Agents and robots for collaborating and supporting physicians in healthcare scenarios

Monitoring patients through robotics telehealth systems is an interesting scenario where patients' conditions, and their environment, are dynamic and unknown variables. We propose to improve telehealth systems' features to include the ability to serve patients with their needs, operating as human caregivers. The objective is to support the independent living of patients at home without losing the opportunity to monitor their health status. Application scenarios are several, and they spread from simple clinical assisting scenarios to an emergency one. For instance, in the case of a nursing home, the system would support in continuously monitoring the elderly patients. In contrast, in the case of an epidemic diffusion, such as COVID-19 pandemic, the system may help in all the early triage phases, significantly reducing the risk of contagion. However, the system has to let medical assistants perform actions remotely such as changing therapies or interacting with patients that need support. The paper proposes and describes a multi-agent architecture for intelligent medical care. We propose to use the beliefs-desires-intentions agent architecture, part of it is devised to be deployed in a robot. The result is an intelligent system that may allow robots the ability to select the most useful plan for unhandled situations and to communicate the choice to the physician for his validation and permission.

Essential Noninvasive Multimodality Neuromonitoring for the Critically Ill Patient

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

An Exploratory Study of Sectra Table Visualization Improves the Effectiveness of Emergency Bedside Echocardiography Training

OBJECTIVES

Echocardiography is an essential tool in emergency medicine, and its training is the most challenging of all types of bedside ultrasound (US) training. This study investigated the effectiveness of the Sectra Table (Sectra AB, Linköping, Sweden), an anatomy visualization and collaboration tool, in improving the quality of echocardiography training for emergency medicine physicians.

METHODS

We conducted an exploratory prospective observational study from 2015 to 2017 and enrolled 66 trainees who participated in a 2.5-day bedside US course organized by the emergency department (ED) of Peking Union Medical College Hospital. The study participants underwent 2 different training programs: the first group received standard training, and the second group was trained with Sectra Table experiences integrated into the echocardiography training curriculum. After the training sessions, both groups were evaluated for their hands-on echocardiography performance.

RESULTS

The new training program with the Sectra Table significantly increased trainees' self-confidence in performing bedside echocardiography. The Sectra Table trainees had a higher performance rating than the trainees in the traditional program, with a mean total assessment score of 40.5 versus 26.5 for traditional training (P < .01). The improved performance was evident for all subcategories of echocardiography. The higher performance rating of the Sectra Table trainees was also statistically significant after adjusting for confounders, including prior training experiences, baseline confidence in independently performing ED US examinations, the number of ED US examinations performed, years in ED practice, and physician seniority.

CONCLUSIONS

Our analysis suggests that integrating the Sectra Table into echocardiography training may improve the effectiveness of training programs.

Bleeding Control With Limb Tourniquet Use in the Wilderness Setting: Review of Science

The purpose of this review is to summarize tourniquet science for possible translation to wilderness settings. Much combat casualty data has been studied since 2005, and use of tourniquets in the military has changed from a last resort to first aid. The US Government has made use of tourniquets a health policy aimed to improve public access to bleeding control items. International authorities believe that education in first aid should be universal, as all can and should learn first aid. The safety record of tourniquet use is mixed, but users are reliably safe if trained well. Well-designed tourniquets can reliably attain bleeding control, may mitigate risk of shock progression, and may improve survival rates, but conclusive proof of a survival benefit remains unclear in civilian settings. Even a war setting has a bias toward survivorship by sampling mostly survivors in hospitals. Improvised tourniquets are less reliable than well-designed tourniquets but may be better than none. The tourniquet model used most often in 2016 by the US military is the Combat Application Tourniquet (C-A-T), and civilians use an array of various models, including C-A-T. Evidence on tourniquet use to date indicates that most uses are safe and effective in civilian settings. Future directions for study relevant to the wilderness setting include consideration of research priorities, study of the burdens of injury or capability gaps in caregiving for various wilderness settings, determination of the skill needs of outdoor enthusiasts and wilderness caregivers, and survey of wilderness medicine stewards regarding bleeding control.

Junctional Tourniquet Use During Combat Operations in Afghanistan: The Prehospital Trauma Registry Experience

BACKGROUND

Hemorrhage is the leading cause of potentially preventable death on the battlefield. Although the resurgence of limb tourniquets revolutionized hemorrhage control in combat casualties in the recent conflicts, the mortality rate for patients with junctional hemorrhage is still high. Junctional tourniquets (JTQs) offer a mechanism to address the high mortality rate. The success of these devices in the combat setting is unclear given a dearth of existing data.

METHODS

From the Prehospital Trauma Registry (PHTR) and the Department of Defense Trauma Registry, we extracted cases of JTQ use in Afghanistan.

RESULTS

We identified 13 uses of a JTQ. We excluded one case in which an improvised pelvic binder was used. Of the remaining 12 cases of JTQ use, seven had documented success of hemorrhage control, three failed to control hemorrhage, and two were missing documentation regarding success or failure.

CONCLUSION

We report 12 cases of prehospital use of JTQ in Afghanistan. The findings from this case series suggest these devices may have some utility in achieving hemorrhage control strictly at junctional sites (e.g., inguinal creases). However, they also highlight device limitations. This analysis demonstrates the need for continued improvements in technologies for junctional hemorrhage control, prehospital documentation, data fidelity and collection, as well as training and sustainment of the training for utilization of prehospital hemorrhage control techniques.

Comparison of the accuracy of hemoglobin point of care testing using HemoCue and GEM Premier 3000 with automated hematology analyzer in emergency room

The laboratory analysis provides accurate, but time consuming hemoglobin level estimation especially in the emergency setting. The reliability of time-sparing point of care devices (POCT) remains uncertain. We tested two POCT devices accuracy (HemoCue^®201⁺ and Gem^®Premier™3000) in routine emergency department workflow. Blood samples taken from patients admitted to the emergency department were analyzed for hemoglobin concentration using a laboratory reference Beckman Coulter LH 750 (HB_LAB), the HemoCue (HB_HC) and the Gem Premier 3000 (HB_GEM). Pairwise comparison for each device and Hb_LAB was performed using correlation and the Bland-Altman methods. The reliability of transfusion decision was assessed using three-zone error grid. A total of 292 measurements were performed in 99 patients. Mean hemoglobin level were 115 ± 33, 110 ± 28 and 111 ± 30 g/l for Hb_HC, Hb_GEM and Hb_LAB respectively. A significant correlation was observed for both devices: Hb_HC versus Hb_LAB (r² = 0.93, p < 0.001) and HB_GEM versus HB_LAB (r² = 0.86, p < 0.001). The Bland-Altman method revealed bias of -3.7 g/l (limits of agreement -20.9 to 13.5) for HB_HC and HB_LAB and 2.5 g/l (-18.6 to 23.5) for HB_GEM and HB_LAB, which significantly differed between POCT devices (p < 0.001). Using the error grid methodology: 94 or 91 % of values (Hb_HC and Hb_GEM) fell in the zone of acceptable difference (A), whereas 0 and 1 % (Hb_HC and Hb_GEM) were unacceptable (zone C). The absolute accuracy of tested POCT devices was low though reaching a high level of correlation with laboratory measurement. The results of the Morey´s error grid were unfavorable for both POCT devices.

Point-of-care ultrasonography by pediatric emergency physicians. Policy statement

Point-of-care ultrasonography is increasingly being used to facilitate accurate and timely diagnoses and to guide procedures. It is important for pediatric emergency physicians caring for patients in the emergency department to receive adequate and continued point-of-care ultrasonography training for those indications used in their practice setting. Emergency departments should have credentialing and quality assurance programs. Pediatric emergency medicine fellowships should provide appropriate training to physician trainees. Hospitals should provide privileges to physicians who demonstrate competency in point-of-care ultrasonography. Ongoing research will provide the necessary measures to define the optimal training and competency assessment standards. Requirements for credentialing and hospital privileges will vary and will be specific to individual departments and hospitals. As more physicians are trained and more research is completed, there should be one national standard for credentialing and privileging in point-of-care ultrasonography for pediatric emergency physicians.

Junctional and Inguinal Hemorrhage Simulation: Tourniquet Master Training

Hemorrhages are the leading cause of potentially survivable combat mortalities when patients are unable to reach a treatment facility in time. New tourniquet devices have been developed to combat hemorrhages in the field. However, there is a lack in training systems to properly teach and assess users on tourniquet device application. We have developed an objective feedback system applicable to various full body manikins. We tested the system with expert users and received improvement feedback and verified the system's usefulness in instructing and assessing correct tourniquet device use.

Adaptive and automated ambiance surveillance and event detection for Ambient Assisted Living

In this paper, we discuss an event detection system using a wireless sensor network in the Ambient Assisted Living context. The sensors measure the environment in which the patients live, not vital parameters of the patient him- or herself, which is important in order to respect the privacy and informational self-determination of the patient. The major difficulties of the given setup with sensors in the environment are that the measurements are taken in an irregular fashion (as opposed to regular sampling) and that some of the sensors may be unreliable. To tackle these problems, we propose an event-detection framework that is based on the theory of conditional random fields [1]. We conduct experiments on real-life sensor data collected from a set of eight households. The experiments show that the conditional random field is well suited for ambiance surveillance.

Point-of-care cardiac ultrasound in acute medicine--the quick scan

The optimum management of acute medical patients requires prompt and accurate diagnosis, monitoring and treatment. The clinical history and physical examination remain central to diagnosis, but often need supplementation by laboratory testing or imaging. Echocardiographic assessment of cardiac structure and function provides valuable information that can aid diagnosis and assess clinical progress. It has many advantages as an imaging modality, and recent technological advances have resulted in hand-held, battery-powered ultrasound devices that provide high-quality images. Three broad applications of cardiac ultrasound now exist: conventional echocardiography, focussed echocardiography and the quick-scan. A quick-scan using a hand-held ultrasound device is readily integrated into the bedside clinical assessment, providing information that can be used immediately in diagnostic reasoning; it can also guide pericardiocentesis. Hand-held ultrasound devices can also be used in acute situations, as well as geographically remote areas or special situations (eg disaster zones) where other imaging is not available. However, the diagnostic yield of echocardiography is user dependent, and training is required for its benefits to be realised, adding to the hardware costs. More data are needed on the incremental value of hand-held ultrasonography and a quick-scan over conventional methods of assessment, their impact on clinical outcomes, and cost effectiveness.

Successful removal of strangulating metal penile ring using a dental handpiece

BACKGROUND

Under emergency conditions, the dental handpiece can be a useful tool for removing a strangulating penile ring.

OBJECTIVE

To report the successful use of a dental handpiece (dental drill) to remove a strangulating penile ring in an emergency.

METHOD

A case report of a strangulating metal penile ring in a psychiatric patient who presented at the accident and emergency unit of Delta State University Teaching Hospital.

RESULT

The metal ring was removed using a diamond bur in a dental handpiece.

CONCLUSIONS

In case of emergency, the dental handpiece is a useful tool for removing a strangulating penile ring.

Introducing RFID technology in dynamic and time-critical medical settings: requirements and challenges

We describe the process of introducing RFID technology in the trauma bay of a trauma center to support fast-paced and complex teamwork during resuscitation. We analyzed trauma resuscitation tasks, photographs of medical tools, and videos of simulated resuscitations to gain insight into resuscitation tasks, work practices and procedures. Based on these data, we discuss strategies for placing RFID tags on medical tools and for placing antennas in the environment for optimal tracking and activity recognition. Results from our preliminary RFID deployment in the trauma bay show the feasibility of our approach for tracking tools and for recognizing trauma team activities. We conclude by discussing implications for and challenges to introducing RFID technology in other similar settings characterized by dynamic and collocated collaboration.

Preliminary studies of an 18-crown-6 ether modified magnetic cation exchange polymer in rapid (90)Sr bioassay

A cation exchange polymer resin embedded with magnetic nanoparticles and modified with crown ether was developed for urinalysis to rapidly monitor levels of (90)Sr exposure in humans who have been involved in a nuclear event. Invention of the resin matrix of 2-acrylamido-2-methyl-1-propanesulfonic acid cross-linked with divinylbenzene incorporated a Sr(2+) chelating agent, di-tert-butyl-cyclohexano-18-crown-6 through surface immobilization using a molecular modifier 1-octanol. The performance of these magnetic cation exchange resin particles was investigated by separating (90)Sr in the presence of (90)Y progeny. Masking agents and precipitants were examined to ascertain that sodium hydroxide at pH 7.5 was capable of selectively removing 89 ± 2% (90)Y before subsequent (90)Sr uptake. Preliminary investigations in rapid urinalysis were successful in isolating 83 ± 2% (90)Sr when pH was optimized to 9, with a sample turnover time <2 h, which is promising for radiological emergencies.

[Emergency medical equipment safety and risk management]

This paper analyzes emergency medical devices, and puts forward the types of risk management mode, risk analysis, risk assessment (including the risk score calculation), and risk control points. Emergency medical equipment which has the high risk and is directly related to the patient's life safety, should be taken seriously.

[Design of a medical folding fridge]

This article introduces a design of a medical folding fridge, which consists of three major components, base, folding frame and insulated cover. The base has a cooling system. The frame and cover are expanded during normal use and folded during storage or transportation. The device is compact, durable, transportable and well environmental adaptable. The system design is proved proper and the temperature inside is reliable. It is very suitable for temperature sensitive supplies stored in the medical emergency field.

Medical devices; exception from general requirements for informed consent. Final rule

The Food and Drug Administration (FDA) is issuing a final regulation to confirm, with one change, the interim final rule (IFR) entitled "Medical Devices; Exception From General Requirements for Informed Consent." This final rule confirms the IFR's establishment of a new exception from the general requirements for informed consent to permit the use of investigational in vitro diagnostic devices to identify chemical, biological, radiological, or nuclear agents without informed consent in certain circumstances. FDA has created this exception to help ensure that individuals who may have been exposed to a chemical, biological, radiological, or nuclear agent are able to benefit from the timely use of the most appropriate diagnostic devices, including those that are investigational. This final rule adds a requirement that the investigator submit the required documentation to FDA, in addition to submitting it to the reviewing Institutional Review Board (IRB).

Special operator level clinical ultrasound: an experience in application and training

Over the past few decades, ultrasound has evolved from a radiology and subspecialist-centric instrument, to a common tool for bedside testing in a variety of specialties. The SOF community is now recognizing the relevancy of training medics to employ this technology for multiple clinical indications in the austere operating environment. In the Fall 2008 issue of Journal of Special Operations Medicine two of the authors described the concept of training SOF medics to employ portable ultrasound as a diagnostic aid. After over two years of concerted effort, the authors trained 29 out of 40 medics of a Special Forces battalion. Retrospective analysis of the quality assurance data for ultrasound studies conducted placed the 109 studies into six categories, allowing inference of trends in clinical indication for ultrasound exams as determined by the SOF medic-ultrasonographer. The resulting distribution suggests that indications for fractures and superficial applications are as prevalent as those for focused abdominal sonography in trauma (FAST) and pneumothorax exams. This analysis focuses on Special Operator Level Clinical Ultrasound (SOLCUS), an ultrasound training curriculum specifically for SOF medics, and helps appropriately prioritize its objectives. Despite the success of this experience, there are several issues requiring resolution before being able to integrate ultrasound training and fielding into the SOF medical armamentarium.

[The design of stretcher integrated first-aid system]

OBJECTIVE

To satisfy the requirements of pre-hospital and first aid at scene for critical patient, rapid transportation, and nonstop treatment in hospital, this paper describes a design of a stretcher integrated first-aid system (SIFAS), which can provide seamless link between pre-hospital and in-hospital first aid.

METHODS

With the requirements of integration and informationization, related functional modules of the former invented SIFAS were redesigned with principle of miniaturization. Adhering to the principle of best man-machine performance, systemic structural characteristic was studied. Aiming at achieving the best maneuverability but with lightest weight, the materials and processing technology of the framework were modified and improved.

RESULTS

The SIFAS designed possessed good flexibility, it could be carried on pushed, and it could be attached to many carriers, with shortened time, and continuous first aid could be realized, and waiting time for first aid was greatly reduced.

CONCLUSION

The SIFAS provides a possibility for establishing a emergency green path for pre-hospital and in-hospital first aid, and it improves emergency of the patient and quick response of relevant medical institutions.

Sweet 16. Four more leads can let you evaluate parts of the heart traditional 12-lead EKGs miss

There's a growing demand for early prehospital determination of acute ST-segment elevation myocardial infarctions (STEMIs) for fast and efficient transport of patients to hospitals with cardiac catheterization and angioplasty capabilities. Accordingly, EMS responders must be well attuned to the true capabilities of electrocardiography machines. Currently, STEMIs require accurate EKG interpretation in the field to save precious heart muscle and decrease the risk of morbidity and mortality.

[Life-threatening emergencies at the office: implications for medical education and equipment of the primary care physician]

Every medical practitioner is confronted on a daily basis with emergencies. Among these, life-threatening emergencies can have disastrous consequences in term of morbidity and mortality; 22 cardiac arrests and 10 deaths were reported among the 1,650 Swiss practices during a 5 year period. The occurrence of life-threatening emergencies at the office necessitates, according to the type and place of the practice, the skills of the practitioner and the organization of his practice, the implementation of procedures, equipments (for example room equipped with a defibrillator, respiratory nebulizer, splints, emergency drugs) and specific continuous education programs that should be encouraged and made available to the whole medical corporation.

The Six-Item Screener to detect cognitive impairment in older emergency department patients

BACKGROUND

Cognitive impairment due to delirium or dementia is common in older emergency department (ED) patients. To prevent errors, emergency physicians (EPs) should use brief, sensitive tests to evaluate older patient's mental status. Prior studies have shown that the Six-Item Screener (SIS) meets these criteria.

OBJECTIVES

The goal was to verify the performance of the SIS in a large, multicenter sample of older ED patients.

METHODS

A prospective, cross-sectional study was conducted in three urban academic medical center EDs. English-speaking ED patients > or = 65 years old were enrolled. Patients who received medications that could affect cognition, were too ill, were unable to cooperate, were previously enrolled, or refused to participate were excluded. Patients were administered either the SIS or the Mini-Mental State Examination (MMSE), followed by the other test 30 minutes later. An MMSE of 23 or less was the criterion standard for cognitive impairment; the SIS cutoff was 4 or less for cognitive impairment. Standard operator characteristics of diagnostic tests were calculated with 95% confidence intervals (CIs), and a receiver operating characteristic curve was plotted.

RESULTS

The authors enrolled 352 subjects; 111 were cognitively impaired by MMSE (32%, 95% CI = 27% to 37%). The SIS was 63% sensitive (95% CI = 53% to 72%) and 81% specific (95% CI = 75% to 85%). The area under the receiver operating characteristic curve was 0.77 (95% CI = 0.72 to 0.83).

CONCLUSIONS

The sensitivity of the SIS was lower than in prior studies. The reasons for this lower sensitivity are unclear. Further study is needed to clarify the ideal brief mental status test for ED use.

A comparison between clinicians' assessment and the Manchester Self-Harm Rule: a cohort study

As identifying patients at risk of subsequent suicidal behaviour is a key goal of assessment, a cohort study of presentations to five emergency departments following episodes of self-harm was carried out. We compared the accuracy of the prediction of subsequent self-harm within 6 months between global clinical assessments and the Manchester Self-harm Rule. Sensitivity, specificity, and positive and negative predictive values with 95% confidence intervals (CI) were calculated. Global clinical assessments and the rule had a sensitivity of 85% (CI 83 to 87) versus 94% (CI 92% to 95%), specificity of 38% (CI 37% to 39%) versus 26% (CI 24% to 27%), a positive predictive value of 22% (CI 21% to 23%) versus 21% (CI 19% to 21%) and a negative predictive value of 92% (CI 91% to 93%) versus 96% (CI 94% to 96%). The accuracy of predicting short-term repetition of self-harm by clinicians could be improved by incorporating this simple rule into their assessment.

Tracheal intubation by non-anaesthetist physicians using the Airway Scope

OBJECTIVE

To evaluate the performance of the Airway Scope for tracheal intubation by non-anaesthetist physicians.

METHODS

Under supervision by staff anaesthetists, non-anaesthesia residents performed tracheal intubation using either the Airway Scope (n = 100) or Macintosh laryngoscope (n = 100). The time required for airway instrumentation and the success rate at first attempt were investigated.

RESULTS

The time to secure the airway was shorter with the Airway Scope than with the Macintosh laryngoscope (p<0.001). The success rate at first attempt was higher with the Airway Scope than with the Macintosh laryngoscope (p<0.001).

CONCLUSION

The Airway Scope may reduce the time to secure the airway and the incidence of failed tracheal intubation in novice laryngoscopists.

Midazolam or ketamine for procedural sedation of children in the emergency department

A short cut review was carried out to establish whether ketamine or midazolam is superior at providing safe and effective conscious sedation in children in the emergency department. A total of 203 papers were found using the reported searches, of which four presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are summarised in table 1. It is concluded that midazolam and ketamine have similar efficacy and safety profiles but that ketamine is preferred by parents and physicians.

Ultrasound to detect haemothorax after chest injury

A short cut review was carried out to establish whether ultrasonography is as sensitive and specific as chest x ray or computed tomography (CT) scan in detecting haemothorax after chest trauma. Thirty-nine papers were found using the reported searches, of which six presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are shown in table 3. It is concluded that ultrasonography is more sensitive and as specific as chest x ray at detecting haemothorax in patients with chest trauma.

EmerLoc: Location-based services for emergency medical incidents

BACKGROUND

Recent developments in positioning systems and telecommunications have provided the technology needed for the development of location aware medical applications. We developed a system, named EmerLoc, which is based upon this technology and uses a set of sensors that are attached to the patient's body, a micro-computing unit which is responsible for processing the sensor readings and a central monitoring unit, which coordinates the data flow.

OBJECTIVE

To demonstrate that the proposed system is technically feasible and acceptable for the potential users.

METHOD

Transmission speed is assessed mostly by means of transmission of DICOM compliant images in various operational scenarios. The positioning functionality was established both outdoor using GPS and indoor using the UCLA Nibble system. User acceptability was assessed in a hospital setting by 15 physicians who filled in a questionnaire after having used the system in an experimental setting.

RESULTS

Transmission speeds ranged from 88kB/s for a IEEE 802.11 infrastructure to 2.5kB/s for a GSM/GPRS scenario. Positioning accuracy based on GPS was 5-10m. The physicians rated the technical aspects on average above 3 on a 5-point scale. Only the data presentation was assessed to be not satisfactory (2.81 on a 5-point scale).

CONCLUSION

The reported results prove the feasibility of the proposed architecture and its alignment with widely established practices and standards, while the reaction of potential users who evaluated the system is quite positive.

[The doctor's emergency bag must be simple but efficient: manual]

It is extremely difficult to stipulate guidelines for the creation of a specific bag containing emergency material, designed solely for the general practitioner. The purpose of this article is to give each generalist a practical guide to create an emergency bag that meets up to his or her needs and practice purposes. Many factors have to be taken into account. First of all we review the material that is at our disposal in a regular emergency vehicle. All encountered pathologies are analysed following a rigid ABCD system (Airway, Breathing, Circulation, Disability--Diabetes--other). In respect to this system we will present a summary of different pathological changes. The dosage of medication will be specified when indicated for infants. Next we follow with a summary of all material that needs to be in the bag in function of the generalist's purpose. This constitutes all needed medication, legal document and emergency material. We then propose a checklist that can be used by the general practitioner in function of his or her needs.

Initial test of emergency procedure performance in temporary negative pressure isolation by using simulation technologies

Study objective

The potential of infectious disease spread in diseases such as tuberculosis, infectious disease epidemic such as avian flu and the threat of terrorism with agents capable of airborne transmission have focused attention on the need for increased surge capacity for patient isolation. Total negative pressure isolation using portable bioisolation tents may provide a solution. The study assesses the ability of health care workers to perform emergency procedures in this environment.

Methods

Physician performance in completing predetermined critical actions in 5 emergency care scenarios inside and outside of a bioisolation tent (“setting”) was studied in an advanced medical simulation laboratory. By design, no pretraining of subjects about total negative pressure isolation use occurred. Impact of setting on time to completion of predetermined critical actions was the primary outcome measured. Secondary variables studied included impact of study groups, scenarios, and run order (inside or outside of the tent first). Subjective assessments were obtained through questionnaires.

Results

Four teams of 3 physicians completed 5 emergency patient care scenarios during 2 4-hour sessions. Mean time to completion of critical actions was for tent/no tent 298 seconds/284 seconds (P=.69, one way ANOVA), respectively. Mean time to completion for first versus second performance of a scenario in the crossover design was 338 versus 243 (P=.01). The mean score for self-assessed performance did not differ according to setting.

Conclusion

The ability of physicians naive to the total negative pressure isolation environment to perform emergency medical critical actions was not significantly degraded by a simulated bioisolation tent patient care environment.

The Livingston Paediatric Dose Calculator

The Livingston Paediatric Dose Calculator is presented and its use explained. It may be of benefit in emergency departments that do not regularly see large numbers of children requiring drug treatment.

The value of loupe magnification: an underused tool in emergency medicine

STUDY OBJECTIVES

Loupe magnification is widely used in medicine. Hand surgeons, in particular, use magnification for virtually all cases. The physical examination is more effective with magnification including improved tissue and foreign body identification. It is valuable for meticulous debridement of foreign material. Skin closure is much improved with more clearly identified wound edges. The detail and precision is vastly better allowing more ideal surgical repairs. These principles could improve wound care quality for emergency physicians as well. This article will compare wound visualization with the naked eye and 2.5 magnification loupes to determine the relative value for an emergency physician.

MATERIALS AND METHODS

Using a cadaver model, this article will compare relative visualization using no magnification and 2.5 loupe magnification. Comparative photographs will be used for identification of wound edges and anatomical structures.

RESULTS

The photographs presented demonstrate relative visualization with the naked eye and the 2.5 loupes. These photographs demonstrate the advantage of magnification in wound care and closure. The only significant costs are the loupes which should not be a deterrent for emergency physicians.

DISCUSSION

Loupe magnification is the standard for quality wound care and closure in hand surgery. They are also used in many other fields of medicine, including facial and plastic surgery. Magnification is now common and has proven effective. Emergency physicians, in general, have not readily embraced the use of magnification. Hand wounds and facial laceration repairs in the emergency department (ED) are 2 areas magnification could be particularly helpful. This study clearly demonstrates the relative advantage of magnification for tissue identification, debridement, and skin closure. Magnification is a potentially valuable tool in laceration repair in the ED. It greatly enhances results at minimal costs.

Validation of the Simplified Motor Score for the Prediction of Brain Injury Outcomes After Trauma

STUDY OBJECTIVE

The Glasgow Coma Scale (GCS) score is widely used in the initial evaluation of patients with traumatic brain injury. This 15-point score, however, has been criticized as unnecessarily complex. Recently, a 3-point Simplified Motor Score (defined as obeys commands=2; localizes pain=1; withdrawals to pain or worse=0) was developed from the motor component of the GCS and was found to have a similar test performance for predicting outcomes after traumatic brain injury when compared with the GCS score as the criterion standard. The purpose of this study was to validate the Simplified Motor Score in a large heterogeneous trauma population.

METHODS

This was a secondary analysis of a prospectively maintained trauma registry with consecutive trauma patients who presented to a Level I trauma center from 1995 through 2004. Test performance of the GCS and the Simplified Motor Score relative to 4 clinically relevant traumatic brain injury outcomes (emergency intubation, clinically significant brain injury, neurosurgical intervention, and mortality) was evaluated with areas under the receiver operating characteristic curves (AUCs).

RESULTS

Of 21,170 patients included in the analysis, 18% underwent emergency intubation, 14% had clinically significant brain injuries, 7% underwent neurosurgical intervention, and 5% died. The AUCs for the GCS and its components ranged from 0.76 to 0.92 across the 4 outcome measures. The AUCs for the Simplified Motor Score ranged from 0.71 to 0.89, and the relative differences from the GCS AUCs ranged from 3% to 7%, with a median difference of 5%.

CONCLUSION

In this external validation study, the 3-point Simplified Motor Score demonstrated similar test performance when compared with the 15-point GCS score and its components for the prediction of 4 clinically important traumatic brain injury outcomes.

The use of a cardiac output monitor to guide the initial fluid resuscitation in a patient with burns

A case of initial resuscitation of a patient with severe burns is described. Such patients can have hypotension and reduced organ perfusion for a number of reasons, and can remain in the emergency department for many hours while awaiting transfer to specialist centres. The case provides a comparison between resuscitation using traditional burns formulae and a relatively new and simple-to-use cardiac output (CO) monitor--the Vigileo monitor (Edwards Lifesciences, Irvine, California, USA). The case demonstrates that relying on fluid regimes alone can lead to insufficient resuscitation. We suggest that using technologies such as those mentioned in this article, which have the potential to be used in the emergency department, could improve the initial resuscitation of patients with burns.

Mice in the emergency department: vector for infection or technological aid?

OBJECTIVE

To study the type of bacterial flora present on computer mice in an emergency department.

METHODS

Computer mice in the emergency department of a single institution, were swabbed on three separate occasions over a 12-month period. Swabs were plated out on McConkey agar and blood agar. Isolated organisms were identified by senior laboratory personnel using Gram stain, colony morphology and susceptibility testing.

RESULTS

No methicillin-resistant Staphylococcus aureus was identified on the equipment. Two samples cultured methicillin-sensitive coagulase positive staphylococci. A range of other organisms were identified.

CONCLUSIONS

In contrast to studies in other hospital departments, no methicillin-resistant Staphylococcus aureus was identified on computer mice in the emergency department. These results suggest that mouse operated software is not adding to infection control problems in relation to methicillin-resistant Staphylococcus aureus in this environment.

Duplex ultrasound in the emergency department for the diagnostic management of clinically suspected deep vein thrombosis

OBJECTIVES

To evaluate the accuracy and safety of an emergency duplex ultrasound (EDUS) evaluation performed by emergency physicians in the emergency department.

METHODS

Consecutive adult patients suspected of having their first episode of deep vein thrombosis (DVT) presenting to the emergency department were included in the study. All examinations were performed by emergency physicians trained with a 30-hour ultrasound course. Based on EDUS findings, patients were classified into one of three groups: normal, abnormal, and uncertain. Patients with abnormal and uncertain findings were initially treated as having a DVT. Patients with normal EDUS findings were discharged from the emergency department without anticoagulant therapy. A formal duplex ultrasound evaluation was repeated by a radiologist in all patients within 24-48 hours. Patients with normal findings on duplex ultrasound evaluation were followed up for symptomatic venous thromboembolism for up to one month.

RESULTS

A total of 399 patients were studied. The EDUS findings were normal in 301 (75%), abnormal in 90 (23%), and uncertain in eight (2%). All abnormal test results were confirmed by the formal duplex ultrasound evaluation, and three patients (0.8%) with uncertain findings on EDUS examination were subsequently diagnosed as having a distal DVT (positive predictive value, 95% [95% confidence interval, 92% to 95%]; negative predictive value, 100% [95% confidence interval = 99% to 100%]). No patients with normal findings on EDUS examination died or experienced venous thromboembolism at the one-month follow-up.

CONCLUSIONS

EDUS examination yielded a high negative predictive value and good positive predictive value, allowing rapid discharge and avoiding improper anticoagulant treatment.

Novel applications of ultrasound in pediatric emergency medicine

A new field, termed emergency ultrasound (EUS), has recently been established. The past decade saw rapid development in the field of EUS in adult patients, especially as performed by emergency medicine physicians. Ultrasound imaging offers several advantages over traditional radiographic techniques, many of which are especially relevant to patients in the pediatric emergency department. Recent literature has documented increased use of EUS for pediatric patients. This review will examine basic principles of ultrasound relevant to pediatric emergency medicine physicians. Emphasis will be placed on understanding the instrument and its limitations. In addition, we will review recent developments in this field. It is our goal that the reader will gain an understanding of the strengths and limitations of this instrument and will therefore be in a position to plan their own program in EUS in pediatrics. Furthermore, it is hoped that this review will serve as an impetus for innovative research, to refine and extend the indications of this modality to benefit patients in the pediatric emergency department.

Review on the importance of an emergency kit for physicians in out-of-hospital emergencies

The importance of an emergency kit for private use by emergency physicians was evaluated. Self-reporting questionnaires were used to assess the satisfaction of emergency physicians who were given a specially adjusted emergency kit for 3 years. Of 73 emergency physicians, 52.1% used the kit at least once during a 3-year interval. Physicians who already used the emergency kit responded more frequently to the importance of having private emergency equipment than those who did not. The kit's low weight and assortment of equipment including ventilation equipment were given higher ratings by users. The majority of physicians regarded a maintenance interval of 6-12 months as sufficient for the emergency equipment. In conclusion, the private emergency kit was used by more than half of the study participants at least once during a 3-year study period. Emergency physicians who used the emergency kit gave it higher ratings than did non-users.

The ability of Lithuanian ambulance services to provide first medical aid in trauma cases

OBJECTIVE

To evaluate the ability of country ambulance services to provide first medical aid in trauma cases.

MATERIAL AND METHODS

A survey of chiefs of emergency medicine service was performed in October-November 2005, in which 34 of the 59 institutions (58%) were participating. The questionnaire presented questions concerning physical and human resources, performance values, and system configuration. The study has shown that emergency medicine service operates in radius of 23 km, each team providing service for about 40,000 inhabitants. Taking into consideration distance and average on-scene time values, emergency medicine service is capable to render the first medical aid within so-called "golden hour" in case the accident is reported immediately. The physical resources are not quite complete. Not all the cars are equipped with essential first aid measures. Among more rarely found resources are vacuum pumps, intubation sets, defibrillators, vacuum splints, back immobilization devices, and hammock immobilization devices. There are less mentioned resources than working teams and even more than two times less than emergency cars at all. Two-thirds of the operating emergency medicine services do not provide advanced life support procedures. The evaluation of theoretical/practical ability to provide some important medical procedures used in emergency medical care showed that medical staff quite often fails to perform defibrillation, intubation, and pleural cavity drainage.

CONCLUSIONS

Country ambulance service network configuration according to area under service, number of people served, and response frequency comply with the requirement set. The ambulance vehicles lack complete set up as well as some important supplies. Only rarely the staff is skilled enough to perform such advanced life support procedures as intubation, defibrillation, and pleural drainage.