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1.
Med J (Ft Sam Houst Tex) ; (PB 8-21-07/08/09): 74-80, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34449865

RESUMO

INTRODUCTION: Emergency department (ED) utilization continues to climb nationwide resulting in overcrowding, increasing wait times, and a surge in patients with non-urgent conditions. Patients frequently choose the ED for apparent non-emergent medical issues or injuries that after-the-fact could be cared for in a primary care setting. We seek to better understand the reasons why patients choose the ED over their primary care managers. METHODS: We prospectively surveyed patients that signed into the ED at the Brooke Army Medical Center as an emergency severity index of 4 or 5 (non-emergent triage) regarding their visit. We then linked their survey data to their ED visit including interventions, diagnoses, diagnostics, and disposition by using their electronic medical record. We defined their visit to be non-urgent and more appropriate for primary care, or primary care eligible, if they were discharged home and received no computed tomography (CT) imaging, ultrasound, magnetic resonance imaging (MRI), intravenous (IV) medications, or intramuscular (IM) controlled substances. RESULTS: During the 2-month period, we collected data on 208 participants out of a total of 252 people offered a survey (82.5%). There were 92% (n=191) that were primary care eligible within our respondent pool. Most reported very good (38%) or excellent (21%) health at baseline. On survey assessing why they came, inability to get a timely appointment (n=73), and a self-reported emergency (n=58) were the most common reported reasons. Most would have utilized primary care if they had a next-morning appointment available (n=86), but many reported they would have utilized the ED regardless of primary care availability (n=77). The most common suggestion for improving access to care was more primary care appointment availability (n=96). X-rays were the most frequent study (37%) followed by laboratory studies (20%). Before coming to the ED, 38% (n=78) reported trying to contact their primary care for an appointment. Before coming to the ED, 22% (n=46) reported contacting the nurse advice line. Based on our predefined model, 92% (n=191) of our respondents were primary care eligible within our respondent pool. CONCLUSIONS: Patient perceptions of difficulty obtaining appointments appear to be a major component of the ED use for non-emergent visits. Within our dataset, most patients surveyed stated they had difficulty obtaining a timely appointment or self-reported as an emergency. Data suggests most patients surveyed could be managed in the primary care setting.


Assuntos
Serviço Hospitalar de Emergência , Triagem , Agendamento de Consultas , Acesso aos Serviços de Saúde , Humanos , Atenção Primária à Saúde
2.
Transfusion ; 61 Suppl 1: S174-S182, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34269446

RESUMO

BACKGROUND: The Compensatory Reserve Measurement (CRM) is a novel method used to provide early assessment of shock based on arterial wave form morphology changes. We hypothesized that (1) CRM would be significantly lower in those trauma patients who received life-saving interventions compared with those not receiving interventions, and (2) CRM in patients who received interventions would recover after the intervention was performed. STUDY DESIGN AND METHODS: We captured vital signs along with analog arterial waveform data from trauma patients meeting major activation criteria using a prospective study design. Study team members tracked interventions throughout their emergency department stay. RESULTS: Ninety subjects met inclusion with 13 receiving a blood product and 10 a major airway intervention. Most trauma was blunt (69%) with motor vehicle collisions making up the largest proportion (37%) of injury mechanism. Patients receiving blood products had lower CRM values just prior to administration versus those who did not (50% versus 58%, p = .045), and lower systolic pressure (SBP; 95 versus 123 mmHg, p = .005), diastolic (DBP; 62 versus 79, p = .007), and mean arterial pressure (MAP; 75 versus 95, p = .006), and a higher pulse rate (HR; 101 versus 89 bpm, p = .039). Patients receiving an airway intervention had lower CRM values just prior to administration versus those who did not (48% versus 58%, p = .062); however, SBP, DBP, MAP, and HR were not statistically distinguishable (p ≥ .645). CONCLUSIONS: Our results support our hypotheses that the CRM distinguished those patients who received blood or an airway intervention from those who did not, and increased appropriately after interventions were performed.


Assuntos
Ferimentos e Lesões/diagnóstico , Ferimentos e Lesões/terapia , Adulto , Pressão Arterial , Pressão Sanguínea , Transfusão de Sangue , Serviço Hospitalar de Emergência , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Ressuscitação/métodos , Choque Traumático/diagnóstico , Choque Traumático/terapia , Ferimentos e Lesões/fisiopatologia
3.
Med J (Ft Sam Houst Tex) ; (PB 8-21-04/05/06): 93-97, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34251672

RESUMO

INTRODUCTION: Airway obstruction is the second leading cause of potentially preventable death on the battlefield. Endotracheal intubation is a critical skill needed by emergency military physicians to manage these patients. Our objective is to describe the development of the Defense Registry for Emergency Airway Management (DREAM) at Brooke Army Medical Center (BAMC), a level 1 trauma center over a 7-month period. METHODS: Emergency physicians (EP) performing endotracheal intubations in the BAMC emergency department (ED) completed standardized data collection forms with information about each event. Trained study team members extracted additional data from the medical records. We cross-referenced each intubation with patient tracking systems in the department and would fill in missing variables through interview with the intubating operator and/or medical records review. RESULTS: The study period comprised January through July 2020. During the study period emergency physicians (EP) performed a total of 74 intubations. Reasons for intubation were related to trauma for 47 patients (64%) and medical conditions for 26 patients (36%). The median age was 51 (interquartile range 30-72) and most were male 48 (65.7%). Difficult airway characteristics encountered included blood in the airway (26%), facial trauma (23%), and airway obstruction (1%). Most intubations utilized video laryngoscopy, and the most frequently used airway devices were Macintosh-shaped (45%) and hyperangulated-shaped (41%). Overall, firstpass success rate was 93% (69) with majority of intubations performed by second-year emergency residents (61%) followed by first-year residents (28%). CONCLUSIONS: Most DREAM intubations were related to traumatic injuries. The most frequently encountered difficult airway characteristics were blood in airway and facial trauma. Most intubations were conducted using video laryngoscopy with a high first-pass success rate similar to other published studies. Expansion of the registry to other military emergency departments would enable a data-driven solution for development of individual critical task lists.


Assuntos
Manuseio das Vias Aéreas , Laringoscópios , Serviço Hospitalar de Emergência , Humanos , Intubação Intratraqueal , Masculino , Pessoa de Meia-Idade , Sistema de Registros
4.
Mil Med ; 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34143215

RESUMO

BACKGROUND: Prehospital cardiopulmonary resuscitation has commonly been considered ineffective in traumatic cardiopulmonary arrest because traditional chest compressions do not produce substantial cardiac output. However, recent evidence suggests that chest compressions located over the left ventricle (LV) produce greater hemodynamics when compared to traditional compressions. We hypothesized that chest compressions located directly over the LV would result in an increase in return of spontaneous circulation (ROSC) and hemodynamic variables, when compared to traditional chest compressions, in a swine model of traumatic pulseless electrical activity (PEA). METHODS: Transthoracic echocardiography was used to mark the location of the aortic root (traditional compressions) and the center of the LV on animals (n = 34) that were randomized to receive chest compressions in one of the two locations. Animals were hemorrhaged to mean arterial pressure <20 to simulate traumatic PEA. After 5 minutes of PEA, basic life support (BLS) with mechanical cardiopulmonary resuscitation was initiated and performed for 10 minutes followed by advanced life support for an additional 10 minutes. Hemodynamic variables were averaged over the final 2 minutes of BLS and advanced life support periods. RESULTS: Six of the LV group (35%) achieved ROSC compared to eight of the traditional group (47%) (P = .73). There was an increase in aortic systolic blood pressure (P < .01), right atrial systolic blood pressure (P < .01), and right atrial diastolic blood pressure (P = .02) at the end of BLS in the LV group compared to the traditional group. CONCLUSIONS: In our swine model of traumatic PEA, chest compressions performed directly over the LV improved blood pressures during BLS but not ROSC.

5.
J Spec Oper Med ; 21(2): 35-42, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34105119

RESUMO

BACKGROUND: Point of care ultrasound (POCUS) offers multiple capabilities in a relatively small, lightweight device to military clinicians of all types and levels in multiple environments. Its application in diagnostics, procedural guidance, and patient monitoring has not been fully explored by the Military Health System (MHS). The purpose of this narrative review of the literature was to examine the overall use of POCUS in military settings, as well as the level of ultrasound training provided. METHODS: Studies related to use of POCUS by military clinicians with reported sensitivity/specificity, accuracy of exam, and/or clinical decision impact met inclusion criteria. After initial topical review and removal of duplicates, two authors selected 17 papers for consideration for inclusion. Four of the authors reviewed the 17 papers and determined the final inclusion of 14 studies. RESULTS: We identified seven prospective studies, of which three randomized subjects to groups. Five reports described use of POCUS in patients, two used healthy volunteers, two were in simulation training environments, four used animal models to simulate specific conditions, and one used a cadaver model. Clinician subjects ranged from one to 34. Conventional medics were subjects in six studies. Four studies included special operations medics. One study included nonmedical food service inspectors. The use of ultrasound in theater by deployed consultant radiologists is described in three reports. CONCLUSIONS: Military clinicians demonstrated the ability to perform focused exams, including FAST exams and fracture detection with acceptable sensitivity and specificity. POCUS in the hands of trained military clinicians has the potential to improve diagnostic accuracy and ultimately care of the war fighter.


Assuntos
Militares , Treinamento por Simulação , Humanos , Sistemas Automatizados de Assistência Junto ao Leito , Estudos Prospectivos , Ultrassonografia
7.
J Med Toxicol ; 17(3): 257-264, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33821433

RESUMO

INTRODUCTION: Cyanide is a deadly poison, particularly with oral exposure where larger doses can occur before symptoms develop. Prior studies and multiple governmentagencies highlight oral cyanide as an agent with the potential for use in a terrorist attack. Currently, there are no FDA approved antidotes specific to oralcyanide. An oral countermeasure that can neutralize and prevent absorption of cyanide from the GI tract after oral exposure is needed. Our objective was toevaluate the efficacy of oral sodium thiosulfate on survival and clinical outcomes in a large, swine model of severe cyanide toxicity. METHODS: Swine (45-55kg) were instrumented, sedated, and stabilized. Potassium cyanide (8 mg/kg KCN) in saline was delivered as a one-time bolus via an orogastric tube. Three minutes after cyanide, animals randomized to the treatment group received sodium thiosulfate (510 mg/kg, 3.25 M solution) via orogastric tube. Our primary outcome was survival at 60 minutes after exposure. We compared survival between groups by log-rank, Mantel-Cox analysis and trended labs and vital signs. RESULTS: At baseline and time of treatment all animals had similar weights, vital signs, and laboratory values. Survival at 60 min was 100% in treated animals compared to 0% in the control group (p=0.0027). Animals in the control group became apneic and subsequently died by 35.0 min (20.2,48.5) after cyanide exposure. Mean arterial pressure was significantly higher in the treatment group compared to controls (p=0.008). Blood lactate (p=0.02) and oxygen saturation (p=0.02) were also significantly different between treatment and control groups at study end. CONCLUSION: Oral administration of sodium thiosulfate improved survival, blood pressure, respirations, and blood lactate concentrations in a large animal model of acute oral cyanide toxicity.


Assuntos
Antídotos/uso terapêutico , Cianetos/toxicidade , Tiossulfatos/uso terapêutico , Administração Oral , Animais , Humanos , Modelos Animais , Suínos , Tiossulfatos/administração & dosagem , Resultado do Tratamento
8.
Mil Med ; 2021 Apr 07.
Artigo em Inglês | MEDLINE | ID: mdl-33825888

RESUMO

INTRODUCTION: American military personnel in U.S. Africa Command (AFRICOM) operate in a continent triple the size of the USA without mature medical facilities, requiring a substantial transportation network for medical evacuation. We describe medical transportation based on ophthalmic complaints analyzed from the U.S. Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from 2008 to 2018. METHODS: We conducted a retrospective review of all TRAC2ES records for medical evacuations for ophthalmic complaints from the AFRICOM theater of operations conducted between January 1, 2008 and December 31, 2018. We analyzed free-text data in TRAC2ES for ophthalmic diagnostic and therapeutic interventions performed before established patient movement requests. An expert panel analyzed evacuations for their indications and interventions. RESULTS: Nine hundred and sixty-one total records originating within AFRICOM were identified in TRAC2ES. Forty-three cases (4%) had ophthalmic complaints. The majority of transports were routine (72%) and originated in Djibouti (83%), and all were transported to Landstuhl Regional Medical Center. The majority of patients were evacuated without a definitive diagnosis (60%). Leading ophthalmic diagnoses were chalazion (14%), corneal abrasion/ulcer (14%), and posterior vitreous detachment (12%). More than one-quarter of patients were transported without recorded evaluation and approximately half (51%) did not receive any intervention before evacuation. Consultation with an ophthalmologist occurred in only 16 (37%) cases. By majority, the expert panel deemed 12 evacuations (28%) potentially unnecessary. CONCLUSION: Evacuations were primarily routine often for disease etiology and further diagnostic evaluation. These findings support opportunities for telemedicine consultation to avoid potentially unnecessary transportation. Increased ophthalmic care and enhanced data collection on transports would support process improvement, optimize ophthalmic care by ensuring proper disposition of patients thus limiting unnecessary evacuations, and ultimately strengthen the entire fighting force.

9.
Mil Med ; 186(3-4): e359-e365, 2021 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-33399866

RESUMO

INTRODUCTION: Within the Military Health System, the process of transporting patients from an initial point of injury and throughout the entire continuum of care is called "en route care." A Committee on En Route Combat Casualty Care was established in 2016 as part of the DoD Joint Trauma System to create practice guidelines, recommend training standards, and identify research priorities within the military en route care system. MATERIALS AND METHODS: Following an analysis of currently funded research, future capabilities, and findings from a comprehensive scoping study, members of a sub-working group for research identified the top research priorities that were needed to better guide evidence-based decisions for practice and policy, as well as the future state of en route care. RESULTS: Based on the input from the entire committee, 10 en route care research topics were rank-ordered in the following manner: (1) medical documentation, (2) clinical decision support, (3) patient monitoring, (4) transport physiology, (5) transfer of care, (6) maintaining normothermia, (7) transport timing following damage control resuscitation or surgery, (8) intelligent tasking, (9) commander's risk assessment, and (10) unmanned transport. Specific research questions and technological development needs were further developed by committee members in an effort to guide future research and development initiatives that can directly support operational en route care needs. The research priorities reflect three common themes, which include efforts to enhance or increase care provider capability and capacity; understand the impact of transportation on patient physiology; and increase the ability to coordinate, communicate, and facilitate patient movement. Technology needs for en route care must support interoperability of medical information, equipment, and supplies across the global military health system in addition to adjusting to a dynamic transport environment with the smallest possible weight, space, and power requirements. CONCLUSIONS: To ensure an evidence-based approach to future military conflicts and other medical challenges, focused research and technological development to address these 10 en route care research gaps are urgently needed.


Assuntos
Militares , Humanos , Monitorização Fisiológica , Pesquisa , Ressuscitação
10.
Mil Med ; 2021 Jan 12.
Artigo em Inglês | MEDLINE | ID: mdl-33433584

RESUMO

BACKGROUND: Military aeromedical transport evacuates critically injured patients are for definitive care, including patients with or at risk for developing traumatic compartment syndrome of the extremities (tCSoE). Compartment pressure changes of the extremities have not been determined to be associated with factors inherent to aeromedical transport in animal models, but the influence of aeromedical evacuation (AE) transport on the timing of tCSoE development has not been studied in humans. Using a registry-based methodology, this study sought to characterize the temporal features of lower extremity compartment syndrome relative to the timing of transcontinental AE. With this approach, this study aims to inform practice in guidelines relating to the timing and possible effects of long-distance AE and the development of lower extremity compartment syndrome. Using patient care records, we sought to characterize the temporal features of tCSoE diagnosis relative to long-range aeromedical transport. In doing so, we aim to inform practice in guidelines relating to the timing and risks of long-range AE and postulate whether there is an ideal time to transport patients who are at risk for or with tCSoE. METHODS: We performed a retrospective record review of patients with a diagnosis of tCSoE who were evacuated out of theater from January 2007 to May 2014 via aeromedical transport. Data abstractors collected flight information, laboratory values, vital signs, procedures, in-flight assessments, and outcomes. We used the duration of time from injury to arrival at Landstuhl Regional Medical Center (LRMC) to represent time to transport. We compared groups based on time of tCSoE (inclusive of upper and lower extremity) diagnosis relative to injury day and time of transport (preflight versus postflight). We used descriptive statistics and multivariable regression models to determine the associations between time to transport, time to tCSoE diagnosis, and outcomes. RESULTS: Within our study window, 238 patients had documentation of tCSoE. We found that 47% of patients with tCSoE were diagnosed preflight and 53% were diagnosed postflight. Over 90% in both groups developed tCSoE within 48 hours of injury; the time to diagnosis was similar for casualties diagnosed pre- and postflight (P = .65). There was no association between time to arrival at LRMC and day of tCSoE diagnosis (risk ratio, 1.06; 95% CI, 0.96-1.16). CONCLUSION: The timing of tCSoE diagnosis is not associated with the timing of transport; therefore, AE likely does not influence the development of tCSoE.

11.
Ann Emerg Med ; 77(3): 317-326, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-32807537

RESUMO

STUDY OBJECTIVE: Resuscitative thoracotomy is a time-sensitive, lifesaving procedure that may be performed by emergency physicians. The left anterolateral thoracotomy (LAT) is the standard technique commonly used in the United States to gain rapid access to critical intrathoracic structures. However, the smaller incision and subsequent limited exposure may not be optimal for the nonsurgical specialist to complete time-sensitive interventions. The modified bilateral anterior clamshell thoracotomy (MCT) developed by Barts Health NHS Trust clinicians at London's Air Ambulance overcomes these inherent difficulties, maximizes thoracic cavity visualization, and may be the ideal technique for the nonsurgical specialist. The aim of this study is to identify the optimal technique for the nonsurgical-specialist-performed resuscitative thoracotomy. Secondary aims of the study are to identify technical difficulties, procedural concerns, and physician preferences. METHODS: Emergency medicine staff and senior resident physicians were recruited from an academic Level I trauma center. Subjects underwent novel standardized didactic and skills-specific training on both the MCT and LAT techniques. Later, subjects were randomized to the order of intervention and performed both techniques on separate fresh, nonfrozen human cadaver specimens. Success was determined by a board-certified surgeon and defined as complete delivery of the heart from the pericardial sac and subsequent 100% occlusion of the descending thoracic aorta with a vascular clamp. The primary outcome was time to successful completion of the resuscitative thoracotomy technique. Secondary outcomes included successful exposure of the heart, successful descending thoracic aortic cross clamping, successful procedural completion, time to exposure of the heart, time to descending thoracic aortic cross-clamp placement, number and type of iatrogenic injuries, correct anatomic structure identification, and poststudy participant questionnaire. RESULTS: Sixteen emergency physicians were recruited; 15 met inclusion criteria. All participants were either emergency medicine resident (47%) or emergency medicine staff (53%). The median number of previously performed training LATs was 12 (interquartile range 6 to 15) and the median number of previously performed MCTs was 1 (interquartile range 1 to 1). The success rates of our study population for the MCT and LAT techniques were not statistically different (67% versus 40%; difference 27%; 95% confidence interval -61% to 8%). However, staff emergency physicians were significantly more successful with the MCT compared with the LAT (88% versus 25%; difference 63%; 95% CI 9% to 92%). Overall, the MCT also had a significantly higher proportion of injury-free trials compared with the LAT technique (33% versus 0%; difference 33%; 95% CI 57% to 9%). Physician procedure preference favored the MCT over the LAT (87% versus 13%; difference 74%; 95% CI 23% to 97%). CONCLUSION: Resuscitative thoracotomy success rates were lower than expected in this capable subject population. Success rates and procedural time for the MCT and LAT were similar. However, the MCT had a higher success rate when performed by staff emergency physicians, resulted in less periprocedural iatrogenic injuries, and was the preferred technique by most subjects. The MCT is a potentially feasible alternative resuscitative thoracotomy technique that requires further investigation.


Assuntos
Medicina de Emergência/métodos , Ressuscitação/métodos , Toracotomia/métodos , Adulto , Competência Clínica/estatística & dados numéricos , Estudos Cross-Over , Medicina de Emergência/normas , Feminino , Humanos , Masculino , Erros Médicos/prevenção & controle , Erros Médicos/estatística & dados numéricos , Avaliação de Resultados em Cuidados de Saúde , Estudos Prospectivos , Ressuscitação/efeitos adversos , Ressuscitação/normas , Toracotomia/efeitos adversos , Toracotomia/normas
12.
Mil Med ; 186(7-8): e743-e748, 2021 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-33216936

RESUMO

BACKGROUND: The U.S. Indo-Pacific Command (INDOPACOM) has over 375,000 military personnel, civilian employees, and their dependents. Routine pediatric care is available in theater, but pediatric subspecialty, surgical, and intensive care often require patient movement. Transfer is frequently performed by military air evacuation teams and intermittently augmented by civilian services. Pediatric care requires special training and equipment, yet most transports are staffed by non-pediatric specialists. We seek to describe the epidemiology of pediatric transport missions in INDOPACOM. METHODS: A retrospective review of all patients less than 18 years old transported within INDOPACOM and logged into the Transportation Command Regulating and Command and Control Evacuation System (TRAC2ES) database from June 2008 through June 2018 was conducted. Data are reported using descriptive statistics. Patients were categorized into four age groups: neonatal (<31 days), infant (31-364 days), young children (1 to <8 years), and older children (8-17 years). RESULTS: During the study period, 687 out of 4,217 (16.3%) transports were children. Median age was 4 years (interquartile range 6 months to 8 years) and 654 patients (95.2%) were transported via military fixed-wing aircraft. There were 219 (31.9%) neonates, 162 (23.6%) infants, 133 (19.4%) young children, and 173 (25.2%) older children. Most common diagnoses encountered were respiratory, cardiac, or abdominal, although older children had a higher percentage of psychiatric diagnoses (28%). Mechanical ventilation was used in 118 (17.2%) patients, and 75 (63.6%) of these patients were neonates. CONCLUSIONS: Within TRAC2ES, nearly one in six encounters were patients aged <18 years, with neonates or infants representing nearly one of three pediatric encounters. Slightly more than one in six pediatric patients required intubation for transport. The data suggest the need for appropriately trained transport teams and equipment be provided to support these missions.


Assuntos
Militares , Adolescente , Aeronaves , Criança , Pré-Escolar , Cuidados Críticos , Humanos , Lactente , Recém-Nascido , Respiração Artificial , Estudos Retrospectivos , Transporte de Pacientes
13.
Prehosp Emerg Care ; 25(5): 656-663, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32940577

RESUMO

BACKGROUND: The emergency department (ED) poses challenges to effective handoff from emergency medical services (EMS) personnel to ED staff. Despite the importance of a complete and accurate patient handoff report between EMS and trauma staff, communication is often interrupted, incomplete, or otherwise ineffective. The Mechanism of injury/Medical Complaint, Injuries or Inspections head to toe, vital Signs, and Treatments (MIST) report initiative was implemented to standardize the handoff process. The objective of this study was to evaluate whether documentation of prehospital care in the inpatient medical record improved after MIST implementation. METHODS: Research staff abstracted data from the EMS and inpatient medical records of trauma patients transported by EMS and treated at a Level I trauma center from January 2015 through June 2017. Data included patient demographics, mechanism and location of injury, vital signs, treatments, and period of data collection (pre-MIST and post-MIST). We summarized the MIST elements in EMS and inpatient medical records and assessed the presence or absence of data elements in the inpatient record from the EMS record and the agreement between the two sets of records over time to determine if implementation of MIST improved documentation. RESULTS: We analyzed data from 533 trauma patients transported by EMS and treated in a Level I trauma center (pre-MIST: n = 281; post-MIST: n = 252). For mechanism of injury, agreement between the two records was ≥96% before and after MIST implementation. Cardiac arrest and location of injury were under-reported in the inpatient record before MIST; post-MIST, there were no significant discrepancies, indicating an improvement in reporting. Reporting of prehospital hypotension improved from 76.5% pre-MIST to 83.3% post-MIST. After MIST implementation, agreement between the EMS and inpatient records increased for the reporting of fluid administration (45.6% to 62.7%) and decreased for reporting of pain medications (72.2% to 61.9%). CONCLUSIONS: The use of the standardized MIST tool for EMS to hospital patient handoff was associated with a mixed value on inpatient documentation of prehospital events. After MIST implementation, agreement was higher for mechanism and location of injury and lower for vital signs and treatments. Further research can advance the prehospital to treatment facility handoff process.


Assuntos
Serviços Médicos de Emergência , Transferência da Responsabilidade pelo Paciente , Documentação , Humanos , Pacientes Internados , Registros Médicos , Centros de Traumatologia
14.
J Surg Res ; 258: 88-99, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33002666

RESUMO

BACKGROUND: Recent evidence demonstrates that closed chest compressions directly over the left ventricle (LV) in a traumatic cardiac arrest (TCA) model improve hemodynamics and return of spontaneous circulation (ROSC) when compared to traditional compressions. Selective aortic arch perfusion (SAAP) also improves hemodynamics and controls hemorrhage in TCA. We hypothesized that chest compressions located over the LV would result in improved hemodynamics and ROSC in a swine model of TCA using SAAP. MATERIALS AND METHODS: Transthoracic echo was used to mark the location of the aortic root (Traditional location) and the center of the LV on animals (n = 24), which were randomized to receive chest compressions in one of the two locations. After hemorrhage, ventricular fibrillation (VF) was induced to simulate TCA. After a period of 10 min of VF, basic life support (BLS) with mechanical CPR was initiated and performed for 10 min, followed by advanced life support (ALS) for an additional 10 min. SAAP balloons were inflated at min 6 of BLS. Hemodynamic variables were averaged over the final 2 min of the BLS and ALS periods. Survival was compared between this SAAP cohort and a control group without SAAP (No-SAAP) (n = 26). RESULTS: There was no significant difference in ROSC between the two SAAP groups (P = 0.67). There was no ROSC difference between SAAP and No-SAAP (P = 0.74). CONCLUSIONS: There was no difference in ROSC between LV and Traditional compressions when SAAP was used in this swine model of TCA. SAAP did not confer a survival benefit compared to historical controls.


Assuntos
Reanimação Cardiopulmonar/métodos , Parada Cardíaca/terapia , Animais , Aorta Torácica/fisiologia , Feminino , Distribuição Aleatória , Retorno da Circulação Espontânea , Suínos
15.
Prehosp Emerg Care ; 25(4): 530-538, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-32772874

RESUMO

INTRODUCTION: Handoff communication between Emergency Medical Services (EMS) and Emergency Department (ED) staff is critical to ensure quality patient care. In January 2016, the Southwest Texas Regional Advisory Council (STRAC) implemented MIST (Mechanism, Injuries, vital Signs, Treatments), a standardized EMS to ED handoff tool. The En route Care Research Center conducted a Pre-MIST implementation survey of ED staff in December 2015 and a Post-MIST follow-up survey in July 2017 to determine the impact of the MIST handoff tool on the perceived quality of transmission of pertinent patient information and in the overall handoff experience. METHODS: We administered a nine-item Likert scale questionnaire to Brooke Army Military Medical Center (BAMC) ED providers and nurses before and after implementation of MIST. The questionnaire captured perceived competence and satisfaction with handoff communication (Cronbach's alpha 0.73). We analyzed responses for the total sample and by occupation (providers and nurses), and we calculated odds ratios to determine items that may be most predictive of a positive handoff experience from the perspective of the ED staff. We performed chi-square tests and reported data as percentages. RESULTS: Total respondents Pre- and Post-MIST were 128 (62%) nurses and 80 (38%) providers (MDs, DOs, and PAs). Following the implementation of MIST, more respondents reported that they were "informed of prehospital treatments" (p < 0.001), that "Red/Blue Trauma Alert Criteria were conveyed" (p < 0.001), and that the "time to give the report was sufficient to convey pertinent information" (p < 0.001). Nurses more frequently reported that "Red/Blue Trauma Alert Criteria were conveyed" post-MIST (p < 0.01). Providers more frequently reported that "Assessment findings were conveyed" (p < 0.05), that they 'interrupted the report for clarification" (p < 0.04), that "time to give the report was sufficient to convey pertinent information" (p < 0.001) and that they "felt positive about the overall handoff experience" (p < 0.03) Post-MIST. Overall satisfaction with the handoff was associated with frequently being informed of prehospital treatments (OR 5.5; 2.1-14.4) and frequently receiving a copy of the prehospital record (OR 2.9; 1.1-7.2). CONCLUSIONS: These data demonstrate that providers and nurses reported an improvement in the handoff experience Post-MIST. This study supports the use of a standardized handoff tool at this critical step in patient care.


Assuntos
Serviços Médicos de Emergência , Transferência da Responsabilidade pelo Paciente , Comunicação , Serviço Hospitalar de Emergência , Humanos , Ocupações , Texas
16.
Mil Med ; 186(3-4): e366-e372, 2021 02 26.
Artigo em Inglês | MEDLINE | ID: mdl-33200779

RESUMO

INTRODUCTION: The U.S. military currently utilizes unmanned aerial vehicles (UAVs) for reconnaissance and attack missions; however, as combat environment technology advances, there is the increasing likelihood of UAV utilization in prehospital aeromedical evacuation. Although some combat casualties require life-saving interventions (LSIs) during medical evacuation, many do not. Our objective was to describe patients transported from the point of injury to the first level of care and characterize differences between patients who received LSIs en route and those who did not. MATERIALS AND METHODS: We conducted a retrospective review of the records of traumatically injured patients evacuated between January 2011 and March 2014. We compared patient characteristics, complications, and outcomes based on whether they had an LSI performed en route (LSI vs. No LSI). We also constructed logistic regression models to determine which characteristics predict uneventful flights (no en route LSI or complications). RESULTS: We examined 1,267 patient records; 47% received an LSI en route. Most patients (72%) sustained a blast injury and injuries to the extremities and head. Over 78% experienced complications en route; the LSI group had higher rates of complications compared to the No LSI group. Logistic regression showed that having a blunt injury or the highest abbreviated injury scale (AIS) severity score in the head/neck region are significant predictors of having an uneventful flight. CONCLUSION: Approximately half of casualties evaluated in our study did not receive an LSI during transport and may have been transported safely by UAV. Having a blunt injury or the highest AIS severity score in the head/neck region significantly predicted an uneventful flight.


Assuntos
Resgate Aéreo , Militares , Traumatismos por Explosões , Humanos , Registros Médicos , Estudos Retrospectivos , Ferimentos não Penetrantes
17.
Inhal Toxicol ; 33(1): 25-32, 2021 01.
Artigo em Inglês | MEDLINE | ID: mdl-33356664

RESUMO

BACKGROUND: Methyl mercaptan occurs naturally in the environment and is found in a variety of occupational settings, including the oil, paper, plastics, and pesticides industries. It is a toxic gas and deaths from methyl mercaptan exposure have occurred. The Department of Homeland Security considers it a high threat chemical agent that could be used by terrorists. Unfortunately, no specific treatment exists for methyl mercaptan poisoning. METHODS: We conducted a randomized trial in 12 swine comparing no treatment to intramuscular injection of the vitamin B12 analog cobinamide (2.0 mL, 12.5 mg/kg) following acute inhalation of methyl mercaptan gas. Physiological and laboratory parameters were similar in the control and cobinamide-treated groups at baseline and at the time of treatment. RESULTS: All six cobinamide-treated animals survived, whereas only one of six control animals lived (17% survival) (p = 0.0043). The cobinamide-treated animals returned to a normal breathing pattern by 3.8 ± 1.1 min after treatment (mean ± SD), while all but one animal in the control group had intermittent gasping, never regaining a normal breathing pattern. Blood pressure and arterial oxygen saturation returned to baseline values within 15 minutes of cobinamide-treatment. Plasma lactate concentration increased progressively until death (10.93 ± 6.02 mmol [mean ± SD]) in control animals, and decreased toward baseline (3.79 ± 2.93 mmol [mean ± SD]) by the end of the experiment in cobinamide-treated animals. CONCLUSION: We conclude that intramuscular administration of cobinamide improves survival and clinical outcomes in a large animal model of acute, high dose methyl mercaptan poisoning.

18.
Mil Med ; 2020 Dec 08.
Artigo em Inglês | MEDLINE | ID: mdl-33289834

RESUMO

BACKGROUND: Airway obstruction is the second leading cause of preventable death on the battlefield. Video laryngoscopy has improved airway management in the emergency setting for several decades, and technology continues to improve. Current technology in the supply chain is cost-prohibitive to incorporate at Role 1 facilities, which is where many intubations occur by novice intubators. The i-view is a novel video laryngoscopy device that is handheld, inexpensive, and disposable. The aim of this study was to determine if the i-view is suitable based on performance assessments by physician assistant trainees and survey feedback. MATERIALS AND METHODS: We prospectively enrolled physician assistant students at the Interservice Physician Assistant Program at Joint Base San Antonio-Fort Sam Houston. We provided them structured training on how to use the device, and then, a board-certified emergency medicine physician or certified registered nurse anesthetist assessed their intubations performed on a SynDaver mannequin model. We surveyed the participants afterward. RESULTS: We enrolled 60 Interservice Physician Assistant Program students. Most participants were male (75%) with a median age of 32 years. Service affiliations included Army (50%), Navy (23%), Air Force (18%), and Coast Guard (8%). Most (70%) had previous deployment experience. All the participants successfully cannulated the mannequins and 98% achieved first-attempt success. Most participants (78%) reported a grade 1 view. On postprocedure survey, 91% strongly agreed with using this device in the deployed setting and 89% strongly agreed with finding it easy to use. CONCLUSIONS: All physician assistant trainees successfully and rapidly performed endotracheal intubation using the disposable i-view video laryngoscope. Study participants rated the device as easy to use and desirable for deployment. Further research is necessary to validate this novel device in the clinical setting before recommending dissemination to the deployed military medical force sets, kits, and outfits.

19.
AEM Educ Train ; 4(4): 347-358, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33150277

RESUMO

Background: Extracorporeal membrane oxygenation (ECMO) is a modification of cardiopulmonary bypass that allows prolonged support of patients with severe respiratory or cardiac failure. ECMO indications arse rapidly evolving and there is growing interest in its use for cardiac arrest and cardiogenic shock. However, ECMO training programs are limited. Training of emergency medicine and critical care clinicians could expand the use of this lifesaving intervention. Our objective was to develop and evaluate an abbreviated ECMO course that can be taught to emergency and critical care physicians and nurses. Methods: We developed a training model using Yorkshire swine (Sus scrofa), a procedure instruction checklist, a confidence assessment, and a knowledge assessment. Participants were assigned to teams of one emergency medicine or critical care physician and one nurse and completed an abbreviated 8-hour ECMO course. An ECMO specialist trained participants on preparation of the ECMO circuit and oversaw vascular access and ECMO initiation. We used the instruction checklist to evaluate performance. Participants completed confidence and knowledge assessments before and after the course. Results: Seventeen teams (34 clinicians) completed the abbreviated ECMO course. None had previously completed an ECMO certification course. Immediately following the course, all teams successfully primed and prepared the ECMO circuit. Fifteen teams (88%, 95% confidence interval [CI] = 64% to 99%) successfully initiated ECMO. Participants improved their knowledge (difference 21.2, 95% CI = 16.5 to 25.8) and confidence (difference 40.3, 95% CI = 35.6 to 45.0) scores after completing the course. Conclusions: We developed an accelerated 1-day ECMO course. Clinicians' confidence and knowledge assessments improved and 88% of teams could successfully initiate venoarterial ECMO after the course.

20.
Mil Med ; 2020 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-33219660

RESUMO

INTRODUCTION: With more than 370,000 military and civilian personnel stationed across Pacific Command (PACOM), medical evacuation in this largest command presents unique challenges. The authors describe medical evacuations analyzed from the U.S. Air Force Transportation Command Regulating and Command & Control Evacuation System (TRAC2ES) in PACOM. MATERIALS AND METHODS: We performed a retrospective review of all TRAC2ES medical records for medical evacuations of adult patients from the PACOM theater of operations conducted between January 1, 2008 and December 31, 2018. We abstracted free text data entry in TRAC2ES to characterize the diagnoses requiring patient movement. Data are presented using descriptive statistics. RESULTS: During this 11-year period, 3,328 PACOM TRAC2ES encounters met inclusion criteria. Of these evacuations, 65.8% were male and were comprised mostly of active duty military (1,600, 48.1%) and U.S. civilians (1,706, 51.3%). Most transports originated in Japan (1,210 transports, 36.4%) or Guam (924 transports, 27.8%) with Hawaii (1,278 transports, 38.4%) as the most frequent destination. The majority of evacuations were routine (72.5%) with only 4.9% urgent evacuations. Medical conditions (2,905 transports, 87%) accounted for the largest proportion of transports, surpassing injuries (442 transports, 13%). The most common reasons for medical transports were behavioral health (671 transports, 20.2%) and cardiovascular disease (505 transports, 15.1%). CONCLUSIONS: The majority of medical evacuations in PACOM were because of medical illness with routine precedence category, mirroring the largely noncombat operations occurring across this large area.

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