Developing a Medical Scribe Program at an Academic Hospital: The Hennepin County Medical Center Experience.

BACKGROUND: Medical scribes are frequently incorporated into the patient care model to improve provider efficiency and enable providers to refocus their attention to the patient rather than the electronic health record (EHR). The medical scribe program was based on four pillars (objectives): (1) provider satisfaction, (2) standardized documentation, (3) documentation components for risk adjustment, and (4) revenue enhancement. METHODS: The medical scribe program was deployed in nine non-resident-supported clinics (internal medicine, ophthalmology, orthopedics, hematology/oncology, urology), with the medical scribes (who have no clinical duties) supporting both physicians and advanced practice providers (nurse practitioners and physician assistants). This paper describes a prospective quasi-experimental study conducted at an academic, inner-city, hospital-based clinic system, RESULTS: A pre-post analysis showed positive results; of the 51 providers, 44 responded to the survey pre and 41 responded post. Respondents in the post-scribe group felt that a scribe was valuable (90.2%), that documentation time at the office improved (75.0% poor or marginal pre-scribe, vs. 24% post; p <0.0001), and that time spent on the EHR at home declined (63.6% with excessive or moderately high home EHR time pre vs. 31.7% post; p = 0.003). More providers felt satisfied with their role in clinic with the use of scribes, and more providers felt that with scribes they could listen sufficiently to patients (p <0.05). CONCLUSION: Scribe support was well received across the institution in multiple clinical settings. Benefits for providers were seen in documentation time and ability to listen to patients. Scribes appear to be an effective intervention for improving clinician work life.

Tetrodotoxin poisoning outbreak from imported dried puffer fish--Minneapolis, Minnesota, 2014.

On June 13, 2014, two patients went to the Hennepin County Medical Center Emergency Department in Minneapolis, Minnesota, with symptoms suggestive of tetrodotoxin poisoning (i.e., oral paresthesias, weakness, and dyspnea) after consuming dried puffer fish (also known as globefish) purchased during a recent visit to New York City. The patients said two friends who consumed the same fish had similar, although less pronounced, symptoms and had not sought care. The Minnesota Department of Health conducted an investigation to determine the source of the product and samples were sent to the Food and Drug Administration (FDA) Center for Food Safety and Applied Nutrition for chemical and genetic analysis. Genetic analysis identified the product as puffer fish (Lagocephalus lunaris) and chemical analysis determined it was contaminated with high levels of tetrodotoxin. A traceback investigation was unable to determine the original source of the product. Tetrodotoxin is a deadly, potent poison; the minimum lethal dose in an adult human is estimated to be 2-3 mg. Tetrodotoxin is a heat-stable and acid-stable, nonprotein, alkaloid toxin found in many species of the fish family Tetraodontidae (puffer fish) as well as in certain gobies, amphibians, invertebrates, and the blue-ringed octopus. Tetrodotoxin exerts its effects by blocking voltage-activated sodium channels, terminating nerve conduction and muscle action potentials, leading to progressive paralysis and, in extreme cases, to death from respiratory failure. Because these fish were reportedly purchased in the United States, they pose a substantial U.S. public health hazard given the potency of the toxin and the high levels of toxin found in the fish.

Feasibility of bedside thoracic ultrasound in the helicopter emergency medical services setting.

INTRODUCTION: Bedside thoracic ultrasound has been shown to be a valuable diagnostic tool in the emergency department. The purpose of this study was to evaluate the feasibility of bedside thoracic ultrasound in the prehospital HEMS setting. SETTING: Air ambulance helicopters during patient transportation. METHODS: This was a prospective pilot study. 71 consecutive, nonpregnant patients over 18 years old were enrolled. While in flight, providers completed limited bedside thoracic ultrasounds with the patient supine and recorded their interpretation of the presence or absence of the ultrasonographic sliding lung sign on a closed data-set instrument. RESULTS: 41 (58%) of the eligible patients had a recorded thoracic ultrasound acquired in flight. The level of agreement in image interpretation between the flight crew and expert reviewer was substantial (Kappa 0.67, CI 0.44-0.90). The reviewer rated 54% of all images as "good" in quality. The most common reason cited for not completing the ultrasound was lack of enough provider time or space limitations within the aircraft cabin. CONCLUSION: The results of this study suggest that, with limited training, bedside thoracic ultrasound image acquisition and interpretation for the sliding lung sign in the HEMS setting is feasible.

Successful management of excited delirium syndrome with prehospital ketamine: two case examples.

Excited delirium syndrome (ExDS) is a medical emergency usually presenting first in the prehospital environment. Untreated ExDS is associated with a high mortality rate and is gaining recognition within organized medicine as an emerging public safety problem. It is highly associated with male gender, middle age, chronic illicit stimulant abuse, and mental illness. Management of ExDS often begins in the field when first responders, law enforcement personnel, and emergency medical services (EMS) personnel respond to requests from witnesses who observe subjects exhibiting bizarre, agitated behavior. Although appropriate prehospital management of subjects with ExDS is still under study, there is increasing awareness of the danger of untreated ExDS, and the danger associated with the need for subject restraint, whether physical or chemical. We describe two ExDS patients who were successfully chemically restrained with ketamine in the prehospital environment, and who had good outcomes without complication. These are among the first case reports in the literature of ExDS survival without complication using this novel prehospital sedation management protocol. This strategy bears further study and surveillance by the prehospital care community for evaluation of side effects and unintended complications.

Absence of electrocardiographic change after prolonged application of a conducted electrical weapon in physically exhausted adults.

BACKGROUND: Conducted electrical weapons (CEWs) are used by law enforcement for control of subjects by causing neuromuscular incapacitation. There has been scrutiny of CEWs and their potential role in the occasional sudden death of subjects in custody. There is a hypothesized causal relationship due to induced cardiac dysrhythmia. Previous work has not shown dysrhythmia induction in resting humans. However, these devices are not often used on resting individuals in the field. OBJECTIVE: We sought to determine if exposure to a CEW in a physically exhausted human sample population caused detectable change in the 12-lead electrocardiogram (ECG). METHODS: Human volunteers were enrolled. All subjects had a baseline ECG obtained and then underwent an exercise regimen until exhaustion. The volunteers then received a continuous 15-s application from a TASER® X26 CEW (TASER International, Scottsdale, AZ). CEW electrodes were placed on random positions of their anterior thoraces. Electrode positions involved at least a 12-inch spread and always encompassed the normal anatomic position of the heart. An ECG was obtained immediately after CEW exposure. ECGs were interpreted by a blinded cardiologist. RESULTS: At baseline, 24/25 ECGs were normal. One baseline ECG was abnormal due to several monomorphic premature ventricular complexes. After CEW exposure, all 25 ECGs were interpreted as normal. CONCLUSIONS: Prolonged CEW application in an exhausted human sample did not cause a detectable change in their 12-lead ECGs. Theories of CEW-induced dysrhythmia in non-rested humans are not supported by our findings.

Introduction of the conducted electrical weapon into a hospital setting.

BACKGROUND: The TASER(®) X26 Conducted Electrical Weapon (CEW) provides painful stimuli and neuromuscular incapacitation to potentially violent persons. Use by law enforcement in society is common. Presenting a CEW is known to de-escalate some situations. Health care personnel sometimes encounter violent persons within the confines of the hospital. CEW use by health care security personnel has not been described. OBJECTIVE: The objective is to describe results from the introduction of the CEW into a hospital environment. METHODS: Upon introducing the CEW into an urban hospital campus, standardized reports were made describing all CEW use by hospital security. Reports were retrospectively reviewed for the first 12 months of CEW use. Collected data included force options used, potential injuries avoided, witness comments, outcomes, and whether the CEW required full activation or if inactive presentation was sufficient to control the situation. Rates of security personnel injuries were also gathered. Descriptive analysis was applied. RESULTS: Twenty-seven CEW deployments occurred: four were inactive presentation, 20 were presentation with LASER sight activation, and three were probe deployments with a 5-s delivery of electrical current. Two persons required evaluation for minor injuries not related to CEW use. Witnesses reported that in all incidents, injuries were likely avoided due to CEW presentation or use. CEW use aborted one suicide attempt. Personnel injury rates decreased during the study period. CONCLUSION: CEW introduction into a health care setting demonstrated the ability to avert and control situations that could result in further injury to subjects, patients, and personnel. This correlates with a decrease in injury for hospital personnel. Further study is recommended for validation.

Human research review of the TASER electronic control device.

TASER Electronic Control Devices have become mainstream methods of applying electricity to control unruly suspects. There has been speculation that they may be associated with worsening human physiology or death. The lay impressions that these devices are unsafe are not founded on known human research findings. This presentation briefly reviews the most pertinent human research on this subject.

Unexpected arrest-related deaths in america: 12 months of open source surveillance.

INTRODUCTION: Sudden, unexpected arrest-related death (ARD) has been associated with drug abuse, extreme delirium or certain police practices. There is insufficient surveillance and causation data available. We report 12 months of surveillance data using a novel data collection methodology. METHODS: We used an open-source, prospective method to collect 12 consecutive months of data, including demographics, behavior, illicit substance use, control methods used, and time of collapse after law enforcement contact. Descriptive analysis and chi-square testing were applied. RESULTS: There were 162 ARD events reported that met inclusion criteria. The majority were male with mean age 36 years, and involved bizarre, agitated behavior and reports of drug abuse just prior to death. Law enforcement control techniques included none (14%); empty-hand techniques (69%); intermediate weapons such as TASER((R)) device, impact weapon or chemical irritant spray (52%); and deadly force (12%). Time from contact to subject collapse included instantaneous (13%), within the first hour (53%) and 1-48 hours (35%). Significant collapse time associations occurred with the use of certain intermediate weapons. CONCLUSION: This surveillance report can be a foundation for discussing ARD. These data support the premise that ARDs primarily occur in persons with a certain demographic and behavior profile that includes middle-aged males exhibiting agitated, bizarre behavior generally following illicit drug abuse. Collapse time associations were demonstrated with the use of TASER devices and impact weapons. We recommend further study in this area to validate our data collection method and findings.

Hospital response to a major freeway bridge collapse.

BACKGROUND: We describe the hospital system response to the Interstate 35W bridge collapse in Minneapolis into the Mississippi River on August 1, 2007, which resulted in 13 deaths and 127 injuries. Comparative analysis of response activities at the 3 hospitals that received critical or serious casualties is provided. METHODS: First-hand experiences of hospital physicians, issues identified in after-action reports, injury severity scores, and other relevant patient data were collected from the 3 hospitals that received seriously injured patients, including the closest hospitals to the collapse on each side of the river. RESULTS/DISCUSSION: Injuries were consistent with major acceleration/deceleration force injuries. The most critical patients arrived first at each hospital, suggesting appropriate prehospital triage. Capacity of the health care system was not overwhelmed and the involved hospitals generally reported an overresponse by staff. Communication and patient tracking problems occurred at all of the hospitals. Situational awareness was limited due to the scope of structural collapse and incomplete information from the scene. CONCLUSIONS: Hospitals were generally satisfied with their surge capacity and incident management plan activation. Issues such as communications, patient tracking, and staff overreporting that have been identified in past incidents also were problematic in this event. Hospitals will need to address deficiencies and build on successful actions to cope with future, potentially larger incidents.

Emergency medical services response to a major freeway bridge collapse.

BACKGROUND: The Interstate 35W Bridge in Minneapolis collapsed into the Mississippi River on August 1, 2007, killing 13 people and injuring 127. METHODS: This article describes the emergency medical services response to this incident. RESULTS/DISCUSSION: Complexities of the event included difficult patient access, multiple sectors of operation, and multiple mutual-aid agencies. Patient evacuation and transportation was rapid, with the collapse zone cleared of victims 95 minutes after the initial 9-1-1 call. A common regional emergency medical service incident management plan that was exercised was critical to the success of the response. CONCLUSIONS: Communication and patient tracking difficulties could be improved in future responses.

Successful transcutaneous pacing in 2 severely hypothermic patients.

The clinical condition of profound hypothermia is well described in the medical literature. There have been many case reports and studies describing successful aspects of caring for this problem. Significant bradycardia is a known pathophysiologic consequence of profound hypothermia. Transcutaneous pacing for this condition is not a routine or recommended practice in the literature. This case report details 2 patients with profound hypothermia and resultant bradycardia with hypotension. In both cases, transcutaneous pacing was successfully applied and used as part of the resuscitation. In both cases, transcutaneous pacing was required to maintain an adequate blood pressure so that continuous arteriovenous rewarming could be used during the resuscitation. Both cases had successful outcomes, and the rewarming process was greatly assisted by the pacing procedure.

Cardiovascular and physiologic effects of conducted electrical weapon discharge in resting adults.

OBJECTIVES: The TASER is a conducted electrical weapon (CEW) that has been used on people in custody. Individuals occasionally die unexpectedly while in custody, proximal to the application of a CEW. In this study, the authors sought to examine the effects of CEW application in resting adult volunteers to determine if there was evidence of induced electrical dysrhythmia or direct cellular damage that would indicate a causal relationship between application of the device and in-custody death. METHODS: Human subjects (N = 66) underwent 24-hour monitoring after a standard CEW application. Blood samples were collected before and after exposure and again at 16 and 24 hours after exposure. A subpopulation (n = 32) had 12-lead electrocardiography performed at similar time intervals. Blood samples were analyzed for markers of skeletal and cardiac muscle injury and renal impairment. The electrocardiograms were read by a cardiologist blinded to the study. Data were analyzed using descriptive statistics. RESULTS: There was no significant change from baseline at any of the four time points for serum electrolyte levels and the blood urea nitrogen/creatinine ratio. An increase in serum bicarbonate and creatine kinase levels was noted at 16 and 24 hours. An increase in serum lactate level was noted immediately after exposure that decreased at 16 and 24 hours. Serum myoglobin level was increased from baseline at all three time points. All troponin levels measured were < 0.3 ng/mL, except for a single value of 0.6 ng/mL in a single subject. This subject was evaluated, and no evidence of acute myocardial infarction or disability was identified. At baseline, 30 of 32 electrocardiograms were interpreted as normal. The two abnormal electrocardiograms were abnormal at baseline and remained the same at all four time points. CONCLUSIONS: In this resting adult population, the TASER X26 CEW did not affect the recordable cardiac electrical activity within a 24-hour period following a standard five-second application. The authors were unable to detect any induced electrical dysrhythmias or significant direct cardiac cellular damage that may be related to sudden and unexpected death proximal to CEW exposure. Additionally, no evidence of dangerous hyperkalemia or induced acidosis was found. Further study in the area of the in-custody death phenomenon to better understand its causes is recommended.

Use of the endotracheal tube introducer as an adjunct for oral tracheal intubation in the prehospital setting.

OBJECTIVE: To prospectively evaluate the effectiveness of the endotracheal tube introducer (ETTI) versus standard orotracheal intubation (SOTI) in the prehospital air medical setting. METHODS: Critically ill patients were randomized to ETTI versus SOTI based on an odd/even day regimen. Data were collected on initial intubation attempt used, success using initial approach, number of intubation attempts until success, and laryngeal view encountered. The 2 approaches then were compared and statistically analyzed. RESULTS: Fifty-one patients were entered into the 10-month study; 20 patients were randomized to the ETTI group and 31 to SOTI. Overall success rate for first intubation attempt was 70% for the ETTI and 65% SOTI (P =.67). Total intubation time was 62 seconds (95% CI = 16-108) for the ETTI versus 62 seconds (95% CI = 38-86) for SOTI (P =.4). The ETTI group had a higher percentage of intubating difficult laryngeal views (grade 3 and 4) on first attempts than SOTI. CONCLUSION: In this study, the authors found the ETTI to be a safe airway adjunct with results equal to SOTI. The ETTI may have a useful role in prehospital airway management.