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Levy MJ, Crowe RP, Abraham H, Bailey A, Blue M, Ekl R, Garfinkel E, Holloman JB, Hutchens J, Jacobsen R, Johnson C, Margolis A, Troncoso R, Williams JG, Myers JB. Dispatch Categories as Indicators of Out-of-Hospital Time Critical Interventions and Associated Emergency Department Outcomes. PREHOSP EMERG CARE 2024:1-6. [PMID: 38626286 DOI: 10.1080/10903127.2024.2342015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 04/04/2024] [Indexed: 04/18/2024]
Abstract
OBJECTIVES Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. METHODS This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). RESULTS Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. CONCLUSIONS In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.
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Affiliation(s)
| | | | | | - Anna Bailey
- Office of the Medical Director, Metropolitan Oklahoma City and Tulsa, Oklahoma
| | - Matt Blue
- Charleston County EMS, Charleston, South Carolina
| | | | | | | | | | - Ryan Jacobsen
- Office of the Medical Director, Johnson County EMS System, Olathe, Kansas
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Levy MJ, Wend CM, Flemming WP, Lazieh A, Rosenblum AJ, Pineda CM, Wolfberg DM, Jenkins JL, Goolsby CA, Margolis AM. Bleeding Control Protections Within US Good Samaritan Laws. Prehosp Disaster Med 2024; 39:156-162. [PMID: 38572644 DOI: 10.1017/s1049023x24000268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
INTRODUCTION In the United States, all 50 states and the District of Columbia have Good Samaritan Laws (GSLs). Designed to encourage bystanders to aid at the scene of an emergency, GSLs generally limit the risk of civil tort liability if the care is rendered in good faith. Nation-wide, a leading cause of preventable death is uncontrolled external hemorrhage. Public bleeding control initiatives aim to train the public to recognize life-threatening external bleeding, perform life-sustaining interventions (including direct pressure, tourniquet application, and wound packing), and to promote access to bleeding control equipment to ensure a rapid response from bystanders. METHODS This study sought to identify the GSLs in each state and the District of Columbia to identify what type of responder is covered by the law (eg, all laypersons, only trained individuals, or only licensed health care providers) and if bleeding control is explicitly included or excluded in their Good Samaritan coverage. RESULTS Good Samaritan Laws providing civil liability qualified immunity were identified in all 50 states and the District of Columbia. One state, Oklahoma, specifically includes bleeding control in its GSLs. Six states - Connecticut, Illinois, Kansas, Kentucky, Michigan, and Missouri - have laws that define those covered under Good Samaritan immunity, generally limiting protection to individuals trained in a standard first aid or resuscitation course or health care clinicians. No state explicitly excludes bleeding control from their GSLs, and one state expressly includes it. CONCLUSION Nation-wide across the United States, most states have broad bystander coverage within GSLs for emergency medical conditions of all types, including bleeding emergencies, and no state explicitly excludes bleeding control interventions. Some states restrict coverage to those health care personnel or bystanders who have completed a specific training program. Opportunity exists for additional research into those states whose GSLs may not be inclusive of bleeding control interventions.
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Affiliation(s)
- Matthew J Levy
- Johns Hopkins School of Medicine, Baltimore, MarylandUSA
| | | | | | - Antoin Lazieh
- Rutgers New Jersey Medical School, Newark, New JerseyUSA
| | | | | | | | | | | | - Asa M Margolis
- Johns Hopkins School of Medicine, Baltimore, MarylandUSA
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Levy MJ, Garfinkel EM, May R, Cohn E, Tillett Z, Wend C, Sikorksi RA, Troncoso R, Jenkins JL, Chizmar TP, Margolis AM. Implementation of a prehospital whole blood program: Lessons learned. J Am Coll Emerg Physicians Open 2024; 5:e13142. [PMID: 38524357 PMCID: PMC10958095 DOI: 10.1002/emp2.13142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/21/2024] [Accepted: 02/27/2024] [Indexed: 03/26/2024] Open
Abstract
Early blood administration by Emergency Medical Services (EMS) to patients suffering from hemorrhagic shock improves outcomes. Prehospital blood programs represent an invaluable resuscitation capability that directly addresses hemorrhagic shock and mitigates subsequent multiple organ dysfunction syndrome. Prehospital blood programs must be thoughtfully planned, have multiple safeguards, ensure adequate training and credentialing processes, and be responsible stewards of blood resources. According to the 2022 best practices model by Yazer et al, the four key pillars of a successful prehospital program include the following: (1) the rationale for the use and a description of blood products that can be transfused in the prehospital setting, (2) storage of blood products outside the hospital blood bank and how to move them to the patient in the prehospital setting, (3) prehospital transfusion criteria and administration personnel, and (4) documentation of prehospital transfusion and handover to the hospital team. This concepts paper describes our operational experience using these four pillars to make Maryland's inaugural prehospital ground-based low-titer O-positive whole blood program successful. These lessons learned may inform other EMS systems as they establish prehospital blood programs to help improve outcomes and enhance mass casualty response.
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Affiliation(s)
- Matthew J. Levy
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Fire and Rescue ServicesHoward County GovernmentMarriottsvilleMarylandUSA
- Office of the Medical DirectorMaryland Institute for Emergency Medical Services SystemsBaltimoreMarylandUSA
| | - Eric M. Garfinkel
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Fire and Rescue ServicesHoward County GovernmentMarriottsvilleMarylandUSA
| | - Robert May
- Department of Fire and Rescue ServicesHoward County GovernmentMarriottsvilleMarylandUSA
| | - Eric Cohn
- Department of Fire and Rescue ServicesHoward County GovernmentMarriottsvilleMarylandUSA
| | - Zachary Tillett
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Fire and Rescue ServicesHoward County GovernmentMarriottsvilleMarylandUSA
| | - Christopher Wend
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Robert A Sikorksi
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Ruben Troncoso
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - J. Lee Jenkins
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Timothy P. Chizmar
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Office of the Medical DirectorMaryland Institute for Emergency Medical Services SystemsBaltimoreMarylandUSA
| | - Asa M. Margolis
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- Department of Fire and Rescue ServicesHoward County GovernmentMarriottsvilleMarylandUSA
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Troncoso R, Garfinkel EM, Hinson JS, Smith A, Margolis AM, Levy MJ. Do prehospital sepsis alerts decrease time to complete CMS sepsis measures? Am J Emerg Med 2023; 71:81-85. [PMID: 37354893 DOI: 10.1016/j.ajem.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 06/26/2023] Open
Abstract
INTRODUCTION In an effort to improve sepsis outcomes the Centers for Medicare and Medicaid Services (CMS) established a time sensitive sepsis management bundle as a core quality measure that includes blood culture collection, serum lactate collection, initiation of intravenous fluid administration, and initiation of broad-spectrum antibiotics. Few studies examine the effects of a prehospital sepsis alert protocol on decreasing time to complete CMS sepsis core measures. METHODS This study was a retrospective cohort study of patients transported via EMS from December 1, 2018 to December 1, 2019 who met the criteria of the Maryland Statewide EMS sepsis protocol and compared outcomes between patients who activated a prehospital sepsis alert and patients who did not activate a prehospital sepsis alert. The Maryland Institute for Emergency Medical Services Systems developed a sepsis protocol that instructs EMS providers to notify the nearest appropriate facility with a sepsis alert if a patient 18 years of age and older is suspected of having an infection and also presents with at least two of the following: temperature >38 °C or <35.5 °C, a heart rate >100 beats per minute, a respiratory rate >25 breaths per minute or end-tidal carbon dioxide less than or equal to 32 mmHg, a systolic blood pressure <90 mmHg, or a point of care lactate reading greater than or equal to 4 mmol/L. RESULTS Median time to achieve all four studied CMS sepsis core measures was 103 min [IQR 61-153] for patients who received a prehospital sepsis alert and 106.5 min [IQR 75-189] for patients who did not receive a prehospital sepsis alert (p-value 0.105). Median time to completion was shorter for serum lactate collection (28 min. vs 35 min., p-value 0.019), blood culture collection (28 min. vs 38 min., p-value <0.01), and intravenous fluid administration (54 min. vs 61 min., p-value 0.025) but was not significantly different for antibiotic administration (94 min. vs 103 min., p-value 0.12) among patients who triggered a sepsis alert. CONCLUSION This study questions the effectiveness of prehospital sepsis alert protocols on decreasing time to complete CMS sepsis core measures. Future studies should address if these times can be impacted by having EMS providers independently administer antibiotics.
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Affiliation(s)
- Ruben Troncoso
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America.
| | - Eric M Garfinkel
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Jeremiah S Hinson
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Aria Smith
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Asa M Margolis
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD, United States of America
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Hack KE, Levy MJ, Garfinkel E, Margolis AM. Establishing consensus-based high-acuity low-occurrence skills for EMS physicians: A pilot survey of EMS fellowship faculty. AEM Educ Train 2022; 6:e10828. [PMID: 36562031 PMCID: PMC9763967 DOI: 10.1002/aet2.10828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/20/2022] [Accepted: 11/02/2022] [Indexed: 06/17/2023]
Abstract
Background The specialty of emergency medical services (EMS) medicine focuses on providing out-of-hospital patient care, including initial stabilization, treatment, and transport in specially equipped vehicles including ambulances and airframe platforms to hospitals and better-resourced destinations. The Core Content of EMS Medicine outlines the knowledge, procedures, and psychomotor skills relevant to prehospital patient care. However, this document does not specify the high-consequence skills that are infrequently performed and that carry high levels of complexity as well as potential morbidity. We refer to these as high-acuity low-occurrence (HALO) skills. Additionally, there is no consensus definition of what meets the criteria for a HALO skill. The goals of this pilot study were twofold: (1) to determine a consensus definition for a HALO skill and (2) to survey EMS fellowship faculty to identify an initial set of EMS physician trainee skills that meet the HALO definition. Methods Using a modified Delphi method, we established a consensus definition of a HALO skill as well as skills that met this definition for EMS physicians. Demographic information was collected from the experts. Results There was 100% agreement in the definition provided of a HALO skill. No additional proposed definitions were provided. Thirteen HALO skills were suggested by the panel from the originally proposed 56 skills, requiring three rounds to establish consensus. Final skill domains emphasized by the expert panel include airway management, obstetric emergencies, and shock management. Conclusions We present an initial consensus definition of a HALO skill and a recommended list of HALO skills for EMS physicians in training. Opportunity exists for further research to validate the definition and list of HALO skills through the sampling of a broader group of EMS physicians.
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Affiliation(s)
- Kaytlin E. Hack
- Department of Emergency MedicineJohns Hopkins Medical InstitutionsBaltimoreMarylandUSA
- Department of Emergency MedicineMedStar Georgetown University HospitalWashingtonDCUSA
| | - Matthew J. Levy
- Department of Emergency MedicineJohns Hopkins Medical InstitutionsBaltimoreMarylandUSA
| | - Eric Garfinkel
- Department of Emergency MedicineJohns Hopkins Medical InstitutionsBaltimoreMarylandUSA
| | - Asa M. Margolis
- Department of Emergency MedicineJohns Hopkins Medical InstitutionsBaltimoreMarylandUSA
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Levy MJ, Krohmer J, Goralnick E, Charlton N, Nemeth I, Jacobs L, Goolsby CA. A framework for the design and implementation of Stop the Bleed and public access trauma equipment programs. J Am Coll Emerg Physicians Open 2022; 3:e12833. [PMID: 36311340 PMCID: PMC9611563 DOI: 10.1002/emp2.12833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/06/2022] [Accepted: 09/27/2022] [Indexed: 12/03/2022] Open
Abstract
Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.
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Affiliation(s)
- Matthew J. Levy
- Department of Emergency MedicineJohns Hopkins University School of MedicineBaltimoreMarylandUSA
- National Center for Disaster Medicine and Public HealthBethesdaMarylandUSA
| | - Jon Krohmer
- Department of Emergency MedicineMichigan State UniversityGrand RapidsMichiganUSA
| | - Eric Goralnick
- Department of Emergency MedicineHarvard Medical SchoolBostonMassachusettsUSA
| | - Nathan Charlton
- Department of Emergency MedicineUniversity of Virginia School of MedicineCharlottesvilleVirginiaUSA
| | - Ira Nemeth
- Department of Emergency MedicineUniversity of Massachusetts Medical SchoolWorcesterMassachusettsUSA
| | - Lenworth Jacobs
- Hartford Health CareAcademic Affairs, Hartford HospitalHartfordConnecticutUSA
| | - Craig A. Goolsby
- Department of Emergency Medicine, Harbor‐UCLA Medical CenterDavid Geffen School of Medicine at UCLALos AngelesCaliforniaUSA
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Linaro D, Levy MJ, Hunt DL. Cell type-specific mechanisms of information transfer in data-driven biophysical models of hippocampal CA3 principal neurons. PLoS Comput Biol 2022; 18:e1010071. [PMID: 35452457 PMCID: PMC9089861 DOI: 10.1371/journal.pcbi.1010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 05/10/2022] [Accepted: 03/31/2022] [Indexed: 11/19/2022] Open
Abstract
The transformation of synaptic input into action potential output is a fundamental single-cell computation resulting from the complex interaction of distinct cellular morphology and the unique expression profile of ion channels that define the cellular phenotype. Experimental studies aimed at uncovering the mechanisms of the transfer function have led to important insights, yet are limited in scope by technical feasibility, making biophysical simulations an attractive complementary approach to push the boundaries in our understanding of cellular computation. Here we take a data-driven approach by utilizing high-resolution morphological reconstructions and patch-clamp electrophysiology data together with a multi-objective optimization algorithm to build two populations of biophysically detailed models of murine hippocampal CA3 pyramidal neurons based on the two principal cell types that comprise this region. We evaluated the performance of these models and find that our approach quantitatively matches the cell type-specific firing phenotypes and recapitulate the intrinsic population-level variability in the data. Moreover, we confirm that the conductance values found by the optimization algorithm are consistent with differentially expressed ion channel genes in single-cell transcriptomic data for the two cell types. We then use these models to investigate the cell type-specific biophysical properties involved in the generation of complex-spiking output driven by synaptic input through an information-theoretic treatment of their respective transfer functions. Our simulations identify a host of cell type-specific biophysical mechanisms that define the morpho-functional phenotype to shape the cellular transfer function and place these findings in the context of a role for bursting in CA3 recurrent network synchronization dynamics. The hippocampus is comprised of numerous types of neurons, which constitute the cellular substrate for its rich repertoire of network dynamics. Among these are sharp waves, sequential activations of ensembles of neurons that have been shown to be crucially involved in learning and memory. In the CA3 area of the hippocampus, two types of excitatory cells, thorny and a-thorny neurons, are preferentially active during distinct phases of a sharp wave, suggesting a differential role for these cell types in phenomena such as memory consolidation. Using a strictly data-driven approach, we built biophysically realistic models of both thorny and a-thorny cells and used them to investigate the integrative differences between these two cell types. We found that both neuron classes have the capability of integrating incoming synaptic inputs in a supralinear fashion, although only a-thorny cells respond with bursts of action potentials to spatially and temporally clustered synaptic inputs. Additionally, by using a computational approach based on information theory, we show that, owing to this propensity for bursting, a-thorny cells can encode more information in their spiking output than their thorny counterpart. These results shed new light on the computational capabilities of two types of excitatory neurons and suggest that thorny and a-thorny cells may play distinct roles in the generation of hippocampal network synchronization.
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Affiliation(s)
- Daniele Linaro
- Dipartimento di Elettronica, Informazione e Bioingegneria (DEIB), Politecnico di Milano, Milan, Italy
- * E-mail: (DL); (DLH)
| | - Matthew J. Levy
- Center for Neural Science and Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United State of America
| | - David L. Hunt
- Center for Neural Science and Medicine, Cedars-Sinai Medical Center, Los Angeles, California, United State of America
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United State of America
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, California, United State of America
- Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, United State of America
- * E-mail: (DL); (DLH)
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Morse KA, Balhara KS, Irvin NA, Levy MJ. The Health Humanities and Emergency Medical Services (EMS): A Call to Action. Prehosp Disaster Med 2022; 37:1-2. [PMID: 35172914 DOI: 10.1017/s1049023x22000243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the context of an on-going global pandemic that has demanded increasingly more of our Emergency Medical Services (EMS) clinicians, the health humanities can function to aid in educational training, promoting resilience and wellness, and allowing opportunity for self-expression to help prevent vicarious trauma.As the social, cultural, and political landscape of the United States continues to require an expanded scope of practice from our EMS clinicians, it is critical that the health humanities are implemented as not only part of EMS training, but also as part of continued practice in order to ensure the highest quality patient-centered care while protecting the longevity and resilience of EMS clinicians.
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Affiliation(s)
- Kiriana A Morse
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Kamna S Balhara
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Nathan A Irvin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MarylandUSA
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Levy MJ, Chizmar TP, Alemayehu T, Sidik MM, Garfinkel E, Stone R, Wendell J, Vesselinov R, Margolis AM, Delbridge TR. A Statewide EMS Viral Syndrome Pandemic Triage Protocol: 24 Hour Outcomes. PREHOSP EMERG CARE 2021; 26:623-631. [PMID: 34550053 DOI: 10.1080/10903127.2021.1983091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Background: Early during the COVID-19 pandemic, Emergency Medical Services (EMS) systems encountered many challenges that prompted crisis-level strategies. Maryland's statewide EMS system implemented the Viral Syndrome Pandemic Triage Protocol which contained a decision tool to help identify patients potentially safe for self-care at home. Objectives: This study assessed the effects of the Maryland Viral Syndrome Pandemic Triage Protocol and the safety of referring patients for self-care at home. Methods: This is a retrospective statewide analysis of EMS patients from March 19 thru September 4, 2020, who were not transported and had documentation of the Viral Syndrome Pandemic Triage Protocol's decision support tool completed, as well as a random sample of 150 patients who were not transported and did not have documentation of the decision tool. Descriptive statistics were performed as well as a two-stage multivariable logistic regression model for the outcomes of ED presentation within 24 hours and subsequent hospitalization. Results: 301 EMS patients were documented as triaged to home using the protocol and outcomes data were available for 282 (94%). 41(14.5%) patients presented to an ED within 24 hours and 14 (5% of 282) required inpatient hospitalization. Nine (3.2%) patients were subsequently hospitalized with a diagnosis of COVID-19 illness. Of those patients for whom the decision tool was not documented, 35 (23%) had an ED visit within 24 hours and 15 (10%) were hospitalized (p = 0.075). Multivariate logistic regression model results (N = 432) suggest that those with documentation of triage protocol use had some advantage over those patients without documentation. The 95% CIs of the estimated effect of Triage/No Triage protocol documented were wide and crossed the 1.0 limit but overall, all effects Odds Ratios and Adjust Odds Ratios were consistently over 1.0 with the lowest value of 1.3 and the highest value of 2.1. Conclusion: Most patients (95%) who were triaged to self-care at home with home documented decision support tool use did not require hospitalization within 24 hours following EMS encounter and this appears to be safe. Future opportunity exists to incorporate such tools into comprehensive pandemic preparedness strategies along with appropriate follow up and quality improvement mechanisms.
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Hadley ME, Vaught AJ, Margolis AM, Chizmar TP, Alemayehu T, Halscott T, Jenkins JL, Levy MJ. 911 EMS Activations by Pregnant Patients in Maryland (USA) during the COVID-19 Pandemic. Prehosp Disaster Med 2021; 36:570-575. [PMID: 34256885 PMCID: PMC8314197 DOI: 10.1017/s1049023x21000728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 04/24/2021] [Accepted: 05/16/2021] [Indexed: 02/07/2023]
Abstract
INTRODUCTION In the early phase of the coronavirus disease 2019 (COVID-19) pandemic, United States Emergency Medical Services (EMS) experienced a decrease in calls, and at the same time, an increase in out-of-hospital deaths. This finding led to a concern for the implications of potential delays in care for the obstetric population. HYPOTHESIS/PROBLEM This study examines the impact of the pandemic on prehospital care amongst pregnant women. METHODS A retrospective observational study was conducted comparing obstetric-related EMS activations in Maryland (USA) during the pandemic (March 10-July 20, 2020) to a pre-pandemic period (March 10-July 20, 2019). Comparative analysis was used to analyze the difference in frequency and acuity of calls between the two periods. RESULTS There were fewer obstetric-related EMS encounters during the pandemic compared to the year prior (daily average during the pandemic 12.5 [SD = 3.8] versus 14.6 [SD = 4.1] pre-pandemic; P <.001), although the percent of total female encounters remained unchanged (1.6% in 2020 versus 1.5% in 2019; P = .091). Key indicators of maternal status were not significantly different between the two periods. African-American women represented a disproportionately high percentage of obstetric-related activations (36.2% in 2019 and 34.8% in 2020). CONCLUSIONS In this state-wide analysis of EMS calls in Maryland early in the pandemic, no significant differences existed in the utilization of EMS by pregnant women. Prehospital EMS activations amongst pregnant women in Maryland only decreased slightly without an increase in acuity. Of note, over-representation by African-American women compared to population statistics raises concern for broader systemic differences in access to obstetric care.
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Affiliation(s)
| | - Arthur J. Vaught
- Maternal-Fetal Medicine and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MarylandUSA
| | - Asa M. Margolis
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MarylandUSA
| | - Timothy P. Chizmar
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MarylandUSA
| | - Teferra Alemayehu
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MarylandUSA
| | - Torre Halscott
- Maternal-Fetal Medicine and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MarylandUSA
| | - J. Lee Jenkins
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MarylandUSA
| | - Matthew J. Levy
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, MarylandUSA
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MarylandUSA
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Anders JF, Fishe JN, Fratta KA, Katznelson JH, Levy MJ, Lichenstein R, Milin MG, Simpson JN, Walls TA, Winger HL. Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method. Children (Basel) 2021; 8:children8080658. [PMID: 34438548 PMCID: PMC8394584 DOI: 10.3390/children8080658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022]
Abstract
Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.
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Affiliation(s)
- Jennifer F. Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
- Correspondence: ; Tel.: +1-410-955-6143
| | - Jennifer N. Fishe
- Department of Emergency Medicine, University of Florida–Jacksonville, Jacksonville, FL 32224, USA;
| | - Kyle A. Fratta
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
- Department of Emergency Medicine, University of Pittsburgh Medical Center-Harrisburg, Harrisburg, PA 15213, USA
| | - Jessica H. Katznelson
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
| | - Matthew J. Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (M.J.L.); (M.G.M.)
| | - Richard Lichenstein
- Division of Pediatric Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Michael G. Milin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (M.J.L.); (M.G.M.)
| | - Joelle N. Simpson
- Department of Emergency Medicine, Children’s National Hospital, Washington, DC 20010, USA;
| | - Theresa A. Walls
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
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12
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Brodsky MB, Akst LM, Jedlanek E, Pandian V, Blackford B, Price C, Cole G, Mendez-Tellez PA, Hillel AT, Best SR, Levy MJ. Laryngeal Injury and Upper Airway Symptoms After Endotracheal Intubation During Surgery: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:1023-1032. [PMID: 33196479 DOI: 10.1213/ane.0000000000005276] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Laryngeal injury from intubation can substantially impact airway, voice, and swallowing, thus necessitating multidisciplinary interventions. The goals of this systematic review were (1) to review the types of laryngeal injuries and their patient-reported symptoms and clinical signs resulting from endotracheal intubation in patients intubated for surgeries and (2) to better understand the overall the frequency at which these injuries occur. We conducted a search of 4 online bibliographic databases (ie, PubMed, Embase, Cumulative Index of Nursing and Allied Health Literature [CINAHL], and The Cochrane Library) and ProQuest and Open Access Thesis Dissertations (OPTD) from database inception to September 2019 without restrictions for language. Studies that completed postextubation laryngeal examinations with visualization in adult patients who were endotracheally intubated for surgeries were included. We excluded (1) retrospective studies, (2) case studies, (3) preexisting laryngeal injury/disease, (4) patients with histories of or surgical interventions that risk injury to the recurrent laryngeal nerve, (5) conference abstracts, and (6) patient populations with nonfocal, neurological impairments that may impact voice and swallowing function, thus making it difficult to identify isolated postextubation laryngeal injury. Independent, double-data extraction, and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and the Cochrane Collaboration's criteria. Twenty-one articles (1 cross-sectional, 3 cohort, 5 case series, 12 randomized controlled trials) representing 21 surgical studies containing 6140 patients met eligibility criteria. The mean patient age across studies reporting age was 49 (95% confidence interval [CI], 45-53) years with a mean intubation duration of 132 (95% CI, 106-159) minutes. Studies reported no injuries in 80% (95% CI, 69-88) of patients. All 21 studies presented on type of injury. Edema was the most frequently reported mild injury, with a prevalence of 9%-84%. Vocal fold hematomas were the most frequently reported moderate injury, with a prevalence of 4% (95% CI, 2-10). Severe injuries that include subluxation of the arytenoids and vocal fold paralysis are rare (<1%) outcomes. The most prevalent patient complaints postextubation were dysphagia (43%), pain (38%), coughing (32%), a sore throat (27%), and hoarseness (27%). Overall, laryngeal injury from short-duration surgical intubation is common and is most often mild. No uniform guidelines for laryngeal assessment postextubation from surgery are available and hoarseness is neither a good indicator of laryngeal injury or dysphagia. Protocolized screening for dysphonia and dysphagia postextubation may lead to improved identification of injury and, therefore, improved patient outcomes and reduced health care utilization.
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Affiliation(s)
- Martin B Brodsky
- From the Department of Physical Medicine and Rehabilitation.,Division of Pulmonary and Critical Care Medicine.,Outcomes After Critical Illness and Surgery (OACIS) Research Group
| | - Lee M Akst
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University - School of Medicine, Baltimore, Maryland
| | - Erin Jedlanek
- Department of Physical Medicine and Rehabilitation, Johns Hopkins Hospital, Baltimore, Maryland
| | - Vinciya Pandian
- Outcomes After Critical Illness and Surgery (OACIS) Research Group.,Department of Nursing Faculty, Johns Hopkins - School of Nursing, Baltimore, Maryland
| | | | | | - Gai Cole
- Department of Emergency Medicine
| | - Pedro A Mendez-Tellez
- Outcomes After Critical Illness and Surgery (OACIS) Research Group.,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University - School of Medicine, Baltimore, Maryland
| | - Alexander T Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University - School of Medicine, Baltimore, Maryland
| | - Simon R Best
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University - School of Medicine, Baltimore, Maryland
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13
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Troncoso RD, Garfinkel EM, Leon D, Lopez SM, Lin A, Jones D, Trautman S, Levy MJ, Margolis AM. Decision Making and Interventions During Interfacility Transport of High-Acuity Patients With Severe Acute Respiratory Syndrome Coronavirus 2 Infection. Air Med J 2021; 40:220-224. [PMID: 34172228 PMCID: PMC8020076 DOI: 10.1016/j.amj.2021.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 03/29/2021] [Accepted: 04/02/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE There are limited data regarding the typical characteristics of coronavirus disease 2019 (COVID-19) patients requiring interfacility transport or the clinical capabilities of the out-of-hospital transport clinicians required to provide safe transport. The objective of this study is to provide epidemiologic data and highlight the clinical skill set and decision making needed to transport critically ill COVID-19 patients. METHODS A retrospective chart review of persons under investigation for COVID-19 transported during the first 6 months of the pandemic by Johns Hopkins Lifeline was performed. Patients who required interfacility transport and tested positive for severe acute respiratory syndrome coronavirus 2 by polymerase chain reaction assay were included in the analysis. RESULTS Sixty-eight patients (25.4%) required vasopressor support, 35 patients (13.1%) were pharmacologically paralyzed, 15 (5.60%) were prone, and 1 (0.75%) received an inhaled pulmonary vasodilator. At least 1 ventilator setting change occurred for 59 patients (22.0%), and ventilation mode was changed for 11 patients (4.10%) during transport. CONCLUSION The safe transport of critically ill patients with COVID-19 requires experience with vasopressors, paralytic medications, inhaled vasodilators, prone positioning, and ventilator management. The frequency of initiated critical interventions and ventilator adjustments underscores the tenuous nature of these patients and highlights the importance of transport clinician reassessment, critical thinking, and decision making.
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Affiliation(s)
- Ruben D Troncoso
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Lifeline Critical Care Transportation Program, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Eric M Garfinkel
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David Leon
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sandra M Lopez
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew Lin
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dennis Jones
- Johns Hopkins Lifeline Critical Care Transportation Program, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shawn Trautman
- Johns Hopkins Lifeline Critical Care Transportation Program, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Lifeline Critical Care Transportation Program, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Asa M Margolis
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; Johns Hopkins Lifeline Critical Care Transportation Program, Johns Hopkins University School of Medicine, Baltimore, MD
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14
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Wend CM, Goolsby C, Schuler K, Fischer ST, Levy MJ. Tourniquet Use in Animal Attacks: An Analysis of News Media Reports. Cureus 2021; 13:e13926. [PMID: 33880274 PMCID: PMC8051424 DOI: 10.7759/cureus.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Background Animal attacks pose a significant public health problem in the United States. Non-venomous animals are the leading cause of mortality in these attacks, and extremity injuries leading to hemorrhage are a common pattern. The Stop the Bleed campaign advocates for public training in bleeding control tactics and public access to bleeding control kits. Controlling life-threatening bleeding, as promoted by the Stop the Bleed campaign, may be a method to reduce preventable death in these attacks. Methodology We searched the Nexus Uni database, which compiles international news media articles, to collect newspaper articles in the United States between 2010 and 2019 that referenced animal attacks on humans in which a tourniquet was applied. We screened articles to assess for inclusion criteria and isolated a single report for each attack. Results A total of 50 individual attacks met the inclusion criteria and were included for data collection. Overall, 92% (n = 46) of the victims survived the attacks, and the average victim age was 33. California was the most common location of the attacks (n = 12, 24%), sharks caused the most attacks (n = 26, 52%), and victims most often sustained isolated extremity injuries (n = 24, 48% for arm and n = 24, 48% for leg). Laypeople applied the most tourniquets (n = 29, 58%), and appliers most frequently used improvised tourniquets (n = 30, 60%). Conclusions While mortality in this series was low, there are hundreds of fatalities from non-venomous animal attacks each year. Equipping and training the at-risk public to stop bleeding may save additional lives. Future Stop the Bleed efforts should improve access to public hemorrhage control equipment and expand educational outreach to people engaged in high-risk activities with animals.
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Affiliation(s)
- Christopher M Wend
- Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Craig Goolsby
- Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA.,National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences, Bethesda, USA
| | - Keke Schuler
- Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, USA.,National Center for Disaster Medicine and Public Health, The Henry M Jackson Foundation for the Advancement of Military Medicine, Bethesda, USA
| | - Steven T Fischer
- Emergency Medical Services, Dix Hills Volunteer Fire Department, Dix Hills, USA
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences, Bethesda, USA
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15
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Goolsby C, Rojas LE, Rodzik RH, Gausche-Hill M, Neal MD, Levy MJ. High-School Students Can Stop the Bleed: A Randomized, Controlled Educational Trial. Acad Pediatr 2021; 21:321-328. [PMID: 32473216 DOI: 10.1016/j.acap.2020.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/15/2020] [Accepted: 05/19/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine high-school students' ability to learn hemorrhage control skills and knowledge via 3 educational modalities. BACKGROUND Trauma is the leading cause of death for young Americans, and there are calls to teach children about hemorrhage control. However, little is known about adolescents' ability to perform hemorrhage control, and the ideal way(s) to teach them. METHODS This randomized controlled trial enrolled high-school students from 39 states at a 2019 national conference. After answering questions about their willingness to use tourniquets, participants received hemorrhage control education in 1 of 3 formats: instructor-led, web-only, or blended (combining web and instructor-led). Participants were then assessed on their ability to apply a tourniquet and to identify wounds that require a tourniquet. Finally, they completed an attitude questionnaire. RESULTS Two hundred and four (82%) of 248 participants applied a tourniquet correctly: 72 (88%) instructor-led, 50 (61%) web-only, and 79 (94%) blended. The instructor-led and blended arms were superior to the web-only arm (P < .001). Nearly all participants passed an assessment requiring them to identify wounds warranting a tourniquet (99% instructor-led and blended, and 98% web-only). All modalities improved participants' self-reported willingness and comfort in using tourniquets (P < .001). CONCLUSIONS This is the first study to demonstrate that high-school students can learn hemorrhage control via multiple methods. Blended and instructor-led education led to highly successful skill performance. Students learned to identify wounds requiring tourniquets and showed an improved willingness to aid from all modalities. These findings should encourage educators to offer multiple educational modalities.
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Affiliation(s)
- Craig Goolsby
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences (C Goolsby), Bethesda, Md; National Center for Disaster Medicine and Public Health (C Goolsby, LE Rojas, and RH Rodzik), Rockville, Md.
| | - Luis E Rojas
- National Center for Disaster Medicine and Public Health (C Goolsby, LE Rojas, and RH Rodzik), Rockville, Md; The Henry M. Jackson Foundation for the Advancement of Military Medicine (LE Rojas and RH Rodzik), Bethesda, Md
| | - Raphaelle H Rodzik
- National Center for Disaster Medicine and Public Health (C Goolsby, LE Rojas, and RH Rodzik), Rockville, Md; The Henry M. Jackson Foundation for the Advancement of Military Medicine (LE Rojas and RH Rodzik), Bethesda, Md
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services Agency (M Gausche-Hill), Los Angeles, Calif; Departments of Emergency Medicine and Pediatrics, David Geffen School of Medicine at the University of California (M Gausche-Hill), Los Angeles, Calif; Departments of Emergency Medicine and Pediatrics, Harbor-UCLA Medical Center (M Gausche-Hill), Torrance, Calif
| | - Matthew D Neal
- Departments of Surgery, Critical Care Medicine, and the Clinical and Translational Science Institute (CTSI), University of Pittsburgh (MD Neal), Pittsburgh, Pa; University of Pittsburgh Medical Center (MD Neal), Pittsburgh, Pa
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine (MJ Levy), Baltimore, Md; Howard County Department of Fire and Rescue Services (MJ Levy), Columbia, Md
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16
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Levy MJ, Klein E, Chizmar TP, Pinet Peralta LM, Alemayehu T, Sidik MM, Delbridge TR. Correlation between Emergency Medical Services Suspected COVID-19 Patients and Daily Hospitalizations. PREHOSP EMERG CARE 2021; 25:785-789. [PMID: 33320720 DOI: 10.1080/10903127.2020.1864074] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: We sought to determine if Emergency Medical Services (EMS) identified Persons Under Investigation (PUI) for COVID-19 are associated with hospitalizations for COVID-19 disease for the purposes of serving as a potential early indicator of hospital surge. Methods: A retrospective analysis was conducted using data from the Maryland statewide EMS electronic medical records and daily COVID-19 hospitalizations from March 13, 2020 through July 31, 2020. All unique EMS patients who were identified as COVID-19 PUIs during the study period were included. Descriptive analysis was performed. The Box-Jenkins approach was used to evaluate the relationship between EMS transports and daily new hospitalizations. Separate Auto Regressive Integrated Moving Average (ARIMA) models were constructed to transform the data into a series of independent, identically distributed random variables. Fit was measured using the Akaike Information Criterion (AIC). The Box-Ljung white noise test was utilized to ensure there was no autocorrelation in the residuals. Results: EMS units in Maryland identified a total of 26,855 COVID-19 PUIs during the 141-day study period. The median patient age was 62 years old, and 19,111 (71.3%) were 50 years and older. 6,886 (25.6%) patients had an abnormal initial pulse oximetry (<92%). A strong degree of correlation was observed between EMS PUI transports and new hospitalizations. The correlation was strongest and significant at a 9-day lag from time of EMS PUI transports to new COVID-19 hospitalizations, with a cross correlation coefficient of 0.26 (p < .01). Conclusions: A strong correlation between EMS PUIs and COVID-19 hospitalizations was noted in this state-wide analysis. These findings demonstrate the potential value of incorporating EMS clinical information into the development of a robust syndromic surveillance system for COVID-19. This correlation has important utility in the development of predictive tools and models that seek to provide indicators of an impending surge on the healthcare system at large.
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17
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Kemp SJ, Levy MJ, Knapp JG, Steiner LA, Tang N. Fresh Whole Blood Transfusion: Perspectives From a Federal Law Enforcement Agency Tactical Program. J Spec Oper Med 2021; 21:108-111. [PMID: 34105133 DOI: 10.55460/ti5x-7go1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/01/2021] [Indexed: 06/12/2023]
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18
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Levy MJ, Pasley J, Remick KN, Eastman AL, Margolis AM, Tang N, Goolsby CA. Removal of the Prehospital Tourniquet in the Emergency Department. J Emerg Med 2020; 60:98-102. [PMID: 33303278 DOI: 10.1016/j.jemermed.2020.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/01/2020] [Accepted: 10/04/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Life-threatening hemorrhage from extremity injuries can be effectively controlled in the prehospital environment through direct pressure, wound packing, and the use of tourniquets. Early tourniquet application has been prioritized for rapid control of severe extremity hemorrhage and is a cornerstone of prehospital trauma resuscitation guidelines. Emergency physicians must be knowledgeable regarding the initial assessment and appropriate management of patients who present with a prehospital tourniquet in place. DISCUSSION An interdisciplinary group of experts including emergency physicians, trauma surgeons, and tactical and Emergency Medical Services physicians collaborated to develop a stepwise approach to the assessment and removal (discontinuation) of an extremity tourniquet in the emergency department after being placed in the prehospital setting. We have developed a best-practices guideline to serve as a resource to aid the emergency physician in how to safely remove a tourniquet. The guideline contains five steps that include: 1) Determine how long the tourniquet has been in place; 2) Evaluate for contraindications to tourniquet removal; 3) Prepare for tourniquet removal; 4) Release the tourniquet; and 5) Monitor and reassess the patient. CONCLUSION These steps outlined will help emergency medicine clinicians appropriately evaluate and manage patients presenting with tourniquets in place. Tourniquet removal should be performed in a systematic manner with plans in place to immediately address complications.
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Affiliation(s)
- Matthew J Levy
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Jason Pasley
- Department of Surgery, School of Medicine, Michigan State University, East Lansing, Michigan
| | - Kyle N Remick
- McLaren Oakland Hospital Pontiac, Michigan Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | | | - Asa M Margolis
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Nelson Tang
- Department of Emergency Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Craig A Goolsby
- McLaren Oakland Hospital Pontiac, Michigan Uniformed Services University of the Health Sciences, Bethesda, Maryland
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19
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Goolsby C, Rojas LE, Andersen M, Charlton N, Tilley L, Pasley J, Rasmussen TE, Levy MJ. Potentially survivable fatal vascular access hemorrhage with tourniquet use: A post-mortem analysis. J Am Coll Emerg Physicians Open 2020; 1:1224-1229. [PMID: 33392527 PMCID: PMC7771778 DOI: 10.1002/emp2.12201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/12/2020] [Accepted: 07/06/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The US military has prioritized battlefield hemorrhage control. Researchers credit tourniquet use, and a novel trauma care training program, with saving 1000-2000 lives in Iraq and Afghanistan. The Stop the Bleed campaign translates these lessons learned to the public. This is the first analysis of the potential impact of this newfound knowledge about tourniquet use for extremity fatal vascular access hemorrhage in a civilian population. Fatal vascular access hemorrhage includes bleeding from arteriovenous fistulas and grafts used for hemodialysis and central venous catheters. METHODS This is a retrospective study of decedent records. We selected Maryland death records from 2002-2017 using the following search terms: "graft," "shunt," "fistula," "dialysis," and "central venous catheter." The records were analyzed for potential survivability with a checklist of military criteria modified for a civilian population. Suicides were excluded. Two reviewers independently classified the deaths as either potentially survivable or non-survivable, and a third reviewer broke ties. RESULTS There were 111 deaths included in the final analysis. Ninety-two of the 111 decedents had potentially survivable extremity fatal vascular access hemorrhage. The remaining 19 records were excluded, because they did not have extremity hemorrhage. Zero decedents had hemorrhage deemed to be non-survivable with prompt tourniquet application. CONCLUSION This study identified 92 Maryland extremity fatal vascular access hemorrhage decedents who potentially could have survived with tourniquet use-an average of 6 per year. These results suggest the need for further epidemiology investigation, as well as exploration of the risks and benefits of teaching and equipping vascular access patients and their caregivers to use tourniquets for life-threatening bleeding.
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Affiliation(s)
- Craig Goolsby
- Department of Military & Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
- National Center for Disaster Medicine & Public HealthBethesdaMarylandUSA
| | - Luis E. Rojas
- National Center for Disaster Medicine & Public HealthBethesdaMarylandUSA
- Henry M. Jackson Foundation for the Advancement of Military MedicineBethesdaMarylandUSA
| | | | - Nathan Charlton
- Department of Emergency MedicineUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Laura Tilley
- Department of Military & Emergency MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Jason Pasley
- Department of SurgeryMcLaren Oakland HospitalPontiacMichiganUSA
| | - Todd E. Rasmussen
- F. Edward Hebert School of MedicineUniformed Services University of the Health SciencesBethesdaMarylandUSA
| | - Matthew J. Levy
- Department of Emergency MedicineJohns Hopkins UniversityBaltimoreMarylandUSA
- Medical Director, Howard County Department of Fire and Rescue ServicesColumbiaMarylandUSA
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20
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Ogle ME, Doron G, Levy MJ, Temenoff JS. Hydrogel Culture Surface Stiffness Modulates Mesenchymal Stromal Cell Secretome and Alters Senescence. Tissue Eng Part A 2020; 26:1259-1271. [DOI: 10.1089/ten.tea.2020.0030] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Molly E. Ogle
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Gilad Doron
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Matthew J. Levy
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
| | - Johnna S. Temenoff
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia, USA
- Parker H. Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, Georgia, USA
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21
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Abstract
INTRODUCTION The opioid crisis continues to claim lives at historically unprecedented levels and shows few signs of abating. One means of mitigating the harm from opioid abuse and unintentional overdose is training and equipping police officers to administer intranasal (IN) naloxone as part of a broader public health response. While an increasing number of state and local agencies have implemented law enforcement officer (LEO) naloxone training programs, due to the novelty of these programs, the evidence of program efficacy is limited. This study describes the implementation and evaluation of a LEO training program in opioid overdose recognition, management, and administration of IN naloxone. METHODS This evaluation consisted of a secondary analysis of de-identified administrative quality assurance data. Police officers in Howard County, Maryland (n=281) underwent an IN naloxone training program between June and July 2015. The training program entailed a 30-minute online component, a 45-minute in-service session, and a 15-question post-test (n=228). The success of the training program was evaluated via an opioid overdose knowledge survey administered at 30 days (n=207) and 6 months (n=182) after training. RESULTS The 30-day and 6-month scores for all knowledge outcomes indicated that officers retained the contents of the training program well over time. After six months, 100% of respondents correctly identified the physiological effects of naloxone administration, and 95.6% correctly identified the opioid-containing drugs that may result in overdose. At the six-month mark, 74.59% correctly identified the initial signs of opioid overdose, and 60.99% correctly identified the time required for IN to begin working. CONCLUSION LEOs exhibit the ability to retain the contents of IN training over 30-day and 6-month periods and express confidence in their ability to assist suspected opioid overdose victims. Further research is necessary to determine the degree to which further knowledge decay might occur, the sustained ability to implement this knowledge under real-world conditions, and the subsequent effects on overdose victim survival.
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Affiliation(s)
- Jennifer M Nath
- Emergency Medicine, Upstate University Hospital, Syracuse, USA
| | - Becca Scharf
- Office of the Medical Director, Howard County Department of Fire and Rescue Services, Marriottsville, USA.,Emergency Health Services, University of Maryland, Baltimore County, Baltimore, USA
| | - Andrew Stolbach
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Nelson Tang
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA
| | - J Lee Jenkins
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Emergency Health Services, University of Maryland, Baltimore County, Baltimore, USA
| | - Asa Margolis
- Emergency Medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Matthew J Levy
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Office of the Medical Director, Howard County Department of Fire and Rescue Services, Mariottsville, USA
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22
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Fratta KA, Levy MJ, Brothers JM, Baer GD, Scharf B. Occupational Injury Claims Related to Patient Lifting and Moving in a Safety-Oriented Emergency Medical Services Agency. Cureus 2020; 12:e10404. [PMID: 33062522 PMCID: PMC7550220 DOI: 10.7759/cureus.10404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Patient lifting injuries remain a significant hazard to Emergency Medical Services (EMS) providers despite preventative and mitigative strategies. OBJECTIVE To better characterize the nature of occupational injury involving patient and stretcher handling. METHODS A retrospective review of existing de-identified claims data was performed for the study period of January 1, 1999, through December 31, 2017. Independent reviewers analyzed each claim to determine if the claim was related to lifting or moving a patient. Any discrepancies between the two reviewers were analyzed by a third reviewer. RESULTS Eighty-two claims were identified as resulting from lifting or maneuvering patients. Fifty-two of these injuries (63.4%) resulted in at least one lost workday (LWD). Strains and sprains accounted for the majority of injuries with 63.4% (n=52) and 18.3% (n=15) respectively. Forty-two (51.2%) of these reports occurred when the provider was moving a patient, not involving a stretcher, while 37.8% (n=31) occurred due to lifting or maneuvering a stretcher with or without a patient. Conclusion: While the overall incidence of lifting injuries was less than reported in other occupational health data series, these injuries continue to occur, and cause significant operational and fiscal impact for EMS systems. This occurrence is despite advances in engineering controls and the organizational embracement of a culture of safety that focuses on risk identification and mitigation. Understanding the types of lifting/moving injuries, circumstances surrounding the injury, and contributing factors will help to maintain a heightened awareness of potential injuries associated with EMS work, and opportunities to reduce them.
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Affiliation(s)
- Kyle A Fratta
- Emergency Medicine, Campbell University, Lillington, USA
| | - Matthew J Levy
- Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, USA.,Office of the Medical Director, Howard County Department of Fire and Rescue Services, Marriottsville, USA
| | - James M Brothers
- Emergency Medical Services, Howard County Department of Fire and Rescue Services, Ellicott City, USA
| | - Gamaliel D Baer
- Emergency Medical Services, Howard County Department of Fire and Rescue Services, Ellicott City, USA
| | - Becca Scharf
- Emergency Medical Services, Howard County Department of Fire and Rescue Services, Marriottsville, USA
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23
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Abstract
BACKGROUND Increasing naloxone access has been identified as a primary strategy to reduce opioid overdose deaths. To supplement community naloxone training and distribution access points, EMS systems have instituted public safety-based naloxone leave behind (NLB) programs that allow emergency medical responders to distribute "leave behind" naloxone kits on the scene of an overdose. This model presents an opportunity to expand naloxone access for individuals at high risk for future overdoses. Objectives: To evaluate the preliminary outcomes of a novel EMS-based NLB program in Howard County, Maryland. Methods: This exploratory study involved analysis of data from the Howard County NLB Program. Basic statistical analysis of program performance metrics and participant demographic characteristics were performed. Results: From June 2018 to June 2019, Howard County Department of Fire and Rescue Services responded to 239 overdose calls and distributed 120 naloxone kits to individuals on the scene of an overdose, a 50.21% distribution rate. The HCNLB program connected 143 patients (59.83%) to peer recovery specialists. Among the 143 patients linked to peer recovery support specialist services, 87 (60.84%) had accepted an NLB kit from EMS. The fully adjusted logistic regression model revealed that those whose kit was left with a family member on the scene were 5.16 times more likely to be connected to peer support specialists (OR = 5.16, CI= 2.35 - 11.29, p = 0.000) while those whose kit was left with a friend or given directly to the patient were 3.69 times (OR = 3.69, CI= 1.13 - 12.06, p < 0.05) and 2.37 times (OR = 2.37, CI= 1.10 - 5.14, p < 0.05) more likely, respectively, to be connected to follow up services as compared to those who did not accept a kit, controlling for other variables in the model. Conclusion: This study highlights the importance of engaging an individual's family and social network when offering connections to treatment and recovery resources. NLB initiatives can potentially augment existing community-based naloxone training structures, thus widening the scope of the life-saving drug and reaching those most at risk of dying from an opioid overdose.
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Affiliation(s)
- Becca M Scharf
- Howard County Department of Fire and Rescue Services, Marriottsville, Maryland (BMS, DJS, JMB, AMM, MJL).,Department of Public Policy, University of Maryland, Baltimore County, Baltimore, Maryland (BMS)
| | - David J Sabat
- Howard County Department of Fire and Rescue Services, Marriottsville, Maryland (BMS, DJS, JMB, AMM, MJL)
| | - James M Brothers
- Howard County Department of Fire and Rescue Services, Marriottsville, Maryland (BMS, DJS, JMB, AMM, MJL)
| | | | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, Maryland (AMM, MJL)
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24
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Goodwin T, Moore KN, Pasley JD, Troncoso R, Levy MJ, Goolsby C. From the battlefield to main street: Tourniquet acceptance, use, and translation from the military to civilian settings. J Trauma Acute Care Surg 2019; 87:S35-S39. [PMID: 31246904 DOI: 10.1097/ta.0000000000002198] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Throughout history, battlefield medicine has led to advancements in civilian trauma care. In the most recent conflicts of Operation Enduring Freedom in Afghanistan/Operation Iraqi Freedom, one of the most important advances is increasing use of point-of-injury hemorrhage control with tourniquets. Tourniquets are gradually gaining acceptance in the civilian medical world-in both the prehospital setting and trauma centers. An analysis of Emergency Medical Services (EMS) data shows an increase of prehospital tourniquet utilization from 0 to nearly 4,000 between 2008 and 2016. Additionally, bystander educational campaigns such as the Stop the Bleed program is expanding, now with over 125,000 trained on tourniquet placement. Because the medical community and the population at large has broader acceptance and training on the use of tourniquets, there is greater potential for saving lives from preventable hemorrhagic deaths.
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Affiliation(s)
- Tress Goodwin
- From the Department of Military and Emergency Medicine, Uniformed Services (T.G., K.N.M., C.G.), University of the Health Sciences, Bethesda, MD; Department of Emergency Medicine (T.G.), Children's National Health System and George Washington University, Washington, DC; Department of Surgery (J.D.P.), Cedars Sinai Medical Center, Los Angeles, CA; Johns Hopkins Department of Emergency Medicine (R.T.Jr., M.J.L.), Baltimore, MD; Department of Fire and Rescue (M.J.L.), Howard County. MD; and National Center for Disaster Medicine & Public Health (C.G.), Rockville, MD
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25
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Fratta KA, Bouland AJ, Lawner BJ, Comer AC, Halliday MH, Levy MJ, Seaman KG. Barriers to bystander CPR: Evaluating socio-economic and cultural factors influencing students attending community CPR training. Am J Emerg Med 2019; 37:159-161. [DOI: 10.1016/j.ajem.2018.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 05/10/2018] [Accepted: 05/13/2018] [Indexed: 11/27/2022] Open
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26
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Goolsby C, Strauss-Riggs K, Rozenfeld M, Charlton N, Goralnick E, Peleg K, Levy MJ, Davis T, Hurst N. Equipping Public Spaces to Facilitate Rapid Point-of-Injury Hemorrhage Control After Mass Casualty. Am J Public Health 2018; 109:236-241. [PMID: 30571311 DOI: 10.2105/ajph.2018.304773] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
In response to increasing violent attacks, the Stop the Bleed campaign recommends that everyone have access to both personal and public bleeding-control kits. There are currently no guidelines about how many bleeding victims public sites should be equipped to treat during a mass casualty incident. We conducted a retrospective review of intentional mass casualty incidents, including shootings, stabbings, vehicle attacks, and bombings, to determine the typical number of people who might benefit from immediate hemorrhage control by a bystander before professional medical help arrives. On the basis of our analysis, we recommend that planners at public venues consider equipping their sites with supplies to treat a minimum of 20 bleeding victims during an intentional mass casualty incident.
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Affiliation(s)
- Craig Goolsby
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Kandra Strauss-Riggs
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Michael Rozenfeld
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Nathan Charlton
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Eric Goralnick
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Kobi Peleg
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Matthew J Levy
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Tim Davis
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
| | - Nicole Hurst
- Craig Goolsby and Nicole Hurst are with the Department of Military & Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD. Kandra Strauss-Riggs is with the National Center for Disaster Medicine and Public Health, Rockville, MD. Michael Rozenfeld and Kobi Peleg are with the National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology & Health Policy Research, Tel-Hashomer, Israel. Nathan Charlton is with the Department of Emergency Medicine, University of Virginia, Charlottesville. Eric Goralnick is with the Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA. Matthew J. Levy is with the Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD. Tim Davis is with the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC
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27
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Brodsky MB, Levy MJ, Jedlanek E, Pandian V, Blackford B, Price C, Cole G, Hillel AT, Best SR, Akst LM. Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review. Crit Care Med 2018; 46:2010-2017. [PMID: 30096101 PMCID: PMC7219530 DOI: 10.1097/ccm.0000000000003368] [Citation(s) in RCA: 155] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To systematically review the symptoms and types of laryngeal injuries resulting from endotracheal intubation in mechanically ventilated patients in the ICU. DATA SOURCES PubMed, Embase, CINAHL, and Cochrane Library from database inception to September 2017. STUDY SELECTION Studies of adult patients who were endotracheally intubated with mechanical ventilation in the ICU and completed postextubation laryngeal examinations with either direct or indirect visualization. DATA EXTRACTION Independent, double-data extraction and risk of bias assessment followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Risk of bias assessment followed the Cochrane Collaboration's criteria. DATA SYNTHESIS Nine studies (seven cohorts, two cross-sectional) representing 775 patients met eligibility criteria. The mean (SD; 95% CI) duration of intubation was 8.2 days (6.0 d; 7.7-8.7 d). A high prevalence (83%) of laryngeal injury was found. Many of these were mild injuries, although moderate to severe injuries occurred in 13-31% of patients across studies. The most frequently occurring clinical symptoms reported post extubation were dysphonia (76%), pain (76%), hoarseness (63%), and dysphagia (49%) across studies. CONCLUSIONS Laryngeal injury from intubation is common in the ICU setting. Guidelines for laryngeal assessment and postextubation surveillance do not exist. A systematic approach to more robust investigations could increase knowledge of the association between particular injuries and corresponding functional impairments, improving understanding of both time course and prognosis for resolution of injury. Our findings identify targets for future research and highlight the long-known, but understudied, clinical outcomes from endotracheal intubation with mechanical ventilation in ICU.
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Affiliation(s)
- Martin B. Brodsky
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University
| | | | - Erin Jedlanek
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University
| | - Vinciya Pandian
- Outcomes After Critical Illness and Surgery (OACIS) Research Group, Johns Hopkins University
- Department of Acute and Chronic Care-School of Nursing, Johns Hopkins University
| | | | | | - Gai Cole
- Department of Emergency Medicine, Johns Hopkins University
| | - Alexander T. Hillel
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University
| | - Simon R. Best
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University
| | - Lee M. Akst
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University
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28
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Pasley AM, Parker BM, Levy MJ, Christiani A, Dubose J, Brenner ML, Scalea T, Pasley JD. Stop the Bleed: Does the Training Work One Month Out? Am Surg 2018; 84:1635-1638. [PMID: 30747685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The Stop the Bleed initiative empowers and trains citizens as immediate responders, to recognize and control severe hemorrhage. We sought to determine the retention of short-term knowledge and ability to apply a Combat Application Tourniquet (CAT) in 10 nonmedical personnel. A standard "Stop the Bleed" (Bleeding Control) course was taught including CAT application. Posttraining performance was assessed at 30 days using a standardized mannequin with a traumatic below-knee amputation. Technique, time, pitfalls, and feedback were all recorded. No participant had placed a CAT before the initial class. After the initial class, self-report by a Likert scale survey revealed an increased confidence in tourniquet application from 2.4 pretraining to 4.7 posttraining. At 30 days, confidence decreased to 3.4 before testing. Six of 10 were successful at tourniquet placement. Completion time was 77.75 seconds (43-157 seconds). Successful participants reported a confidence level of 4.7 versus those unsuccessful at 3.3. The "Stop the Bleed" initiative teaches lifesaving skills to the public through a short training course. This information regarding the training of nonmedical personnel may assist in strengthening training efforts for the public. Further investigations are needed to characterize skill degradation and retention over time.
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29
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Abstract
The Stop the Bleed initiative empowers and trains citizens as immediate responders, to recognize and control severe hemorrhage. We sought to determine the retention of short-term knowledge and ability to apply a Combat Application Tourniquet (CAT) in 10 nonmedical personnel. A standard “Stop the Bleed” (Bleeding Control) course was taught including CAT application. Posttraining performance was assessed at 30 days using a standardized mannequin with a traumatic below-knee amputation. Technique, time, pitfalls, and feedback were all recorded. No participant had placed a CAT before the initial class. After the initial class, self-report by a Likert scale survey revealed an increased confidence in tourniquet application from 2.4 pretraining to 4.7 posttraining. At 30 days, confidence decreased to 3.4 before testing. Six of 10 were successful at tourniquet placement. Completion time was 77.75 seconds (43–157 seconds). Successful participants reported a confidence level of 4.7 versus those unsuccessful at 3.3. The “Stop the Bleed” initiative teaches lifesaving skills to the public through a short training course. This information regarding the training of nonmedical personnel may assist in strengthening training efforts for the public. Further investigations are needed to characterize skill degradation and retention over time.
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Affiliation(s)
| | | | - Matthew J. Levy
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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30
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Goolsby C, Rouse E, Rojas L, Goralnick E, Levy MJ, Kirsch T, Eastman AL, Kellermann A, Strauss-Riggs K, Hurst N. Post-Mortem Evaluation of Potentially Survivable Hemorrhagic Death in a Civilian Population. J Am Coll Surg 2018; 227:502-506. [PMID: 30201524 DOI: 10.1016/j.jamcollsurg.2018.08.692] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 08/15/2018] [Accepted: 08/20/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Although the survivability of military extremity hemorrhage is well documented, equivalent civilian data are limited. We analyzed statewide autopsy records in Maryland to determine the number of hemorrhagic deaths that might have been potentially survivable with prompt hemorrhage control. Similar analyses of battlefield deaths led to life-saving changes in military medical practice. STUDY DESIGN This is a retrospective study of decedent records. The objective is to estimate the number of hemorrhagic deaths that might have been prevented by prompt placement of an extremity tourniquet. Maryland autopsy records from 2002 to 2016 were selected using the following search terms: amputation, arm/arms, avulsion, exsanguination, extremity/extremities, leg/legs. The records were analyzed by applying a checklist of previously developed military criteria to characterize deaths as potentially survivable or nonsurvivable with prompt use of a tourniquet. Suicides and decedents less than 18 years old were excluded. The study did not use information about living participants. Two expert reviewers independently evaluated and scored the death records. Deaths were classified as either potentially survivable or nonsurvivable. A third reviewer broke any ties. RESULTS There were 288 full autopsy records included in the final analysis. Of the eligible decedents reviewed during the 14-year period, 124 of 288 had potentially survivable wounds; 164 had nonsurvivable wounds. CONCLUSIONS Over the 14-year study interval, 124 Maryland decedents-an average of 9 per year-might have been saved with prompt placement of a tourniquet. If extrapolated, approximately 480 people in the US might be saved per year. These results provide evidence to support educating and equipping the public to provide bleeding control.
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Affiliation(s)
- Craig Goolsby
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD; National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences, Bethesda, MD.
| | - Elizabeth Rouse
- Department of Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Luis Rojas
- National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Eric Goralnick
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD; Howard County Department of Fire and Rescue Services, Columbia, MD
| | - Thomas Kirsch
- National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Alexander L Eastman
- Rees-Jones Trauma Center, Parkland Hospital, Dallas, TX; Division of Burns, Trauma and Critical Care, The University of Texas Southwestern Medical Center, Dallas, TX
| | - Arthur Kellermann
- School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Kandra Strauss-Riggs
- National Center for Disaster Medicine and Public Health, Uniformed Services University of the Health Sciences, Bethesda, MD
| | - Nicole Hurst
- Department of Military and Emergency Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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Galvagno SM, Massey M, Bouzat P, Vesselinov R, Levy MJ, Millin MG, Stein DM, Scalea TM, Hirshon JM. Correlation Between the Revised Trauma Score and Injury Severity Score: Implications for Prehospital Trauma Triage. PREHOSP EMERG CARE 2018; 23:263-270. [PMID: 30118369 DOI: 10.1080/10903127.2018.1489019] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Prehospital triage of the seriously injured patient is fraught with challenges, and trauma scoring systems in current triage guidelines warrant further investigation. The primary objective of this study was to assess the correlation of the physiologically based Revised Trauma Score (RTS) and MGAP score (mechanism of injury, Glasgow Coma Scale, age, blood pressure) with the anatomically based Injury Severity Score (ISS). The secondary objectives for this study were to compare the accuracy of the MGAP score and the RTS for the prediction of in-hospital mortality for trauma patients. METHODS This study was a retrospective cohort including 10 years of patient data in a large single-center trauma registry at a primary adult resource center (Level I) for trauma patients. Participants included adults (age ≥18 years). The primary outcome measure was injury severity (measured by ISS) and a secondary analysis compared the RTS and MGAP for the prediction of patient mortality. Descriptive statistics were used to describe the cohort and correlation methods were employed. Each score's accuracy for the prediction of mortality was calculated using the area under receiver operating characteristic (AUROC) curves. RESULTS In total, 43,082 trauma patient records were reviewed; 32,798 patients had complete RTS data available and 32,371 patients had complete data available for MGAP analyses. The correlation between scene RTS and ISS was poor (-.29), as was the correlation between MGAP and ISS (-.28). For the prediction of mortality, admission MGAP demonstrated the highest sensitivity and specificity for mortality (AUROC 0.96; 95% CI, 0.95-0.96). CONCLUSIONS While elements of the RTS remain the first criterion recommended to quantify the totality of physiological injury severity, the composite RTS score derived from this system correlates poorly with actual anatomical injury severity. The MGAP scoring system demonstrated higher sensitivity and specificity for mortality but was not superior to the RTS for predicting anatomical injury severity. In the future development of national and international field triage guidelines for trauma patients, the findings from this study may be considered in order to improve the accuracy of prehospital triage. The findings in this analysis complement a growing body of evidence that suggests that MGAP may be a superior and more easily calculable prehospital scoring system for the prediction of mortality in trauma patients.
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32
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Baldeweg SE, Ball S, Brooke A, Gleeson HK, Levy MJ, Prentice M, Wass J. SOCIETY FOR ENDOCRINOLOGY CLINICAL GUIDANCE: Inpatient management of cranial diabetes insipidus. Endocr Connect 2018; 7:G8-G11. [PMID: 29930026 PMCID: PMC6013691 DOI: 10.1530/ec-18-0154] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 05/08/2018] [Indexed: 11/10/2022]
Abstract
Cranial diabetes insipidus (CDI) is a treatable chronic condition that can potentially develop into a life-threatening medical emergency. CDI is due to the relative or absolute lack of the posterior pituitary hormone vasopressin (AVP), also known as anti-diuretic hormone. AVP deficiency results in uncontrolled diuresis. Complete deficiency can lead to polyuria exceeding 10 L/24 h. Given a functioning thirst mechanism and free access to water, patients with CDI can normally maintain adequate fluid balance through increased drinking. Desmopressin (DDAVP, a synthetic AVP analogue) reduces uncontrolled water excretion in CDI and is commonly used in treatment. Critically, loss of thirst perception (through primary pathology or reduced consciousness) or limited access to water (through non-availability, disability or inter-current illness) in a patient with CDI can lead to life-threatening dehydration. This position can be further exacerbated through the omission of DDAVP. Recent data have highlighted serious adverse events (including deaths) in patients with CDI. These adverse outcomes and deaths have occurred through a combination of lack of knowledge and treatment failures by health professionals. Here, with our guideline, we recommend treatment pathways for patients with known CDI admitted to hospital. Following these guidelines is essential for the safe management of patients with CDI.
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Affiliation(s)
- S E Baldeweg
- Department of Diabetes and EndocrinologyUniversity College London NHS Foundation Trust and Univeristy College London, London, UK
| | - S Ball
- Department of Medicine and EndocrinologyManchester University Foundation Trust & Manchester Academic Health Science Centre Manchester, Manchester, UK
| | - A Brooke
- Royal Devon and Exeter NHS Foundation TrustExeter, UK
| | - H K Gleeson
- Department of EndocrinologyQueen Elizabeth Hospital, Birmingham, UK
| | - M J Levy
- University of Leicester and University of Leicester Hospitals TrustLeicester, UK
| | - M Prentice
- Croydon Health Services NHS TrustCroydon, UK
| | - J Wass
- Department of EndocrinologyOxford Centre for Diabetes, Endocrinology & Metabolism, Oxford, UK
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Hamade B, Barnett B, Malcolm TR, Levy MJ. Young Woman With Eye Pressure. Ann Emerg Med 2017; 70:e53-e54. [PMID: 29157720 DOI: 10.1016/j.annemergmed.2017.06.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Bachar Hamade
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Trent R Malcolm
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew J Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Affiliation(s)
- Matthew J Levy
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Craig Goolsby
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Bouland AJ, Halliday MH, Comer AC, Levy MJ, Seaman KG, Lawner BJ. Evaluating Barriers to Bystander CPR among Laypersons before and after Compression-only CPR Training. PREHOSP EMERG CARE 2017; 21:662-669. [PMID: 28422540 DOI: 10.1080/10903127.2017.1308605] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Bystander CPR is an essential part of out-of-hospital cardiac arrest (OHCA) survival. EMS and public safety jurisdictions have embraced initiatives to teach compression-only CPR to laypersons in order to increase rates of bystander CPR. We examined barriers to bystander CPR amongst laypersons participating in community compression-only CPR training and the ability of the training to alleviate these barriers. The barriers analyzed include fear of litigation, risk of disease transmission, fear of hurting someone as a result of doing CPR when unnecessary, and fear of hurting someone as a result of doing CPR incorrectly. METHODS Laypersons attending community compression-only CPR training were administered surveys before and after community CPR training. Data were analyzed via standard statistical analyses. RESULTS A total of 238 surveys were collected and analyzed between September 2015 and January 2016. The most common reported motivation for attending CPR training was "to be prepared/just in case" followed by "infant or child at home." Respondents reported that they were significantly more likely to perform CPR on a family member than a stranger in both pre-and post-training responses. Nevertheless, reported self-confidence in and likelihood of doing CPR on both family and strangers increased from pre-training to post-training. There was a statistically significant decrease in reported likelihood of all four barriers to prevent respondents from performing bystander CPR when pre-training responses were compared to post-training responses. Previous CPR training and history of having witnessed a sudden cardiac arrest (SCA) were both associated with decreased barriers to CPR, but previous training had no effect on reported likelihood of or confidence in performing CPR. CONCLUSION The training initiative studied significantly reduced the reported likelihood of all barriers studied to prevent respondents from performing bystander CPR and also increased the reported confidence in doing CPR and likelihood of doing CPR on both strangers and family. However, it did not alleviate the pre-training discrepancy between likelihood of performing CPR on strangers versus family. Previous CPR training or certification had no impact on likelihood of or confidence in performing CPR.
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Tang N, Levy MJ, Margolis AM, Woltman N. Graduate Medical Education in Tactical Medicine and the Impact of ACGME Accreditation of EMS Fellowships. J Spec Oper Med 2017; 17:101-104. [PMID: 28285488 DOI: 10.55460/41bh-e3tt] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/01/2017] [Indexed: 06/06/2023]
Abstract
Physician interest in tactical medicine as an area of professional practice has grown significantly over the past decade. The prevalence of physician involvement in terms of medical oversight and operational support of civilian tactical medicine has experienced tremendous growth during this timeframe. Factors contributing to this trend are multifactorial and include enhanced law enforcement agency understanding of the role of the tactical physician, support for the engagement of qualified medical oversight, increasing numbers of physicians formally trained in tactical medicine, and the ongoing escalation of intentional mass-casualty incidents worldwide. Continued vigilance for the sustenance of adequate and appropriate graduate medical education resources for physicians seeking training in the comprehensive aspects of tactical medicine is essential to ensure continued advancement of the quality of casualty care in the civilian high-threat environment.
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Affiliation(s)
- Matthew J. Levy
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland2Howard County Department of Fire and Rescue Services, Columbia, Maryland
| | - Lenworth M. Jacobs
- Department of Surgery, Hartford Hospital, Hartford, Connecticut4Department of Surgery, University of Connecticut, Farmington
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Millin MG, Comer AC, Nable JV, Johnston PV, Lawner BJ, Woltman N, Levy MJ, Seaman KG, Hirshon JM. Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis. Resuscitation 2016; 108:54-60. [PMID: 27640933 DOI: 10.1016/j.resuscitation.2016.09.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 08/30/2016] [Accepted: 09/05/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The American Heart Association recommends that post-arrest patients with evidence of ST elevation myocardial infarction (STEMI) on electrocardiogram (ECG) be emergently taken to the catheterization lab for percutaneous coronary intervention (PCI). However, recommendations regarding the utility of emergent PCI for patients without ST elevation are less specific. This review examined the literature on the utility of PCI in post-arrest patients without ST elevation compared to patients with STEMI. METHODS A systematic review of the English language literature was performed for all years to March 1, 2015 to examine the hypothesis that a percentage of post-cardiac arrest patients without ST elevation will benefit from emergent PCI as defined by evidence of an acute culprit coronary lesion. RESULTS Out of 1067 articles reviewed, 11 articles were identified that allowed for analysis of data to examine our study hypothesis. These studies show that patients presenting post cardiac arrest with STEMI are thirteen times more likely to be emergently taken to the catheterization lab than patients without STEMI; OR 13.8 (95% CI 4.9-39.0). Most importantly, the cumulative data show that when taken to the catheterization lab as much as 32.2% of patients without ST elevation had an acute culprit lesion requiring intervention, compared to 71.9% of patients with STEMI; OR 0.15 (95% CI 0.06-0.34). CONCLUSION The results of this systematic review demonstrate that nearly one third of patients who have been successfully resuscitated from cardiopulmonary arrest without ST elevation on ECG have an acute lesion that would benefit from emergent percutaneous coronary intervention.
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Affiliation(s)
- Michael G Millin
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Angela C Comer
- National Study Center for the Study of Trauma and EMS Baltimore, MD, United States.
| | - Jose V Nable
- MedStar Georgetown University Hospital, United States.
| | - Peter V Johnston
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Benjamin J Lawner
- University of Maryland School of Medicine Baltimore, MD, United States.
| | - Nathan Woltman
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Matthew J Levy
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Kevin G Seaman
- Maryland Institute for Emergency Medical Services Systems, Baltimore, MD, United States.
| | - Jon Mark Hirshon
- University of Maryland School of Medicine Baltimore, MD, United States.
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Levy MJ, Straight KM, Marino MJ, Alcorta RL. A Threat-based, Statewide EMS Protocol To Address Lifesaving Interventions In Potentially Volatile Environments. J Spec Oper Med 2016; 16:98-102. [PMID: 27045505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 06/05/2023]
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Tang N, Margolis AM, Woltman N, Levy MJ. Force Protection Medical Support at National Special Security Events: Experience From the 2016 Republican and Democratic National Conventions. J Spec Oper Med 2016; 16:72-75. [PMID: 27734447 DOI: 10.55460/pptp-hteb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2016] [Indexed: 06/06/2023]
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Levy MJ. Intentional mass casualty events: Implications for prehospital emergency medical services systems. Bull Am Coll Surg 2015; 100:72-74. [PMID: 26477141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Cole G, Stefanus D, Gardner H, Levy MJ, Klein EY. The impact of interruptions on the duration of nursing interventions: a direct observation study in an academic emergency department. BMJ Qual Saf 2015; 25:457-65. [PMID: 26294689 DOI: 10.1136/bmjqs-2014-003683] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 07/29/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Interruptions to nursing workload may contribute to procedural failures and clinical errors impacting quality/safety of care, but the impact of interruptions on the duration of these activities has not been closely scrutinised. This study analyses the effect of interruptions to care provided by nurses and clinical technicians on the length of clinical procedures and interventions (excluding the length of the interruption). METHODS An observational time study of the effect of interruptions on common nursing interventions in the emergency department (ED) of a large academic medical centre was conducted. This study used direct observations of nurses and clinical technicians while delivering care to patients. RESULTS The average time spent on an uninterrupted intervention was 296.47 s (median:185.15, SD:319.05), while interrupted interventions took 682.02 s (median:589.63, SD:504.59). Controlling for intervention type and other potential confounding factors using multiple linear regression found that interrupted interventions were 121.36 s (95% CI 79.57 to 163.15) longer, a 19 percentage point increase (95% CI 11.31 to 26.89), than an intervention without (excluding the length of the interruption). Family/patient interruptions effected duration the most while staff interruptions affected the intervention time the least. DISCUSSION Our findings are consistent with outcomes of studies in non-healthcare domains, but are contrary to a study of ED physicians, suggesting differential responses to interruptions by physicians and nurses. Future studies on interruptions in healthcare should thus be discipline specific. Though the effect of interruptions on intervention length is only about 2 min, in an ED setting, this can increase patient risks and costs. To better focus efforts to reduce interruptions future research should focus on further separation of interruption type (eg, urgent vs routine or unnecessary).
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Affiliation(s)
- Gai Cole
- Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Dicky Stefanus
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, USA
| | - Heather Gardner
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Matthew J Levy
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eili Y Klein
- Emergency Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Bouland AJ, Risko N, Lawner BJ, Seaman KG, Godar CM, Levy MJ. The Price of a Helping Hand: Modeling the Outcomes and Costs of Bystander CPR. PREHOSP EMERG CARE 2015; 19:524-34. [PMID: 25665010 DOI: 10.3109/10903127.2014.995844] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Early, high-quality, minimally interrupted bystander cardio-pulmonary resuscitation (BCPR) is essential for out-of-hospital cardiac arrest survival. However, rates of bystander intervention remain low in many geographic areas. Community CPR programs have been initiated to combat these low numbers by teaching compression-only CPR to laypersons. This study examined bystander CPR and the cost-effectiveness of a countywide CPR program to improve out-of-hospital cardiac arrest survival. METHODS A 2-year retrospective review of emergency medical services (EMS) run reports for adult nontraumatic cardiac arrests was performed using existing prehospital EMS quality assurance data. The incidence and success of bystander CPR to produce prehospital return of spontaneous circulation and favorable neurologic outcomes at hospital discharge were analyzed. The outcomes were paired with cost data for the jurisdiction's community CPR program to develop a cost-effectiveness model. RESULTS During the 23-month study period, a total of 371 nontraumatic adult out-of-hospital cardiac arrests occurred, with a 33.4% incidence of bystander CPR. Incremental cost-effectiveness analysis for the community CPR program demonstrated a total cost of $22,539 per quality-adjusted life-year (QALY). A significantly increased proportion of those who received BCPR also had an automated external defibrillator (AED) applied. There was no correlation between witnessed arrest and performance of BCPR. A significantly increased proportion of those who received BCPR were found to be in a shockable rhythm when the initial ECG was performed. In the home setting, the chances of receiving BCPR were significantly smaller, whereas in the public setting a nearly equal number of people received and did not receive BCPR. Witnessed arrest, AED application, public location, and shockable rhythm on initial ECG were all significantly associated with positive ROSC and neurologic outcomes. A home arrest was significantly associated with worse neurologic outcome. CONCLUSIONS Cost-effectiveness analysis demonstrates that a community CPR outreach program is a cost-effective means for saving lives when compared to other healthcare-related interventions. Bystander CPR showed a clear trend toward improving the neurologic outcome of survivors. The findings of this study indicate a need for additional research into the economic effects of bystander CPR.
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Levy MJ. Public Access Hemorrhage Control and the Stop the Bleeding Coalition. J Spec Oper Med 2015; 15:126-128. [PMID: 26360367 DOI: 10.55460/ozxy-zkw5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/01/2015] [Indexed: 06/05/2023]
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Levy MJ. Intentional Mass Casualty Events: Implications for Prehospital Emergency Medical Services Systems. J Spec Oper Med 2015; 15:157-159. [PMID: 26630112 DOI: 10.55460/k4bk-wqnr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/01/2015] [Indexed: 06/05/2023]
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Levy MJ, Tang N. Medical support for law enforcement-extended operations incidents. Am J Disaster Med 2014; 9:127-35. [PMID: 25068942 DOI: 10.5055/ajdm.2014.0149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE As the complexity and frequency of law enforcement-extended operations incidents continue to increase, so do the opportunities for adverse health and well-being impacts on the responding officers. These types of clinical encounters have not been well characterized nor have the medical response strategies which have been developed to effectively manage these encounters been well described. The purpose of this article is to provide a descriptive epidemiology of the clinical encounters reported during extended law enforcement operations, as well as to describe a best practices approach for their effective management. DESIGN This study retrospectively examined the clinical encounters of the Maryland State Police (MSP) Tactical Medical Unit (TMU) during law enforcement extended operations incidents lasting 8 or more hours. In addition, a qualitative analysis was performed on clinical data collected by federal law enforcement agencies during their extended operations. RESULTS Forty-four percent of missions (455/1,047) supported by the MSP TMU lasted 8 or more hours. Twenty-six percent of these missions (117/455) resulted in at least one patient encounter. Nineteen percent of patient chief complaints (45/238) were related to heat illness/ dehydration. Fifteen percent of encounters (36/238) were for musculoskeletal injury/pain. Eight percent of patients (19/238) had nonspecific sick call (minor illness) complaints. The next most common occurring complaints were cold-related injuries, headache, sinus congestion, and wound/laceration, each of which accounted for 7 percent of patients (16/238), respectively. Analysis of federal law enforcement agencies' response to such events yielded similar clinical encounters. CONCLUSIONS A wide range of health problems are reported by extended law enforcement operations personnel. Timely and effective treatment of these problems can help ensure that the broader operations mission is not compromised. An appropriate operational strategy for managing health complaints reported during extended operations involves the deployment of a well-trained medical support team using the core concepts of tactical emergency medical support.
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Affiliation(s)
- Matthew J Levy
- Assistant Professor, Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland
| | - Nelson Tang
- Associate Professor, Department of Emergency Medicine, Johns Hopkins University, School of Medicine, Baltimore, Maryland
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Parekh S, Bodicoat DH, Brady E, Webb D, Mani H, Mostafa S, Levy MJ, Khunti K, Davies MJ. Clinical characteristics of people experiencing biochemical hypoglycaemia during an oral glucose tolerance test: cross-sectional analyses from a UK multi-ethnic population. Diabetes Res Clin Pract 2014; 104:427-34. [PMID: 24685116 DOI: 10.1016/j.diabres.2014.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 01/21/2014] [Accepted: 02/19/2014] [Indexed: 01/21/2023]
Abstract
AIMS People who experience biochemical hypoglycaemia during an oral glucose tolerance test (OGTT) may be insulin resistant, but this has not been investigated robustly, therefore we examined this in a population-based multi-ethnic UK study. METHODS Cross-sectional data from 6478 diabetes-free participants (849 with fasting insulin data available) who had an OGTT in the ADDITION-Leicester screening study (2005-2009) were analysed. People with biochemical hypoglycaemia (2-h glucose <3.3mmol/l) were compared with people with normal glucose tolerance (NGT) or impaired glucose regulation (IGR) using regression methods. RESULTS 359 participants (5.5%) had biochemical hypoglycaemia, 1079 (16.7%) IGR and 5040 (77.8%) NGT. Biochemical hypoglycaemia was associated with younger age (P<0.01), white European ethnicity (P<0.001), higher HDL cholesterol (P<0.01), higher insulin sensitivity (P<0.05), and lower body mass index (P<0.001), blood pressure (P<0.01), fasting glucose (P<0.001), HbA1C (P<0.01), and triglycerides (P<0.01) compared with NGT and IGR separately in both unadjusted and adjusted (age, sex, ethnicity, body mass index, smoking status) models. CONCLUSIONS Biochemical hypoglycaemia during an OGTT in the absence of diabetes or IGR was not associated with insulin resistance, but instead appeared to be associated with more favourable glycaemic risk profiles than IGR and NGT. Thus, clinicians may not need to intervene due to biochemical hypoglycaemia on a 2-h OGTT.
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Affiliation(s)
- S Parekh
- University of Leicester, Diabetes Research Centre, UK
| | - D H Bodicoat
- University of Leicester, Diabetes Research Centre, UK; University of Leicester, Leicester Clinical Trials Unit, UK.
| | - E Brady
- University of Leicester, Leicester Clinical Trials Unit, UK; Department of Diabetes Research, University Hospitals of Leicester, NHS Trust, UK
| | - D Webb
- University of Leicester, Diabetes Research Centre, UK; University of Leicester, Leicester Clinical Trials Unit, UK
| | - H Mani
- University of Leicester, Diabetes Research Centre, UK; Department of Diabetes and Endocrinology, University Hospitals of Leicester, NHS Trust, UK
| | - S Mostafa
- University of Leicester, Diabetes Research Centre, UK
| | - M J Levy
- Department of Diabetes Research, University Hospitals of Leicester, NHS Trust, UK
| | - K Khunti
- University of Leicester, Diabetes Research Centre, UK; University of Leicester, Leicester Clinical Trials Unit, UK
| | - M J Davies
- University of Leicester, Diabetes Research Centre, UK; University of Leicester, Leicester Clinical Trials Unit, UK
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Fujii LL, Gomez V, Song LMWK, Levy MJ. Endoscopic ultrasound-assisted endoscopic submucosal dissection of a gastric subepithelial tumor. Endoscopy 2014; 45 Suppl 2 UCTN:E225-6. [PMID: 23945921 DOI: 10.1055/s-0033-1344157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- L L Fujii
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, United States of America
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Gleeson FC, Levy MJ. Retrorectal cystic hamartoma: this cyst has a "tail" to tell. Endoscopy 2014; 45 Suppl 2 UCTN:E191-2. [PMID: 23832502 DOI: 10.1055/s-0033-1344130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- F C Gleeson
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, United States of America.
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50
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Topazian M, Levy MJ, Patel S, Charlton MR, Baron TH. Hepatic artery pseudoaneurysm formation following intraductal biliary radiofrequency ablation. Endoscopy 2014; 45 Suppl 2 UCTN:E161-2. [PMID: 23716112 DOI: 10.1055/s-0032-1326644] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- M Topazian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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