Pediatric emergency care capabilities of Indian Health Service emergency medical service agencies serving American Indians/Alaska Natives in rural and frontier areas

INTRODUCTION

In the USA, the emergency medical services (EMS) system is vital for American Indians and Alaska Natives, who are disproportionately burdened by injuries and diseases and often live in rural areas geographically far from hospitals. In rural areas, where significant health disparities exist, EMS is often a primary source of healthcare providing a safety net for uninsured individuals or families who otherwise lack access to health-related services. EMS is frequently the first entry point for children and their families into the healthcare system. The Indian Health Service (IHS) supports the federally funded, tribally operated EMS agencies to help meet the affiliated American Indian and Alaska Natives' pre-hospital needs. While periodic assessments of state EMS agencies capabilities to care for children occur, it appears a systematic assessment of IHS EMS agencies in regards to children had not been previously conducted.

METHODS

A consensus process, involving stakeholders, was used to identify topic areas for a survey for assessing the pediatric capabilities of IHS EMS. The survey was sent to 75 of 88 IHS EMS agency contacts.

RESULTS

Sixty-one agencies (81%) responded. Nine agencies (15%) did not have a medical director. Agencies without a medical director were less likely to report the availability of online (p=0.1) or offline (p<0.01) pediatric medical direction. Half (51%) of the agencies had a mass casualties plan; however, 29% reported responding to a mass casualty incident, involving a large number of pediatric patients, that overwhelmed their service. Most agencies were well integrated with their state EMS system with almost all (95%) collecting EMS patient care data and 47% using national standard data elements.

CONCLUSIONS

In some areas, IHS EMS agencies did not have the infrastructure to treat pediatric patients during day-to-day operations as well as disasters. Similar to operational challenges faced by rural EMS agencies, the IHS agencies lacked a medical director, were unable to provide pediatric continuing education, and were overwhelmed during mass casualty incidents. Moreover, the overall ratio of IHS EMS to service population is almost double that for other EMS agencies. In other areas, agencies were well integrated with their state EMS system. One possible solution to increase capabilities to care for pediatric patients is combining and sharing of common resources including medical directors with their state EMS systems and authorities.

The tourniquet revisited as an adjunct to lower limb revascularization

PURPOSE

The purpose of this study was to evaluate the role and efficacy of the tourniquet in lower limb revascularization.

METHODS

During a 3-year period, 195 patients underwent 205 infrainguinal reconstruction operations in the lower extremity. These patients underwent bypass with a tourniquet and inflow occlusion (group 1) or bypass without a tourniquet (group 2). The type of infrainguinal reconstruction, tourniquet ischemia time, blood loss, and complications related to tourniquet use were recorded. A subset of patients underwent serial muscle biopsies. Specimens from calf muscle were taken just (1) before application of the tourniquet, (2) before tourniquet release, and (3) once wound closure was initiated. These biopsy specimens were studied by histochemical staining and also analyzed for phosphorylase enzyme, a marker for subcellular ischemia.

RESULTS

One hundred eleven patients underwent 117 infrainguinal reconstruction procedures in which the tourniquet and inflow occlusion were used. These patients were matched against 84 patients who underwent 88 infrainguinal reconstructions without the use of the tourniquet. Complete hemostatic control in group 1 was obtained in 108 of the procedures (92%). Eight percent of the procedures required minor additional techniques to obtain complete hemostasis; in two instances, the tourniquet was removed because it did not provide hemostasis. Mean tourniquet time was less than 1 hour for all reconstruction groups. There were no instances of neurologic deficit, thrombosis of distal vessels, or vascular injury that was related to the use of a tourniquet. A comparison of the two groups revealed no differences with regard to overall blood loss (P =.63) or duration of operation (P = 0.60), observations that reflect the complexity of the cases rather than the use or nonuse of a tourniquet. When tourniquet control was used, we noted a definite decrease in the time for the distal dissection, because total vascular control with extensive dissection was unnecessary. Histochemical analysis with phosphorylase revealed a conversion of tissue with active enzyme activity to a low level with tourniquet use (P <.05).

CONCLUSION

The use of a tourniquet for lower limb revascularization is safe and effective and improves visualization of the operative field. Less dissection of the target vessels is required. With a combination of the nonuse of clamps and other occluding devices, we project a decrease in host hyperplastic response that will, in turn, impact favorably on patency rates. The possibility exists that early failure may be prevented by avoiding the application of traumatic forces to diseased and brittle or calcified arteries. In this study, tourniquet time had no impact on overall operative procedural time, although certain phases of the operation were clearly shortened and facilitated, particularly in complex and difficult reconstructions. Histochemical changes found in muscle biopsy specimens did not adversely impact patients clinically, but further investigation is required to elucidate subcellular events.

Field anesthesia of free-living mountain gorillas (Gorilla gorilla beringei) from the Virunga Volcano region, Central Africa

Twenty-six anesthetic procedures involving 24 free-living mountain gorillas (Gorilla gorilla beringei) from Rwanda or the Democratic Republic of Congo were performed between February 1987 and October 1997. Sixteen procedures were performed to remove snares or to treat snare-related wounds, and four of the animals died without recovering consciousness because of their severe medical conditions. Ketamine was used for induction 19 times, tiletamine/zolazepam was used five times, and the agent was not recorded for two procedures. The mean (+/- SD) ketamine dosage for four animals of known weight was 7.1 +/- 0.9 mg/kg. All induction agents were delivered i.m. by remote injection, and mean induction times for ketamine and tiletamine/zolazepam were 5.5 +/- 2.6 min (n = 12) and 5.4 +/- 3.7 min (n = 5), respectively. Mean recovery times were significantly shorter with ketamine compared with tiletamine/zolazepam (42.0 +/- 24.9 min, n = 9 vs. 75.25 +/- 22.1 min, n = 4). Low hemoglobin oxygen saturation (mean = 86.7%) was recorded in three cases under ketamine anesthesia, and oxygen insufflation is therefore recommended to prevent hypoxemia. Gorillas induced with tiletamine/zolazepam had significantly higher respiratory rates compared with animals given ketamine. Successful anesthesia and recovery, in particular, depended on the assistance of local personnel.

Femorocaval bypass with femoral crossover bypass for iliofemoral and caval occlusion

Progress in the management of major venous obstruction has lagged far behind advances in arterial reconstruction. As a result, literature reports consist of small numbers of patients, and most vascular surgeons have little or no experience in performing bypass procedures for major venous obstruction. In this setting, individual reports add to our cumulative knowledge in treating this disease. We therefore present our experience in the management of a patient with extensive bilateral femoropopliteal, iliac, and vena caval occlusion.

Wound coverage: is there a difference?

Many different wound-covering materials, making various claims regarding wound healing effectiveness, are currently available. However, no controlled, comparison trials have been performed to document these claims. This prospective, randomized study was undertaken to compare wound healing among several synthetic burn dressings. Micrografts were placed on 20 New Zealand white rabbits, then randomly covered with four commonly used synthetic burn dressings, to evaluate the impact on wound healing. No statistically significant difference in wound healing was observed among the dressings. With equal wound healing, the choice of wound coverage should be based on other factors such as availability, cost, and handling properties of the dressing.

Childhood sexual abuse and parental alcoholism: interactive effects in adult women

Symptoms associated with histories of childhood sexual abuse and parental alcoholism were investigated in a sample of 364 university women. A significant association was found in occurrence between the two stressors, and a substantially higher level of symptoms was revealed in women who had experienced both during childhood.

Continuous care teams in intensive outpatient treatment of chronic mentally ill patients

A continuous care team provides ongoing treatment for chronic mentally ill patients at a community mental health center in an inner-city area. The team, which consists of a nurse-social worker, a psychiatrist, four clinicians, and an addictions counselor, uses aggressive outreach and remains in charge of treatment while the patient is hospitalized. Preliminary outcomes for 32 of 39 patients treated during the first 15 months of the program included increased rates of treatment compliance, decreased frequency of crises, and decreased frequency and duration of hospitalization. However, substance abuse continued to be a problem and was negatively correlated with improvement.

Lithium: a modulator of cyclic AMP-dependent events in lymphocytes?

Theophylline, salbutamol, isoproterenol, and dibutyryl cyclic AMP inhibited E-rosette formation by human T lymphocytes and immunoglobulin M secretion from human plaque-forming B cells and augmented T-suppressor cell activity in three patients with agammaglobulinemia. Lithium chloride increased mitogen-induced lymphocyte proliferation and inhibited suppressor cell activity. In the presence of lithium, the effects of all the drugs except dibutyryl cyclic AMP could be prevented. The data suggest a role for lithium in the modulation of cyclic AMP-dependent events in lymphocytes. Its potential role as an inhibitor of suppressor cell activity warrants further attention.