job satisfaction was cited as extremely satisfying by 11%, very satisfying by 29%, satisfying by 45%, and not satisfying by 15% of respondents. On univariate analysis, only the quality of training, quality of physician interaction, and career choice were associated with global job satisfaction. On multivariate analysis, only career choice (p = 0.005) and quality of physician interaction (p = 0.05) were predictive of global job satisfaction. CONCLUSIONS: Quality of career choice and interactions with physicians are predictive of global job satisfaction within this urban emergency medical service (EMS). Future studies should examine specific characteristics of the physician-paramedic interface that influence job satisfaction and attempt to generalize these results to other settings.

Injury-control education in six U.S. medical schools.

PURPOSE: To assess knowledge, attitudes, and formal instruction related to injury control among fourth-year medical students. Injury is the leading cause of death among Americans aged 1 to 44 years. METHOD: The authors conducted a cross-sectional survey of fourth-year students at six U.S. medical schools, four of which maintain federally funded injury prevention research centers. Main outcome measures included injury-related knowledge scores, three attitude measures, and self-reported exposures to injury prevention education. RESULTS: Six hundred and thirty-five fourth-year medical students (73% of those eligible) participated. The responding students were, on average, unable to correctly answer half of the questions testing injury-related knowledge. They rated medical problems more important and more preventable than injury problems, and they felt more comfortable asking their patients about risk factors for medical problems. These findings may be explained, in part, by the students' reported minimal exposure to injury control education in medical school. The students encountered the topic more frequently on rotations in pediatrics (84%), family medicine (73%), and preventive medicine (66%) than on rotations in emergency medicine (47%), internal medicine (41%), or obstetrics and gynecology (34%). Injury control was encountered least often on rotations in psychiatry (23%) and surgery (14%). CONCLUSIONS: These findings suggest that injury control is given limited coverage in the curricula of U.S. medical schools. As a result, students have little understanding of the principles and benefits of injury control.

Randomized, controlled trial of video self-instruction versus traditional CPR training.

STUDY OBJECTIVE: We conducted a prospective, randomized, controlled trial to test the hypothesis that a 34-minute video self-instruction (VSI) training program for adult CPR would yield comparable or better CPR performance than the current community standard, the American Heart Association Heartsaver course. METHODS: Incoming freshman medical students were randomly assigned to VSI or the Heartsaver CPR course. Two to 6 months after training, we tested subjects to determine their ability to perform CPR in a simulated cardiac arrest setting. Blinded observers used explicit criteria to assess our primary outcome, CPR performance skill. In addition, we assessed secondary outcomes including sequential performance of individual skills, ventilation and chest compression characteristics, and written tests of CPR-related knowledge and attitudes. RESULTS: VSI trainees displayed superior overall performance compared with traditional trainees. Twenty of 47 traditional trainees (43%) were judged not competent in their performance of CPR, compared with only 8 of 42 VSI trainees (19%; absolute difference, 24%; 95% confidence interval, 5% to 42%). CONCLUSION: In a group of incoming freshman medical students, we found that a half-hour of VSI resulted in superior overall CPR performance compared with that in traditional trainees. If validated by further research, VSI may provide a simple, quick, and inexpensive alternative to traditional CPR instruction for health care workers and, perhaps, the general population.