Tuesday, May 31, 2005

Medical Malpractice Legislation in Illinois

From Modern Physician

"Ilinois OKs malpractice reform, with push from Democrats"

Medical-malpractice reform is close to reality in Illinois, awaiting only the signature of Gov. Rod Blagojevich.

The Illinois Senate, in a 36-22 vote shortly after midnight, approved a reform package that includes a cap on noneconomic damages, online publication of physician disciplinary histories, standards for expert witnesses and legal protection for physician apologies to patients.

Noneconomic damage awards will be capped at $500,000 in cases against physicians and $1 million in cases against hospitals.

The House approved the bill 68-46 on Monday.

Blagojevich, a Democrat, has indicated he will sign it.

Both the Illinois State Medical Society and the Illinois Hospital Association supported the measure.

State Rep. Mark Beaubien Jr., a Republican, said the bill contains provisions that Republicans have supported for years but that have only recently gained the support of Democrats -- especially in southern Illinois counties that have been losing physicians.

Democrats in those counties must be re-elected for the party to maintain its narrow majority in the House.

"This is all about five southern Democratic House members who are under tremendous fire and (state House Speaker Michael Madigan, a Democrat) has to protect them," Beaubien said.

"If Madigan wants a bill to go through, it will go through."

Paramedics Providing Preventive Care

From the Daytona Beach News-Journal:

"Proposal aims to head off avoidable 911 calls, Preventative care program could reduce ER visits"

Under a new proposal, city and county firefighter paramedics could provide preventive care -- like checking in to see whether a forgetful diabetic is taking her medicine and eating her meals. Expensive medical costs could be avoided. Paramedics could get needed patient care training, and their departments might even bring in some cash, county officials said.

"The core is that we've got a whole army of health care providers who are extremely well-trained, talented, young and aggressive," said Dr. John Shedd, the county's medical director. "They've got the time, and they know their municipalities and the citizens who would benefit most from this better than anybody."

Boarding in the ER

Excerpted from an article in the Washington Post, "Holdover in the ER"

The boarder phenomenon arises because there are not enough hospital beds and nursing staff to accommodate all the patients who need to be admitted on an emergency basis. Financial incentives reward hospitals for keeping their beds full, which favors patients scheduled for elective procedures. As a result, few empty beds are available for ER patients. Besides, Medicare pays hospitals more for taking care of a patient who has elective surgery than a patient like Rowe, who has a medical emergency. So there is built-in financial resistance to admitting many patients from the ER.

Yet, boarding is hazardous to health and it increases costs. Last week at the annual meeting of the Society for Academic Emergency Medicine in New York, researchers presented a study of 50,322 patients from 120 hospitals who were admitted to the ICU from the ER over a three-year period. Boarding in the ER for more than six hours led to increased mortality in the ICU and on the medical floor, longer hospital stays and higher than expected costs.

Friday, May 27, 2005

Google Scholar

A great new research tool...

Google Scholar Review from Kidney Notes

There are several ways of searching the medical literature. Previously I used PubMed, the interface from the National Library of Medicine. I've recently switched to Google Scholar, which has these advantages:

Papers are listed not in order of publication, but in order of relevance, which is determined by PageRank, the same system used in regular Google searches.

Next to each publication is a link to other publications that cite it. This allows you to immediately determine whether a paper is influential and who it has influenced.

Scholar also includes searches of publications that don't make it to Medline, like books, small journals, and private collections.

Scholar uses the familiar uncluttered Google interface.

Visits to U.S. Emergency Departments at All-Time High; Number of Departments Shrinking

From the National Center for Health Statistics

Visits to the nation’s emergency departments (EDs) reached a record high of nearly 114 million in 2003, but the number of EDs decreased by 12 percent from 1993 to 2003, according to a new report released today by the Centers for Disease Control and Prevention (CDC).

The report attributes the rise in ED visits to increased use by adults, especially those 65 years old and over. Among people aged 65-74, the ED visit rate was more than five times higher for those residing in a nursing home or other institution compared with those not living in an institutionalized setting.

The report also finds that Medicaid patients were four times (81 visits per 100 people) more likely to seek treatment from an ED than those with private insurance (22 visits per 100 people).

“Emergency departments are a safety net and often the place of first resort for health care for America’s poor and uninsured,” said Linda McCaig of CDC’s National Center for Health Statistics and the report’s lead author. “This annual study of the nation’s emergency departments is part of a series of surveys of health care in the United States and provides current information for the development of policies and programs designed to meet America’s health care needs.”

Other findings in the report include:

From 1993 through 2003, the number of ED visits increased 26 percent from 90.3 million visits in 1993 to 114 million in 2003. The U.S. population rose 12.3 percent during this period, and the 65-and-over population rose 9.6 percent.

The average waiting time to see a physician was 46.5 minutes, the same as it was in 2000. The wait time was unchanged despite increased visits. EDs have implemented a number of efficiencies, including “fast track” units, which may have kept the wait time constant. On average, patients spent 3.2 hours in the ED, which includes time with the physician as well as other clinical services.

Injury, poisoning, and the adverse effects of medical treatment accounted for over 35 percent of ED visits. The leading causes of injuries were falls, being struck by or striking against objects or persons, and motor vehicle traffic incidents, accounting for 41 percent of injury-related visits. Some 1.7 million visits were for adverse effects of medical treatment.

In 2003, patients arrived at the ED by ambulance in 14 percent of the visits, representing over 16 million ambulance transports. More than a third of patients who arrived at the ED by ambulance was 65 years of age and over.

X-rays, CT scans, or other imaging tests were provided in about 43 percent of visits. Medications were provided in over 77 percent of visits, with painkillers being the most frequent prescription, accounting for just over 14 percent of medications reported.

About 58 percent of all EDs were located in metropolitan areas, and they represented 82 percent of the annual usage. Board-certified emergency medicine physicians were available at 64 percent of EDs.

The CDC report describes hospital, patient, and visit characteristics for hospital emergency departments in the United States as well as trends in ED use between 1993 and 2003. The information is based on data from the 2003 National Hospital Ambulatory Medical Care Survey (NHAMCS) Emergency Department Summary, which is a national probability-based sample survey of visits to emergency and outpatient departments of non-Federal, short stay, and general hospitals in the United States conducted by CDC’s National Center for Health Statistics.

Thursday, May 26, 2005

Illinois Medical Malpractice: A Compromise

From the Chicago Tribune

Springfield forges cap on malpractice
SPRINGFIELD -- After months of bitter feuding, medical leaders and key Illinois lawmakers from both political parties agreed Wednesday on a plan to cap pain-and-suffering damages in medical malpractice cases.

The hard-fought compromise paved the way for passage of legislation in the next few days. It reflects concerns by Democrats and Republicans alike that the public increasingly blames costly jury awards and expensive malpractice insurance for skyrocketing medical costs and the loss of specialist physicians.

The proposal would set a limit of $1 million on pain-and-suffering awards, also called non-economic damages, from hospitals and a $500,000 limit from doctors.

Wednesday, May 25, 2005

Iowa Malpractice: A Net Gain of Doctors?

From a Cedar Rapids TV station, a story I believe went out on the AP wire:

"Malpractice costs both attract and drive doctors away"

The cost of medical malpractice insurance appears to cut both ways in Iowa.

Critics say the rising cost of malpractice premiums is driving doctors away from Iowa, but a report by the University of Iowa-based Iowa Physician Information System shows that Iowa has actually gained doctors in recent years.

And for some doctors the reason they come to Iowa is the cost of medical malpractice insurance.

Dr. Jeffrey Piccirillo moved his family and medical practice to the eastern Iowa town of Grinnell where he pays 74-thousand dollars a year in malpractice premiums. He says that's about one-third of what he paid in suburban Chicago.

The tracking system shows that 264 doctors left Iowa in 2004 for a variety of reasons. It also shows that 303 doctors came to Iowa. That's a net gain of 39 for a total of nearly five-thousand.

The cost of malpractice insurance doesn't seem to be tied to the number of lawsuits filed in Iowa.

State records show the number of malpractice lawsuits has dropped since 2002.

Tuesday, May 24, 2005

Sock in the Eye

Boy, the New York Times sure comes in handy...

"Treating a Sock in the Eye"

Q. Does it work to slap a steak on a black eye, as they do in cartoons and after fistfights in old movies?

A. Experts in modern emergency medicine uniformly reject the steak approach to first aid for a bruise in the eye area, though many suggest that if the meat is refrigerated, it probably helps counter the swelling and discoloration. But any benefit will be outweighed by possible bacterial contamination from uncooked meat placed on an abrasion.

Monday, May 23, 2005

AutoPulse Resuscitation System

I was browsing the excellent MedGadget blog and, lurking in the Emergency Medicine section, I found mention of the new Revivant (sold through Zoll) AutoPulse Resuscitation System. A participant in one of my ACLS Provider classes mentioned this device and provided me with a brochure. I thought I'd share news of this innovation with the blog.

Manufactured by California-based Revivant Corp., the device was in development and testing for four years and has been on the market for little more than a year. Dozens of fire departments, ambulance services and hospitals across the country have started using it, according to the company and news reports.

The device, which looks like a big chest belt, generates blood flow across the chest area. A patient is placed onto a platform similar to a backboard, and a belt is strapped across the chest. After the push of a few buttons and simple instruction prompts from a small LCD screen, the machine automatically sizes and adjusts to the patient and begins compression. The belt then alternates between snapping tight and slackening, to induce blood circulation.

Saturday, May 21, 2005

Supraglottic Airways

I've found a rather comprehensive resource for consideration and comparison of supraglottic airways: King LT, Cobra PLA, (both the subject of posts and pictures in this blog)and several styles of the Laryngeal Mask Airway (LMA). The resource is built with Shockwave so you'll need that plug-in (and a broadband connection), but the descriptions, 3-D models, illustrations and resources are worth the hassle.

Road Test the Supraglottic Airway Devices

Another New Airway: Cobra PLA

This airway has been mentioned in my research about the King airway (a previous post) so I thought I'd share what I've found thus far.

CobraPLA™ is an advancement in superlaryngeal airway management.

The CobraPLA is designed (Perilaryngeal Airway) is designed to be positioned in the hypopharynx where it abuts the structure of the laryngeal inlet.

Danger from the Backseat

I was tipped off to this site via the GruntDoc blog:

As reported in the DeRidder Beauregard Daily News (which, in turn, is reporting on an article in Academic Emergency Medicine):

Passengers in the rear seats of vehicles who do not buckle up pose increased risks to themselves and to drivers, according to a recent medical study.

According to a recent issue of the medical journal Academic Emergency Medicine, a driver in a serious, head-on crash is more than twice as likely to be killed if a passenger sitting directly behind him is not wearing a seat belt. A separate 2004 study by the American Medical Association estimates that one in six crash deaths of drivers or front-seat passengers could be prevented if passengers in the back seat were buckled up.

"These studies tell us that back-seat passengers who don't buckle up put themselves and the driver and front-seat passengers at greater risk in the event of a crash," said Col. James E. Champagne, executive director of the Louisiana Highway Safety Commission. "Some people believe they're safe and do not need to buckle up because they are riding in the back seat. While a rear seat can be safer, it is by no means totally safe in a serious crash. Our advice is for every person in a vehicle to buckle up."

Thursday, May 19, 2005

Words of Wisdom from Greg Henry

I was doing some research on other Emergency Medicine Physician blogs and came upon an interesting post at Emerg Med Doc. I copied the relevant portion of the site and shared it with our Chief Medical Officer, Ken Schultheis, and he shared with me news of his respect for Dr. Henry. The post is available in Emerg Med Doc's archives, and is reproduced below.

Words of Wisdom from Greg Henry

For those of you who do not know, Dr. Greg Henry is one of Emergency Medicines preeminent philosophers, and educators. Having heard him speak on many occasions, I would describe his style as in-your-face eloquence. Anyway, I wanted to summarize some points he made in a recent article, because they are not only relevant to medicine but also to life. If we were to live by these philosophic truths, the world would be a better place.

1. Life Goes On - No matter how bad today is, the sun will come up tomorrow. I tell this to my kids when they have had one of those days of complete misbehavior. Tomorrow is a new day, and God let's start all over again.

2. Treat Everyone As a One - As Dr. Henry says this is incredibly simple, but very difficult. Basically, it is that everyone thinks you will treat them like they see you treat others. Therefore, how we behave matters. Perception matters. Using simple common courtesy, admitting you are wrong, your general attitude all matter not only to you but to those around you. Ever have a bad day because all the people around you are in a bad mood or have a bad attitude?

3. Be Slow to Criticize Other Physician's Methods - What may have once been viewed as poor practice may become truth and vice versa. The fact is that most of what we do has little to know evidence to back it up.

4. There Is No Scientific Fact That Can Tell Us How to Live- Basically, there is no science to tell us how to relate to one another.

5. Happiness for a Healthcare Practitioner Also Needs To Be Defined - Happiness should not be a goal but rather a method of travel. We spend too much time wallowing in self-pity and whining in our daily lives and in medicine. If you are miserable being a doctor or a plumber, then do something else. A physician's happiness should come from helping people when they are in their worst in whatever small way possible.

6. Emergency Medicine (or any career) Is Not Your Life - We all say yes too much to our jobs and no to our families. You have to maintain your life connections with those who mean the most to you. These relations do not come easily and require regular maintenance.

7. Success - Is is money, power, fame, status? More likely these are byproducts of success, but are a poor excuse for goals. Sit down with your spouse or family and decide what will give your lives meaning and purpose.

8. Certain Insights Come to You Harder Than Others - When we are young we are tricked into believing that life is mostly about amusement and sex. As we get older, age , have children, watch the ebb and flow of human misery we realize that life is mostly about problems and problem solving. Life is not about avoiding pain, but how we handle and confront those painful situations and resolve them with grace and consistency in belief.

9. Getting To the Point - Basically this is that the direct answer is not always black and white, and sometimes questioning the way we found the answer is most important part of the process.

10. Honor - Is honor dead? I hope not, but it does seem lacking in so many. Giving your word and keeping it. Doing what you said you would do. Never inflicting unnecessary emotional or physical pain. It is an attitude of how you will treat yourself, others and situations.

Drug-Assisted Intubation

The American College of Emergency Medicine (ACEP) website includes notice of several new - and in my opinion, important - Policy Statements. One such statement, on Drug-Assisted Intubation in the Prehospital Setting, is excerpted below.

The American College of Emergency Physicians (ACEP), American College of Surgeons Committee on Trauma (ACS-COT), and the National Association of EMS Physicians (NAEMSP) recognize that expert prehospital airway management by trained, non-physician, EMS providers is of paramount importance in the treatment of critically ill and injured patients. Endotracheal intubation (ETI) may be difficult or impossible, especially if the patient is combative or has intact airway reflexes. The scope of prehospital care may include drug-assisted intubation (DAI) to facilitate ETI.

DAI is an advanced airway procedure that should not be considered mandatory, nor is it appropriate, for many prehospital EMS systems. DAI should be utilized only by EMS systems that, in the judgment of the EMS medical director(s), have a specific need for the procedure and possess adequate resources to develop and maintain a prehospital DAI protocol. It must be understood that DAI is a powerful technique used to facilitate endotracheal intubation, which can be harmful if not performed properly. Every effort must be made to ensure that EMS providers authorized to perform DAI demonstrate ongoing competence in order to maximize patient safety and quality of care. This position statement is not an advocacy statement for or against the use of DAI.

EMS providers performing DAI should possess training, knowledge, and experience in the techniques and in the use of pharmacologic agents used to perform DAI. Confirmation of proper endotracheal tube placement is essential.

Tuesday, May 17, 2005

Medical Humor

From the Des Moines Register

Do you think hospitals generally do a good or bad job of serving their consumers?"

An interesting study, as noted in this press release, indicates some improvement in the public's perception of hospitals.

An excerpt:
Every year at this time, Harris Interactive(R) presents a cross section of U.S. adults a list of differentindustries and asks whether they are generally doing "a good job or a bad job of serving their consumers."

Hospitals now have a net score of 59 points positive (79 percent good job
minus 20 percent bad job), a 10 point improvement since last year and their
best score in all eight years of this series.

Now, the "bad" news:
In this year's survey the industry which gets the most positive and lowest negative replies is the supermarket industry. Fully 92 percent of adults think supermarkets generally do a good job and only eight percent think they do a bad job, giving them a net positive score (i.e. good job minus bad job) of 84 percentage points.

We've a ways to go...

Monday, May 16, 2005

Day in the Life of an ER - Baghdad

I found this TIME article interesting for two reasons.
1. The challenges these professionals face and the resources they have available to care for their patients, and the contrast to our own, privileged, situation.
2. The fact that the reporter is on site when his colleagues are brought into the ER after a car bombing. The transition from dispassionate observer to a person with a personal stake in the survival of his friends is remarkable.

An excerpt:
To chronicle the devastating toll of the war on the daily lives of Iraqis, I spent part of last week in Bayati's ER. In the midst of my reporting, the story turned highly personal: two members of TIME's Baghdad staff became victims of a bomb blast and were rushed to Yarmouk Hospital. From that point on, I was intimately involved in nearly every decision the doctors and staff made as they struggled to keep my badly wounded colleagues alive. In the process, I experienced the anger, anxiety, frustration and sorrow that so many Iraqis must endure, often in far greater measure, on a daily basis. For every story like ours--which turned out better than we could ever have hoped--there are dozens of others at the ER that end in quiet tragedy.

Saturday, May 14, 2005

EMS Week

Welcome to EMS Week (May 15-21, 2005). ACUTE CARE offers our enthusiastic support of the celebration of the contribution of prehospital professionals to our nation's health and welfare.

Here's a link to an excellent press release from our friends at the University of Iowa and to the American College of Emergency Physicians' (ACEP's) EMS Week page, excerpted below.

Emergency Medical Services Week brings together local communities and medical personnel to publicize safety and honor the dedication of those who provide the day-to-day lifesaving services of the medical "front line."

EMS Week is sponsored by the American College of Emergency Physicians. Organizational sponsors include The National Highway Traffic Safety Administration and the Emergency Medical Services for Children program.

Thursday, May 12, 2005

King LT Airway

I'm teaching an ACLS / PALS Instructor class in Mason City and have learned about the King LT Airway, pictured below:

It's new to me and appears to have some advantages over the Combitube and Laryngeal Mask Airway.

Here's a description of the airway:
The King LT™ is a superior, disposable supraglottic airway tool that utilizes the latest technological advances in materials and design to provide the best non-intubating airway possible. The King LT™ emergency airway is a safe, reliable, cost effective and efficient tool to provide emergency ventilation when direct laryngoscopy is not feasible or attainable. With the patented elevated ventilatory inlet, subsequent intubation can be achieved in seconds with the use of an intubation catheter and endotracheal tube. Additionally the KING LT™ is made of a pliable material that can withstand the most extreme environmental conditions. The advantage of the King LT™ is that emergency ventilation can take place within seconds and without the need of a laryngoscope. Endotracheal intubation can be achieved when the time is right.

Want to learn more? Here's a web-based resource.

Wednesday, May 11, 2005

Fake Surveyors, Part 2

This is the way the Indianapolis Star reported the issue I'd posted about the fake JCAHO surveyors:

Intruders try to gain access to hospitals' off-limit areas

In Indianapolis and elsewhere, authorities have reported cases, uncertain of motives.

VALPARAISO, Ind. -- Cases of unauthorized people trying to gain access to restricted areas of hospitals in Indiana and across the country puzzle federal authorities and security officials.

Recently, on the same day an Indianapolis hospital reported suspicious people trying to enter its emergency department, two professionally dressed people carrying clipboards walked into the outpatient campus of Porter hospital in Valparaiso, saying they wanted to tour the facility. The two left when challenged.

Earlier, during a two-week period starting Feb. 26, people claiming to be inspectors from the Joint Commission on Accreditation of Healthcare Organizations tried to enter hospitals in Boston, Los Angeles and Detroit. The three incidents had no apparent relationship beyond the tactics of the intruders.

Indiana Department of Health spokesman Andy Zirkle confirmed that one Indianapolis hospital had reported an incident but would not elaborate. He directed further questions to the U.S. Department of Homeland Security and to the FBI, but neither agency confirmed the incident.

GE Sells Off Its Medical Malpractice Unit

As reported in the Wall Street Journal:
On Friday, GE also announced it has sold its medical-malpractice group for $825 million to National Indemnity, a Berkshire Hathaway Inc. unit. The unit, Medical Protective Corp., provides professional liability coverage to physicians and dentists. GE said it expects the transaction to close in the second quarter and result in an after-tax gain of $75 million.

Tuesday, May 10, 2005

Bogus JACHO Surveyors

As a number of our affiliated hospitals are either preparing for or undergoing their Joint Commission surveys, I found this interesting...

Bogus JCAHO Surveyors Visiting Hospitals

The Joint Commission on Accreditation of Healthcare Organizations warned hospitals to be on the lookout for bogus JCAHO surveyors, following reports earlier this month that individuals posing as surveyors were at three hospitals.

In two instances, one on the East Coast and one on the West Coast, the bogus surveyors arrived around 3 am and asked to survey different areas of the hospitals. In another instance in the Midwest, the phony surveyors arrived around 8 am and claimed they did not need to show JCAHO identification. In all three cases, hospital staff questioned the imposters, who then left.

Hospital staff always should request to see a surveyor’s ID badge and an official letter explaining the visit, according to JCAHO officials.

The organization is urging hospitals that experience a similar situation or have any questions about whether an individual is a surveyor to contact their account representative or JCAHO’s vice president of accreditation field operations, Joe Cappiello, at (630) 792-5757.

Monday, May 09, 2005

Open Source EM Textbook

A post to the EMED-L listserv caught my eye:

I've also been working on a new kind of EM textbook. I'm hoping to find some contributors, so please read on. Anyone who has used the Wikipedia will know the potential for this new format.

The new book is called the Open-Content Textbook of Emergency Medicine (OCTEM). Open-content means that anyone - doctor, nurse, PA, EMT or interested layperson - can write chapters, edit existing chapters, and even re-organize the text. I am writing to you today to invite you to take part: jump right in and write or edit a chapter today.


I've copied the entire post to our website, so you can learn more if you're interested.

Sunday, May 08, 2005

DNR Tattoo

We joke about this all the time, and I found it amusing that someone actually did it..."An emergency medicine specialist has given himself an 80th birthday present with a difference – he's had DO NOT RESUSCITATE tattooed across his chest".

He's prudent to have invested in the extra ink. If he had gotten a "DNR" tattoo, it's possible he could have been mistaken for a Department of Natural Resources loyalist.

Iowa Emergency Medicine Physician on Everest

I found a pretty useful EM news website, Topix.net, and (small world) learned of an Emergency Department physician from Iowa City climbing Mount Everest. I thought I'd share.

Friday, May 06, 2005

Service Excellence / Patient Satisfaction

Of late, patient satisfaction has been a topic where we've been focusing a great deal of resources. We're becoming more familiar with the different surveys and the techniques necessary to interpret the data from those surveys and collaborate with our affiliated hospitals to put in place an effective plan of action. We've also been privileged to be associated with facilities that have been awarded recognition for operational excellence and exemplary customer service in the ED. You can read about three hospitals that are recognized as "Top 100" and three more who've recently achieved the 99th percentile in Emergency Department patient satisfaction in the Press Ganey on our What's New page.

In my research, I found this Service Excellence gateway on the Johns Hopkins site. I was impressed and think you will as well.

Thursday, May 05, 2005

Adult Intraosseous

We've been incorporating information about the use of instraosseous (IO) infusions for patients older than six years of age into our PALS and ACLS teaching and decided to include an article on the subject in our next newsletter.

Here's a preview of the newsletter article, excerpted from material posted on the ACUTE CARE website:

In an acute resuscitation situation, after the airway is secured and adequate breathing and gas exchange are established, the next priority is to obtain vascular access. This is often one of the most challenging aspects of patient care. Traditionally, the rescuers utilize intravenous access in a peripheral vein, but the patient’s physiologic state of shock and/or hypothermia with resulting vascular constriction makes this difficult.

Intraosseous (IO) access techniques have been used for decades and have been proven to be safe, reliable, and rapid means of providing crystalloids, colloids, medications, and blood products into the systemic circulation. The marrow cavity provides access to a noncollapsible venous plexus as blood flows from the medullary venous sinusoids into the central venous sinus and is then drained into the central venous circulation via nutrient and emissary veins.

IO access was initially thought to be less applicable in populations older than 6 years; however, historical and current data, as well as the 2000 American Heart Association Emergency Cardiac Care guidelines, support the consideration of intraosseous techniques in patients of any age as rapid and equally effective alternatives to intravenous peripheral lines. The site of choice in children is the proximal tibia; the distal tibia and proximal femur are alternatives. The proximal tibia provides a flat, wide surface and has only a thin layer of overlying tissue, which allows easy identification of landmarks. Additionally, the proximal tibia is distant from the airway and chest, where cardiopulmonary resuscitation (CPR) is often in progress. With increasing age, the cortical thickness increases, which makes penetration more difficult and forceful; thus, in older children and adults, using the distal tibia may be advantageous because it also provides reliable and evident landmarks, has a relatively thin cortex, and is distant from ongoing CPR.

Wednesday, May 04, 2005

Rural Trauma Team Development Course

Greetings from Mt. Vernon, Illinois! I'm engaged in a client service trip and thought I'd share with the blog that which I shared with some of our associates in Southern Illinois: There's an alternative to Advanced Trauma Life Support (ATLS) specifically designed for the non-urban EM provider: the American College of Surgeons' Rural Trauma Team Development Course.

Here's an excerpt from our RTTDC page:
The Rural Trauma Team Development Course, hereafter known as RTTDC, has been developed by the Rural Trauma Subcommittee of the Committee on Trauma, American College of Surgeons to help rural hospitals with development of their trauma teams. It is hoped that the course will improve the quality of care in their community by developing a timely, organized, rational response to the care of the trauma patient and a team approach that addresses the common problems in the initial assessment and stabilization of the injured.

The basic premise of the course is the assumption that, in most situations, rural hospitals can provide three individuals to form the core of a trauma team consisting of a Team Leader - physician or physician extender, Team Member One - a nurse and Team Member Two - an additional individual who could be a nurse, aide, technician, prehospital provider or clerk. Therefore, the rural hospital should have those individuals such as respiratory, radiology and laboratory technicians, additional nurses, prehospital personnel, etc. who might be involved in supportive roles to the trauma team.

The course is designed to be given either in one day of approximately 8 hours or can be given in four separate modules of 1.5 - 2 hours each or combination of modules. The rural hospital, in conjunction with the presenting instruction team, will decide how the course is to be presented. RTTDC is taught by Surgeons, Emergency Physicians and Nurses who are experienced trauma care providers and trauma course instructors. The American College of Surgeons Committee on Trauma Chairperson for your state, or his/her designee, is responsible for the selection of the RTTDC Instructor teams and the quality management of the courses.

Monday, May 02, 2005

Iowa Rural Outcomes Consortium (Iowa ROCS)

Mike Hartley of the University of Iowa Emergency Medical Services Learning Resource Center shared news of an important research initiative.

The National Institutes of Health is funding a grant to establish the Iowa Resuscitation Network, headed by Richard Kerber, M.D., Professor of Cardiology and Internal Medicine in the University of Iowa Roy J. and Lucille A Carver College of Medicine. Twelve emergency medical services throughout the state will be part of a new statewide resuscitation network, based at the University of Iowa Hospitals and Clinics that will assess the effectiveness of new devices, drugs and strategies to treat serious trauma or out-of-hospital cardiac arrest.

Over the five-year life of this grant, a series of clinical trials will be conducted with the intent to improve patient outcome from cardiac arrest and serious traumatic injury. Iowa is unique compared to the other ROC sites because of its rural population. At the forefront of resuscitation research, the Iowa Resuscitation Network will benefit Iowans by providing participating emergency medical services around the State of Iowa with funding, equipment, and specialized training.

On study under consideration is evaluation of Hypertonic Saline. “This is a proposal for two multicenter trials of hypertonic resuscitation in two populations of trauma patients to be conducted simultaneously using the same intervention and infrastructure. Study 1 seeks to determine the impact of hypertonic resuscitation on survival for blunt or penetrating trauma patients in hypovolemic shock. Study 2 seeks to determine the impact of hypertonic resuscitation on long term (6 month) neurologic outcome for blunt trauma patients with severe traumatic brain injury. Both studies will be three arm, randomized, blinded intervention trials comparing hypertonic saline/ dextran (7.5% saline/6% dextran 70, HSD), hypertonic saline alone (7.5% saline, HS), and normal saline (NS) as the initial resuscitation fluid administered to these patients in the prehospital setting.”

Learn more about Iowa ROCS

Advanced Directives and Code Status

Katie Heldt and I have been working on guidance for Emergency Department Physicians about advanced directives in the ED, particularly their role in discussing the matter with the patient prior to admission. Here's an example of an explanatory memo:

The Emergency Department (ED) registration clerk will inquire (as is mandated by federal law) if the patient has an advanced directive. If the patient doesn’t have an advance directive it will be noted in the chart.

If the patient is to be admitted and the patient is older than 65 years of age, the Emergency Department Physician (EDP) will present a packet of information prepared by (Hospital) that pertains to advanced directives and will offer to discuss the matter

All patients admitted from the ED will use a standard set of orders. These orders will include a checkbox notation for “DNR” (Do Not Resuscitate), “Full Code”, and “CPR Only”. The EDP will guide the patient/family through choosing an option for the admission and indicate that the patient’s Primary Care Practitioner will discuss the matter further when they conduct rounds in the AM.