Intraperitoneal blood missed on a FAST examination using portable ultrasound

Bedside ultrasonography is rapidly gaining popularity in the evaluation of emergency patients. Several manufacturers have developed hand-held ultrasound machines that make the technology easy to transport and available in settings where such diagnostic tests were previously unobtainable. The miniaturization of equipment often means compromises and no studies exist comparing the high quality imaging capabilities of larger conventional ultrasound units to hand-held machines on actual patients. We present 3 cases in which intra-abdominal fluid stripes, important markers of intraperitoneal bleeding, were not visible with a popular hand-held unit, but were identified with a larger mobile ultrasound machine. These findings should caution emergency physicians to be aware of this limitation along with the many advantages of these new and popular hand-held ultrasound units.

Nine ways to use handheld computers

Handheld computers can be used to make calculations, share articles with colleagues, store contact information, and even save lives. Translation software can facilitate communication with non-English-speaking patients. You can find out the cost of medications with drug reference software. Make the ED schedules accessible, so that staff can volunteer to fill in gaps.

The impact of information technology on emergency health care outcomes

We analyze the productivity of information technology in emergency response systems. "Enhanced 911" (E911) is information technology that links caller identification to a location database and so speeds up emergency response. We assess the impact of E911 on health outcomes using Pennsylvania ambulance and hospital records between 1994 and 1996, a period of substantial adoption. We find that as a result of E911 adoption, patient health measured at the time of ambulance arrival improves, suggesting that E911 speeds up emergency response. Further analysis using hospital discharge data shows that E911 reduces mortality and hospital costs.

The intubating laryngeal mask airway: suggestions for use in the emergency department

With the increased use of rapid-sequence induction and its potential complications, emergency physicians need a rescue device for unexpected difficult intubations. The intubating laryngeal mask airway (ILMA) is an ideal rescue airway since it can be placed quickly and can provide adequate ventilation in nearly all patients. It can then be used as conduit for endotracheal intubation, while ventilation is ongoing. The authors review the current literature on the ILMA. In conjunction with their experience using the ILMA in the emergency department (ED), a modification of the American Society of Anesthesiologists difficult airway algorithm was derived for use in the ED. The ILMA appears to be valuable for managing difficult airways.

In search of the most suitable technique for truncal spinal immobilization with associated radiography

The spineboard (SB) and the vacuum mattress (VM) are utilized for prehospital and emergency department (ED) immobilization of the spine. While permitting excellent pictures to be taken, the SB is a very painful device that can only be used for a limited time. The current study investigated the feasibility of different models of the VM for radiography. Computed tomography for each of seven VMs showed different degrees of shadows from the sac containing the polystyrole balls. This was related first of all to a high contrast of the sac in comparison with its contents and to a sometimes considerable shrinkage of the latter that resulted in further folding into the sac and, secondly, also to very broad mattresses, additional chambers within the VM and various grips and supports for lifting the mattress. Therefore, some features designed for prehospital use of the VM are actually acting against its use for diagnostic purposes. The aim of this study was to discuss and identify possible properties of a device that is useful for both immobilization and diagnostic purposes.

Critical pediatric equipment availability in Canadian hospital emergency departments

STUDY OBJECTIVE

Of all child visits to emergency departments, 1% to 5% involve critically ill children who require cardiopulmonary resuscitation. Numerous versions of pediatric equipment lists for EDs have been published. Despite these efforts, many EDs remain unprepared for pediatric emergencies. The objectives of this study were to assess the availability of pediatric resuscitation equipment items in Canadian hospital EDs and to identify risk factors for the unavailability of these items.

METHODS

Using the updated database of the Canadian Association of Emergency Physicians (CAEP), a questionnaire survey was sent to 737 Canadian hospital EDs with a maximum of 3 mailings to nonresponders. On-site visits to a selected subset of hospital EDs were completed to validate the results obtained by the mailed questionnaire.

RESULTS

The response rate was 88.3% (650/737). Results showed the following overall equipment unavailability: intraosseous needle, 15.9%; pediatric drug dose guidelines, 6.6%; infant blood pressure cuff, 14.8%; pediatric defibrillator paddles, 10.5%; infant warming device, 59.4%; infant bag-valve-mask device, 3.5%; infant laryngoscope blade, 3.5%; 3-mm endotracheal tube, 2.5%; and pediatric pulse oximeter, 18.0%. Low percentage of pediatric visits, lack of an on-call pediatrician for the ED, and lack of a pediatric advanced life support-trained physician on staff were independently associated with equipment unavailability.

CONCLUSION

This study demonstrated that essential pediatric resuscitation equipment is unavailable in a disturbingly high number of EDs across Canada and has identified several determinants of this unavailability.

Paediatric prehospital care: postal survey of paramedic training managers

BACKGROUND

The process of prehospital care continues to develop in the UK.

AIMS

To evaluate the availability of important paediatric resuscitation equipment in emergency ambulances and the extent of paramedic training in paediatric emergency medicine.

METHODS

Postal survey of paramedic training managers.

RESULTS

Completed questionnaires were returned by 41 (93%) training managers. No trust provided all of the equipment listed. Facemasks and self inflating bags (of appropriate sizes for all children) are provided by 32% and 42% of trusts respectively. Less than one third carry paediatric oximeter probes. Of the respondents, 16 (39%) trusts provide less than eight hours training in paediatric emergency medicine and five (12%) offer no training at all. Ongoing education varies from none to regular yearly updates.

CONCLUSIONS

Paramedics seem ill prepared to deal with paediatric emergencies. Important deficiencies in the provision of equipment and training are noted. The results of this survey provide information against which improvements can be measured.

Nasal wash technique for nasal foreign body removal

Nasal foreign bodies are seen commonly both in the office and pediatric emergency department setting. There have been a number of strategies described for their removal. We describe the "nasal wash" as a technique for nasal foreign body removal in the following three case reports. The "nasal wash" has been used in many pediatric vaccine studies as a method to collect mucus and relies on simple equipment readily available in the office setting.

Computers and connectivity in Illinois emergency departments

Although the Internet has been described as "ubiquitous," little is known about the extent to which physicians have access to the Internet while providing clinical care.

OBJECTIVE

To assess the extent of Internet connectivity within the clinical area of every ED within the state of Illinois.

METHODS

This was a prospective observational study. Each Illinois ED listed in a published directory was called by telephone, and a responsible party was identified to provide information regarding the type and size of the ED, patient demographics, the types of personal computers (PCs) available in the ED (if any), the types of operating systems used, the availability of access to the World Wide Web (Web), and the highest speed at which an Internet connection could be established. Responses regarding the presence and types of PCs and the types of operating systems used were assessed using one-factor chi-square. Univariate and multivariate predictors of the type of PC used, the presence or absence of Web access, and the highest speed of Internet access were evaluated using optimal discriminant analysis and nonlinear classification tree analysis, respectively.

RESULTS

One hundred ninety-eight of the 199 EDs in the state of Illinois (99.5%) completed the survey. Of the responding EDs, 50.5% had PCs, but only 17.6% had Web access. When Web access was available, it was most often available through a high-speed Internet connection that was faster than a dial-up modem. Most departments (68.1%) with PCs used the Windows 95 or Windows 98 operating systems. A majority (62.5%) used the Netscape browser exclusively. Larger EDs (more than six ED beds) in rural or suburban areas were more likely to have a PC compared with smaller EDs (six or fewer beds). Large EDs (more than 12 ED beds) in private tertiary care or academic hospitals were most likely to have Web access.

CONCLUSIONS

Although half of Illinois EDs have PCs, only one in six has access to the Internet; thus, most emergency physicians do not have ready access to the Web from the site where they deliver clinical care.

The efficacy of head immobilization techniques during simulated vehicle motion

STUDY DESIGN

Laboratory experiment.

OBJECTIVE

To compare the efficacy of different head immobilization techniques during motion simulating ambulance transport.

BACKGROUND

A significant number of neurologic injuries associated with cervical spine fractures arise or are aggravated during emergency extrication or patient transport. Previous studies have not addressed the effect of head immobilization on the passive motion that could occur across the neck during transport.

METHODS

Three different head-immobilization methods were compared in six healthy young adults by using a computer-controlled moving platform to simulate the swaying and jarring movements that can occur during ambulance transport. In all tests, the trunk was secured by means of a commonly used "criss-cross" strapping technique. Efficacy of head immobilization was evaluated using measures of head motion and neck rotation.

RESULTS

None of the three immobilization techniques was successful in eliminating head motion or neck rotation. Movement of the trunk contributed substantially to the lateral bending that occurred across the neck. A new product involving the placement of wedges underneath the head provided some small, but statistically significant improvements in fixation of the head to the fracture board; however, there was no improvement in terms of the relative motion occurring across the neck.

CONCLUSIONS

Somewhat improved fixation of the head to the fracture board can be achieved by placing wedges under the head; however, the benefits of any fixation method, in terms of cervical spine immobilization, are likely to be limited unless the motion of the trunk is also controlled effectively. Future research and development should address techniques to better control head and trunk motion.

[Prototype of a new pediatric emergency scale tape: PES tape]

Drug dosage and appropriate size of medical equipment for emergency pediatric patients are determined by age, body weight and/or height. In an emergency situation, however, such information about the patients is not always clear. Body height is easily measured when the patient lies down supine. Furthermore, child's height could be a better parameter than age to predict appropriate endotracheal tube (ETT) size and body weight. We propose a new pediatric emergency scale tape (PES Tape). PES Tape is graduated in centimeters to measure body height in supine position. Height-based body weight, drug dosage, energy dosage for defibrillation, appropriate size of ETT and lip-tip distance (LTD) are printed on the tape. We studied the reliability of this tape in pediatric anesthesia. Body weight estimated from the tape was accurate, and predicted size of ETT and LTD was appropriate. PES Tape is a reliable tool in pediatric emergency.

[The Aesculapius mobile treatment and diagnostic unit in the system of treatment and evacuation support]

"Esculap" is a newly developed hospital complex separated into a number of modules, some of which are unique since they were designed and equipped with a view of specialist and emergency medical care provision in the field on the basis of advanced technologies of hemodialysis, hemosorption and plasmapheresis. Its mobility, comfort and up-to-date equipment will improve the medical treatment results, reduce lethality and invalidity rates.

Guidelines for pediatric equipment and supplies for emergency departments. Committee on Pediatric Equipment and Supplies for Emergency Departments, National Emergency Medical Services for Children Resource Alliance

Appropriate care for ill and injured pediatric patients cannot be given if emergency departments (EDs) are not adequately equipped. Although guidelines for equipment and supplies for EDs have been published by national organizations in pediatric emergency textbooks and by state emergency medical services for children projects, until now there has been no consensus on what constitutes minimum equipment and supplies to care for pediatric patients in the ED setting.

Emergency medicine in France

The Essonne region of France is situated to the south of Paris. A population of more than 1 million, heavy commercial traffic, and industrial centers mandate first-rate prehospital and hospital emergency medicine. Medical education in France comprises 3 years of basic medical science, followed by 3 years of hospital rotations and a residency of variable length. Emergency medicine is struggling for recognition as a specialty. The ED at the hospital center in Corbeil-Essonnes, France, has 21,000 visits per year, accounting for 30% of hospital admissions. The physical plant is modern and well-organized, with 13 beds. Attention is paid to quality improvement. Prehospital emergency care also receives due attention. A two-tiered system of BLS ambulances run by the fire department and ALS ambulances run by hospitals provide 24-hour emergency coverage. Because of aggressive triage, only 65% of requests for service result in dispatch of an ambulance. Tasks for physicians involved in emergency medicine in France today include further development of firemen's medical skills, development and use of telemedicine, and accreditation of emergency medicine as a recognized specialty.

[Use of palm-top computers within the scope of medical data collection and quality assurance]

Computerisation of the medical profession is advancing particularly as the reform of the German medical system is underway and efforts to maintain high quality standards are being made. More and more clinics and private physicians store the data, which they collect in their daily work, in digital form and exchange it via electronic networks. But lacking overall concepts and resistance from monopolistic structures prevent the introduction of innovative technologies, which would allow convenient data collection "on the fly", patterned after proven work routines. This could lead to a real relief from the daily paper work. New approaches using available hard- and software developed abroad demonstrate medical palmtop computing on the Apple Newton.

[The organization of helicopter emergency services for the rescue of aircraft crash victims in the topical forest]

The purpose of this report was to describe lessons learned from experience in the tropical forest of Guyana and one helicopter rescue mission in that hostile environment. With previous data reported in the literature several guidelines for organizing these operations can be proposed. These rescue operations involve hoisting the victim to helicopter, medical treatment itself, and penetration into a hostile environment. Effectiveness and safety mandate that the physicians involved receive regular training in the techniques of helicopter evacuation, first aid, and survival. It is necessary to adapt conventional first aid kits for the purpose and to develop light and adequate survival equipment as listed exhaustively by the author.