On-site and distance education of emergency medicine personnel with a human patient simulator.

BACKGROUND: Infrequent use of emergency medical skills eventually leads to skill degradation. Even during residency training, certain skills may be infrequently encountered. The use of human patient simulators (HPS) is one means by which these skills may be practiced with sufficient numbers to learn and maintain emergency skills. OBJECTIVE: To assess the efficacy and feasibility of training isolated emergency medical personnel with a HPS. DESIGN/METHODS: A sophisticated HPS was placed at the Roosevelt Roads Naval Hospital, Puerto Rico. A convenience sample of emergency naval personnel enrolled in a training program consisting of five HPS-based scenarios. Both on-site (instructor in the room) and off-site (instructor in the United States) training was provided. A pre/post-test design was used to assess the efficacy of HPS training using a survey with a Likert scale measuring participant-perceived preparedness, self-efficacy, and perceptions of HPS training. RESULTS: Eighteen emergency medical personnel participated in the educational program. Eight were physicians, and the remainder were emergency medical technicians and U.S. Navy medical corpsmen. Perceived preparedness and self-efficacy improved overall and for each individual scenario. Participants rated the training highly and felt that it was better than conventional noninteractive mannequins. Off-site training was found to be feasible despite the low-bandwidth services available: Internet (56 K) and telephone service. Participants readily accepted off-site training. CONCLUSIONS: HPS education improves perceived preparedness and self-efficacy in U.S. Navy emergency medical personnel. This type of training may be an important adjunct for emergency medical providers who infrequently have the opportunity to apply learned emergency medical care skills. The use of HPS with distant interactive education capability allows isolated medical personnel the opportunity to practice skills unconstrained by time or distance.

Mucormycosis in diabetes.

Mucormycosis is a rare opportunistic infection caused by ubiquitous fungi typically found in soil, spoiled foods, bread, and dust. The acute infection most commonly is rhinocerebral and is associated with metabolic acidosis. Mucormycosis spreads quickly and can progress from the paranasal area to the brain in a few days. In the case presented, a young diabetic woman had diabetic ketoacidosis and classic signs and symptoms of mucormycosis. Even after aggressive and appropriate treatment with surgical debridement and IV administration of amphotericin B, the fungus invaded the central nervous system. This article discusses current methods of treating mucormycosis and important critical care nursing considerations for patients who have the infection.

Gut dysfunction in critically ill patients: a review of the literature.

BACKGROUND: Critically ill patients are susceptible to injury of the intestinal mucosa, changes in gut permeability, and failure of intestinal defense mechanisms. These conditions put the patients at risk for infection and multiple organ dysfunction syndrome. Specific therapies are needed to prevent gut failure during critical illness. OBJECTIVE: The purpose of this literature review is to provide a better understanding of the normal defense mechanisms of the gut and alterations associated with ischemia-reperfusion injury, risk of infection, and the link to multiple organ dysfunction syndrome in critically ill patients. Implications for early enteral stimulation and nutrition are included. METHODS: Medical and nursing studies on the intestinal response to critical illness and on the implications for early enteral nutrition in critically ill patients were reviewed. RESULTS: Significant advances have been made in understanding the normal defense mechanisms of the gut, including barrier and immune functions. Translocation of bacteria, mediators of the inflammatory response, and the microcirculation play a role in the response to critical illness. Enteral nutrition that includes glutamine and arginine enhances gut function and improves patients' outcomes in some clinical states. DISCUSSION: Further research should focus on specific strategies to enhance gut function, prevent loss of gut integrity, and improve patients' outcomes. These strategies include maintaining mesenteric blood flow, using gastric tonometry to assess oxygenation, inhibiting inflammatory mediators, and using growth factors to modify the metabolic state in patients who are critically ill.

Angulation of the pediatric cervical spine with and without cervical collar.

STUDY OBJECTIVE: To determine whether semirigid cervical collars eliminate cervical spine (CS) flexion in children on back boards. DESIGN: Prospective clinical study. SETTING: An urban pediatric emergency department. PARTICIPANTS: Eighteen head-injured children < 8 years of age undergoing CS radiographs. INTERVENTIONS: Children were secured to back boards, and semirigid cervical collars were applied. Following CS clearance, the collar was removed, and an additional lateral film without collar was obtained. C2-C6 lateral Cobb angles were measured on both lateral films. MAIN RESULTS: Mean flexion with collar was 3.4 +/- 9.9 degrees and 5.6 +/- 6.8 degrees without a collar P > 0.05 CONCLUSION: Most children < 8 years, when immobilized on back boards have flexed CSs. Semirigid cervical collars do not eliminate flexion. Further study is needed to develop and test different methods of CS immobilization as present equipment is unable to position the CS optimally.

Who dispenses pharmaceuticals to children at school?

Use of both prescription and non-prescription pharmaceuticals has increased among children. Many of these drugs are taken during school hours and dispensed by school personnel who are not health professionals. They know little or nothing about the drugs themselves or the medical conditions requiring their use. This survey examined the extent to which pharmaceuticals are dispensed in schools in one Florida county. Public elementary, middle, and high schools and six private schools were surveyed for one week. All medications dispensed by school personnel during that time were recorded. Of 28,134 children surveyed, 1,016 children received 5,411 doses of medication. Thirty-one categories of drugs were dispensed including controlled substances. Methylphenidate was the most widely dispensed drug, comprising about half of all the medications given in school. Medication use was evaluated in terms of gender, race, and socioeconomic status of the children.

Use of a clinical assessment tool for orally intubated patients.

BACKGROUND: Although oral hygiene is difficult to perform in orally intubated, critically ill patients, oropharyngeal status may be related to acquisition of nosocomial organisms and should therefore be addressed. OBJECTIVE: To develop a clinical tool for assessment of the mouth in orally intubated patients. METHODS: Sixteen orally intubated patients from one surgical and one medical intensive care unit were subjects. Demographic, clinical, and baseline oropharyngeal assessment data, including sputum and mouth cultures, were obtained on patient admission to the study and every other day. RESULTS: Oropharyngeal cultures of four subjects grew nosocomial bacterial organisms and of two subjects, fungal species. These same organisms were cultured from sputum specimens. Seven patients displayed severe xerostomia; 10 lip lesions were identified in nine subjects, 8 tongue lesions in nine subjects, and 8 mucosal lesions in nine subjects. CONCLUSION: Systemic oropharyngeal assessment in critically ill orally intubated patients may prevent more serious oropharyngeal infections.

Interruption of enteral feedings in head injured patients.

This study was undertaken to determine differences between caloric intake and requirements of critically ill, enterally fed, neurosurgical and neurotrauma patients and to determine the nature and frequency of interruptions in enteral feedings in this same population. This descriptive, prospective study was conducted in a surgical intensive care unit (ICU) in a university teaching hospital. The sample consisted of 52 mechanically ventilated, critically ill patients with a mean age of 48.96 years who were receiving enteral nutrition for at least two days. Basal energy requirements, daily nutritional intake and enteral feeding interruption characteristics were recorded for a total of 586 study days. Underfeeding due to interruptions occurred in the majority of patients for the first eight days following initiation of enteral feeding. Reasons for underfeeding were interruptions of continuous tube feedings due to medication administration via the feeding tube (31%), feeding tube displacement (27%), surgery (12%), ileus (9%), radiologic studies (9%), airway management (8%), bedside procedures (3%) and agitation (1%). The frequency of these enteral feeding interruptions may indicate inadequate nutritional support, highlighting the importance of performing daily nutritional monitoring to prevent malnutrition.

The effect of nonnutritive sucking on oxygenation in healthy, crying full-term infants.

Crying in healthy, recently born infants has been associated with decreased oxygenation, which may prolong adjustment to extrauterine life. This research investigated the use of nonnutritive sucking (NNS) as an intervention to reduce crying and prevent any decreases in oxygenation that may occur in crying healthy term infants between 9 and 72 hours of life. Twenty-nine experimental group infants, who received a pacifier (NNS) immediately after crying was induced by a heelstick, had statistically significantly higher transcutaneous oxygen tensions (tcPO2S) compared with baseline values than 30 control (ONNS) infants who did not. Infants who received NNS also had higher tcPO2S after crying than infants who did not. NNS, which attenuates crying, may alleviate crying-induced oxygen decreases in healthy, transitional newborn infants.

Neutral cervical spine positioning in children.

STUDY OBJECTIVES: To determine the height of back elevation required to place the cervical spine of children less than 8 years old in neutral position and whether agreement on the height required for neutral position could be reached by two independent observers. STUDY DESIGN: Prospective. SETTING: Pediatric emergency department and outpatient clinics. TYPE OF PARTICIPANTS: Convenience sample of children less than 8 years old. INTERVENTIONS: Independent placement of children in neutral position by two observers using standard sized padding with or without shims to raise the back off a backboard. MEASUREMENTS AND RESULTS: All children required elevation of the back for correct neutral position (mean height, 25.4 +/- 6.7 mm; range, 5 to 41 mm). Children less than 4 years old required more elevation than those > or = 4 years old (27 +/- 7.2 vs 22 +/- 4.2 mm, P < .05). Independent observer measurements were similar (mean, 25 +/- 8.0 vs 25.7 +/- 6.8 mm; interobserver kappa = .56). CONCLUSION: Children less than 8 years old require back elevation to achieve neutral position while lying supine on a backboard. Also, independent observers can agree on what constitutes neutral position in most children.

Death in the city. An American childhood tragedy.

OBJECTIVE: To look at trends in mortality and homicide rates in a specific metropolitan area, comparing the urban and suburban mortality trends. DESIGN: Descriptive study of mortality rates. Linear regression determined whether changes in mortality rates over time represented significant trends. SETTING: Industrial metropolitan area in the United States, population, 2,337,891. PARTICIPANTS: Pediatric deaths (1 to 18 years of age) in a 9-year period. Population characteristics: 36% black, 64% white, 50% each urban and suburban. MAIN OUTCOME MEASURES: Pediatric mortality rates for 1980 through 1988, grouped by urban vs suburban, age, gender, and race. Rates calculated using national census figures and plotted over time. RESULTS: There was a 50% increase in all-cause mortality in the urban pediatric population as compared with no change or a slight decline in the suburban and national populations. The increase was found in the black urban population. Homicide showed the largest increase (252%). Firearm-related homicides accounted for the majority of homicide deaths. CONCLUSIONS: (1) There were significant differences in mortality between the urban and suburban pediatric populations. (2) The increase in homicides, specifically firearm homicides, in the urban population accounted for the increase in overall mortality rates. (3) The increase in homicide rates was significant only for the 10- to 14-year-old males and the 15- to 18-year-old male and female portions of the black urban population. (4) Firearm homicides have become epidemic in the black urban population we studied.

The effect of familiar and unfamiliar voice treatments on intracranial pressure in head-injured patients.

Limited research has been conducted exploring the relationship between verbal stimulation and intracranial pressure (ICP). The purpose of this study was to investigate effects of verbal stimulation on ICP in head-injured patients. The sample consisted of 12 head-injured patients with a mean age of 31.5 years and mean Glasgow Coma Scale score of 7.8. A message was recorded by a familiar voice (family) and an unfamiliar voice (researcher). The familiar voice message was played to each subject. After a rest period, the unfamiliar voice message was played. ICP was recorded before, during and after playing both taped messages. Results demonstrated little change in ICP of head-injured patients when exposed to recorded verbal stimuli. Paired t-tests demonstrated no statistically significant differences between means. Results suggest families of head-injured patients with normal ICP can verbally interact with the patients for short periods without significant increases in ICP.

Use of emergency services by unaccompanied minors.

STUDY OBJECTIVE: The objective of the study was to describe the use of emergency services by minors who are unaccompanied by their parents or guardians and how they are managed in emergency departments. DESIGN: Self-administered survey. TYPE OF PARTICIPANTS: The ED directors of 71 emergency medicine training programs, 82 Michigan community EDs, and 56 pediatric EDs. MEASUREMENTS AND MAIN RESULTS: One hundred eighteen (58%) surveys were returned. A median of five unaccompanied minors (range 0.2 to 150) were seen weekly by responding EDs. Pediatric EDs saw the most unaccompanied minors weekly (ten) compared with training programs (five) and community EDs (three) (P less than .01). Emergency medicine training programs had the greatest percentage (3.0%) of minors who were unaccompanied compared with pediatric EDs (2.2%) and community EDs (2.6%) (P less than .05). For all conditions surveyed, only 3.8% of patients would be refused medical care without parental consent. However, 36.8% of patients would have medical care delayed even for conditions that might be painful or harmful if left untreated for some time. Most EDs (85.5%) screen patients and treat those who are acutely ill, but some (11.1%) treat all regardless of severity. CONCLUSION: Protocols should be developed for unaccompanied minors to ensure that delays in obtaining consent do not jeopardize the child and that the rights of minors for confidentiality and consent are recognized.

Comparison of rectal, axillary, and tympanic membrane temperatures in infants and young children.

STUDY OBJECTIVE: To evaluate the reliability of a tympanic membrane thermometer in detecting fever in young children presenting to the emergency department. SETTING: Pediatric emergency department in an urban teaching hospital, DESIGN/MEASUREMENT/PARTICIPANTS: Temperature measurements were obtained sequentially at three body sites in children less than 3 years old presenting to the pediatric ED. Axillary and rectal temperatures were obtained with an electronic thermistor probe (Diatek 500), and tympanic membrane temperatures were obtained with a noncontact, infrared sensing device (First TEMP). Patients were stratified by age, ear canal patency, presence of otitis media, and rectal temperature. RESULTS: Of 224 patients enrolled, 87 (39%) were febrile. Overall correlation of axillary and tympanic membrane measurements to rectal for all strata was .75 (P = .001) and .81 (P = .001), respectively. Sensitivity in detecting fever for axillary and tympanic membrane sites was .48 and .55, respectively. Otitis media and ear patency did not influence correlation of tympanic membrane measurements. Low tympanic membrane temperature sensitivity may be a result of probe configuration. CONCLUSION: Tympanic membrane and axillary temperatures should be viewed with caution in children less than 3 years old as neither can detect fever reliably.

Acute pulmonary edema after near strangulation.

We report a case of acute, noncardiogenic pulmonary edema in an 11-year-old boy who suffered strangulation during an altercation. The clinical presentation was characterized by moderate respiratory distress and hemoptysis. Both the radiographic and clinical findings resolved during the three day admission which followed. A review of the literature is presented, and possible pathogenesis is discussed.