Manual ventilation quality is improved with a real-time visual feedback system during simulated resuscitation.

INTRODUCTION: Manual ventilations during cardiac arrest are frequently performed outside of recommended guidelines. Real-time feedback has been shown to improve chest compression quality, but the use of feedback to guide ventilation volume and rate has not been studied. The purpose of this study was to determine whether the use of a real-time visual feedback system for ventilation volume and rate improves manual ventilation quality during simulated cardiac arrest. METHODS: Teams of 2 emergency medical technicians (EMTs) performed two 8-min rounds of cardiopulmonary resuscitation (CPR) on a manikin during a simulated cardiac arrest scenario with one EMT performing ventilations while the other performed compressions. The EMTs switched roles every 2 min. During the first round of CPR, ventilation and chest compression feedback was disabled on a monitor/defibrillator. Following a 20-min rest period and a brief session to familiarize the EMTs with the feedback technology, the trial was repeated with feedback enabled. The primary outcome variables for the study were ventilations and chest compressions within target. Ventilation rate (target, 8-10 breaths/minute) and tidal volume (target, 425-575 ml) were measured using a novel differential pressure-based flow sensor. Data were analyzed using paired t tests. RESULTS: Ten teams of 2 EMTs completed the study. Mean percentages of ventilations performed in target for rate (41% vs. 71%, p < 0.01), for volume (31% vs. 79%, p < 0.01), and for rate and volume together (10% vs. 63%, p < 0.01) were significantly greater with feedback. CONCLUSION: The use of a novel visual feedback system for ventilation quality increased the percentage of ventilations in target for rate and volume during simulated CPR. Real-time feedback to perform ventilations within recommended guidelines during cardiac arrest should be further investigated in human resuscitation.

Correction to: The Toronto cognitive assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment.

Upon publication of this article [1], it was brought to our attention that one of the 303 participants in the normative study should have been deleted from the database.

The Toronto Cognitive Assessment (TorCA): normative data and validation to detect amnestic mild cognitive impairment.

BACKGROUND: A need exists for easily administered assessment tools to detect mild cognitive changes that are more comprehensive than screening tests but shorter than a neuropsychological battery and that can be administered by physicians, as well as any health care professional or trained assistant in any medical setting. The Toronto Cognitive Assessment (TorCA) was developed to achieve these goals. METHODS: We obtained normative data on the TorCA (n = 303), determined test reliability, developed an iPad version, and validated the TorCA against neuropsychological assessment for detecting amnestic mild cognitive impairment (aMCI) (n = 50/57, aMCI/normal cognition). For the normative study, healthy volunteers were recruited from the Rotman Research Institute registry. For the validation study, the sample was comprised of participants with aMCI or normal cognition based on neuropsychological assessment. Cognitively normal participants were recruited from both healthy volunteers in the normative study sample and the community. RESULTS: The TorCA provides a stable assessment of multiple cognitive domains. The total score correctly classified 79% of participants (sensitivity 80%; specificity 79%). In an exploratory logistic regression analysis, indices of Immediate Verbal Recall, Delayed Verbal and Visual Recall, Visuospatial Function, and Working Memory/Attention/Executive Control, a subset of the domains assessed by the TorCA, correctly classified 92% of participants (sensitivity 92%; specificity 91%). Paper and iPad version scores were equivalent. CONCLUSIONS: The TorCA can improve resource utilization by identifying patients with aMCI who may not require more resource-intensive neuropsychological assessment. Future studies will focus on cross-validating the TorCA for aMCI, and validation for disorders other than aMCI.

Assessing the impact of an emergency trauma course for senior medical students in Kenya.

INTRODUCTION: Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers. Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries. METHODS: A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret, Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the paired t-test, mean written, simulation and confidence scores were compared pre-course, immediately post-course and nine months post-course. RESULTS: Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9% post-course, mean difference 15.5% (p < 0.001). Simulation test score means were 36.7% pre-course and 82.2% post-course, mean difference 45.5% (p < 0.001). Aggregate confidence scores were 3.21 pre-course and 4.72 post-course (scale 1-5). Ten out of 22 (45.5%) students were re-evaluated nine months post-course. Results showed written test score mean of 75%, simulation score mean of 61.7%, and aggregate confidence score of 4.59 (scale 1-5). Mean differences between immediate post- and nine months post-course were 1.6% (p = 0.75) and 8.7% (p = 0.10) for the written and simulation tests, respectively. CONCLUSION: Senior Kenyan medical students demonstrated statistically significant increases in knowledge, skills and confidence after participating in a novel student trauma course. Nine months post-course, improvements in knowledge skills and confidence were sustained.

Assessing the impact of an emergency trauma course for senior medical students in Kenya

Introduction:Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers.Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries.Methods:A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret,Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the pairedt-test, mean written, simulation and confidence scores were compared pre-course,immediately post-course and nine months post-course.Results:Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9%post-course, mean difference 15.5% (p < 0.001). Simulation test score means were 36.7% pre-course and 82.2% post-course, mean difference 45.5% (p < 0.001). Aggregate confidence scores were 3.21 pre-course and 4.72 post-course (scale 1­5). Ten out of 22 (45.5%) students were re-evaluated nine months post- course. Results showed written test score mean of 75%, simulation score mean of 61.7%, and aggregate confidence score of 4.59 (scale 1­5). Mean differences between immediate post- and nine months post-course were 1.6% (p = 0.75) and 8.7% (p = 0.10) for the written and simulation tests, respectively.Conclusion: Senior Kenyan medical students demonstrated statistically significant increases in knowledge, skills and confidence after participating in a novel student trauma course. Nine months post-course, improvements in knowledge skills and confidence were sustained

Circus disaster: Case report, response, and review of injuries.

Circus acts with human artists performing acrobatic feats are a popular spectator pastime in the United States and in international venues. There is little data in the literature regarding injuries sustained during circus acts. Some injuries are minor, but others can be serious, or even fatal. This article describes a recent circus disaster, a review of the relevant literature, and an analysis of the disaster response.

Disaster-related fatalities among US citizens traveling abroad.

OBJECTIVE: To describe the locations and risk of death associated with natural disaster fatalities for US citizens traveling abroad. DESIGN, SETTING, AND PARTICIPANTS: A retrospective database review of US citizen disaster deaths occurring worldwide. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Information on fatalities due to disasters was abstracted from the US Department of State Web site reporting deaths of US citizens abroad by non-natural causes from October 2002 through June 2012. The main outcome measures were the frequency of disaster deaths and countries where disasters occurred. Descriptive statistics and rates were used to evaluate the study data. RESULTS: There were 7,963 total non-natural deaths of US citizens traveling abroad during the study period. Of these, 163 (2.0 percent) were disaster-related deaths, involving 19 disaster events in 15 countries. Only two disaster-related events resulted in more than two deaths of US travelers-the 2010 earthquake in Haiti causing 121 fatalities (74.2 percent of disaster deaths), and the 2004 tsunami in Thailand causing 22 fatalities (13.5 percent of disaster deaths). The approximate annual mean death rate for US citizen travelers as a result of disaster events is 0.27 deaths/1 million travelers, compared with 1.4 deaths/1 million residents due to disaster annually within the United States. CONCLUSIONS: The risk of disaster-related fatality is low for US citizens traveling abroad. Although disaster-related death among travelers is unpredictable, during a period of almost 10 years, there was only one reported death due to disaster in the five countries most frequently visited by US travelers. Further investigation may identify population-, seasonal-, country-, or location-specific risks from which prevention strategies can be developed.

Characteristics and predictors of readiness to quit among emergency medical patients presenting with respiratory symptoms.

PURPOSE: To examine behavioral factors that lead patients to consider quitting smoking and features associated with readiness to quit among adults who are seeking treatment in the emergency department (ED) for respiratory symptoms. METHODS: A toal of 665 adult smokers seeking treatment in an ED for respiratory symptoms and respiratory illness answered survey questions during the ED visit. RESULTS: Patients self-reported "readiness to quit" was broadly distributed among this patient population. Patients with COPD, pneumonia or asthma perceived higher risks from smoking than other patients with respiratory complaints. Over half of all participants had scores indicative of depression. Regression analysis showed that prior efforts to quit, confidence, perceived importance of quitting and decisional balance were each significantly predictive of readiness to quit, accounting for 40% of the variance. CONCLUSIONS: While many of these patients appear unaware of the connection between their symptoms and their smoking, patients with diagnosed chronic respiratory illness perceived higher risks from their smoking. In patients who do not perceive these risks, physician intervention may increase perceived risk from smoking and perceived importance of quitting. Interventions designed for the ED setting targeting this patient population should consider screening for depressive symptoms and, when appropriate, making referrals for further evaluation and/or treatment. Medications that can help alleviate depression and withdrawal symptoms while quitting smoking, such as bupropion, may be particularly useful for this subset of patients, as depression is a substantial barrier to quitting.

Prenatal and postnatal cocaine exposure predict teen cocaine use.

Preclinical studies have identified alterations in cocaine and alcohol self-administration and behavioral responses to pharmacological challenges in adolescent offspring following prenatal exposure. To date, no published human studies have evaluated the relation between prenatal cocaine exposure and postnatal adolescent cocaine use. Human studies of prenatal cocaine-exposed children have also noted an increase in behaviors previously associated with substance use/abuse in teens and young adults, specifically childhood and teen externalizing behaviors, impulsivity, and attention problems. Despite these findings, human research has not addressed prior prenatal exposure as a potential predictor of teen drug use behavior. The purpose of this study was to evaluate the relations between prenatal cocaine exposure and teen cocaine use in a prospective longitudinal cohort (n=316) that permitted extensive control for child, parent and community risk factors. Logistic regression analyses and Structural Equation Modeling revealed that both prenatal exposure and postnatal parent/caregiver cocaine use were uniquely related to teen use of cocaine at age 14 years. Teen cocaine use was also directly predicted by teen community violence exposure and caregiver negativity, and was indirectly related to teen community drug exposure. These data provide further evidence of the importance of prenatal exposure, family and community factors in the intergenerational transmission of teen/young adult substance abuse/use.

Non-invasive carboxyhemoglobin monitoring: screening emergency medical services patients for carbon monoxide exposure.

INTRODUCTION: Carbon monoxide (CO) toxicity is a significant health problem. The use of non-invasive pulse CO-oximetry screening in the emergency department has demonstrated that the rapid screening of numerous individuals for CO toxicity is simple and capable of identifying occult cases of CO toxicity. OBJECTIVE: The objective of this study was to extend the use of this handheld device to the prehospital arena, assess carboxyhemoglobin (SpCO) levels in emergency medical services (EMS) patients, and correlate these levels with clinical and demographic data. METHODS: This was a retrospective, observational, chart review of adult patients transported to hospital emergency departments by urban fire department EMS ambulances during a six-week period. Each ambulance used a non-invasive pulse CO-oximeter (Rad-57, Masimo Inc.) to record patients' COHb concentrations (SpCO) along with the standard EMS assessment data. Spearman's Rank Correlation tests and Student's t-tests were used to analyze the data and calculate relationships between SpCO and other variables (age, gender, respiratory rate, heart rate, mean arterial pressure, and oxygen saturation measured by pulse oximetry). RESULTS: A total of 36.4% of the patients transported during the study had SpCO documented. Of the 1,017 adults included in this group, 11 (1.1%) had an SpCO >15%. There was no correlation between SpCO and heart rate, ventilatory rate, mean arterial pressure, and oxygen saturation. CONCLUSIONS: Screening for CO toxicity in the EMS setting is possible, and may aid in the early detection and treatment of CO-poisoned patients.

Do emergency physicians use serum D-dimer effectively to determine the need for CT when evaluating patients for pulmonary embolism? Review of 5,344 consecutive patients.

OBJECTIVE: The purpose of our study was to investigate whether D-dimer screening is being used effectively to determine the need for MDCT in diagnosing acute pulmonary embolism (PE) in emergency department patients. MATERIALS AND METHODS: We performed a retrospective review of all patients who underwent D-dimer testing or MDCT in the emergency department from January 1, 2003, through October 31, 2005. A D-dimer value of > 0.43 microg/mL was considered positive. Diagnosis of PE was made on the basis of the MDCT. Clinical algorithms for diagnosing PE mandate that patients with a low clinical suspicion for PE undergo D-dimer testing, then MDCT if positive. For patients with a high clinical suspicion for PE, MDCT should be performed without D-dimer testing. RESULTS: Of 3,716 D-dimer tests, 1,431 (39%) were positive and 2,285 (61%) were negative. MDCT was performed in 166 (7%) patients with negative D-dimer results and in 826 (58%) patients with positive D-dimer results. The prevalence of PE in patients with a high clinical suspicion and no D-dimer testing was 9% (139/1,628), which was higher than the rate of PE in the positive D-dimer group at 2% (19/826) (p < 0.0001). There was no significant difference in the prevalence of PE in the positive and negative D-dimer groups (2% vs 0.6%, respectively) (p = 0.23). The sensitivity and negative predictive value of D-dimer for PE were 95% (95% CI, 73.1-99.7%) and 99% (95% CI, 96.2-99.9%), respectively. CONCLUSION: D-dimer screening is not used according to established diagnostic algorithms to determine the need for MDCT in diagnosing acute pulmonary embolism in our emergency department.

Emergency medicine in Dubai, UAE.

Dubai has rapidly risen to prominence in the Persian Gulf region as a center of global commerce and tourism and as a cultural crossroad between East and West. The health-care infrastructure has undergone rapid development. Collaborations with academic medical centers now exist to advance clinical care, teaching and research. Emergency medicine has also advanced and is undergoing dynamic change. Dubai may soon emerge as a regional leader in emergency medicine training and practice.