Cardiopulmonary resuscitation of newborns. Its application to transport medicine

The outcome of sick infants requiring transport to tertiary care centers is critically dependent on the stabilization of these infants at the hospital of delivery and the quality of care during transport. The American Heart Association/American Academy of Pediatrics guidelines for neonatal resuscitation emphasize a structured, step-wise approach to resuscitation. This article highlights the application of these guidelines to resuscitation of newborns during transport and reviews the experience of a large perinatal network in this area.     

Intrahospital transport of neuro ICU patients

Neuroscience intensive care unit (NICU) patients are frequently transported out of the critical care environment for diagnostic and interventional procedures. Four hundred and seventy-one such transports from seventeen clinical centers were studied to identify the characteristics of intrahospital transport. Data collected included the destination and duration of transport, number and type of personnel involved, changes in monitoring and treatment during transport, adverse patient responses and the impact on patients left in the unit. Differences between transports characterized as elective or emergent in nature were noted. Results validate that intrahospital transport of NICU patients is both time and labor intensive. The study also suggests that the optimal process for safe and efficient transport is yet to be designed.     

Unnecessary emergency transport and care of grand mal seizures

Every source quoted in this study has clearly refuted the need for emergency transport and care of an uncomplicated grand mal seizure in a managed epileptic patient. This review of a large patient population has determined that 27% of emergency department seizures were uncomplicated and occurred in patients already under care. This represented 0.25% of all emergency department visits and nearly $200,000 in claims to this managed care entity per year. Taking some statistical liberties, a national health care expenditure of $270,000,000 is suggested for this single abuse. It is hoped that further education of the public, medical community, and epileptic patients will produce a comfort level that permits decisions about emergency transport and care of seizures. These savings could translate into basic health insurance for thousands of our medically deprived citizens.     

Social work with transport disabled persons: a wayfinding perspective in health care

Transport disabled persons confront extensive architectural and psychosocial barriers during their travel to community based health care services by mass transit. The current health care reform movement affords social work an opportunity to consolidate its expertise with this population. The Certificate of Need program is a method with which social work can provide service to people with transportation disabilities. Social work can also continue its use of the Americans with Disabilities Act and the Urban Mass Transportation Act to assist people with transport disabilities to access community based health care services.     

A comparison of the association of helicopter and ground ambulance transport with the outcome of injury in trauma patients transported from the scene

INTRODUCTION: Comprehensive emergency medical services and helicopter aeromedical transport systems have been developed based on the principle that early definitive care improves outcome. The purpose of this study was to compare outcomes between patients transported by helicopter and those transported by ground. METHODS: Data were obtained from the North Carolina Trauma Registry for the period between 1987 and 1993 on all patients transported by helicopter and ground admitted to one of the eight state designated trauma centers. Study patients included only those who were transported directly from the scene of injury to the trauma center (interhospital transfers were excluded). Mortality (outcome) was compared after patient stratification by injury severity and transport time, using Cochran-Mantel-Haenszel statistics and logistic regression-derived probabilities of survival. RESULTS: One thousand three hundred forty-six patients (7.3% of the total) were transported from scene to trauma center by helicopter and 17,144 were transported by ground. In patients transported by helicopter, the mean Trauma Score was lower (12 +/- 3.6) versus 14.3 +/- 3.6 (p < 0.001) and the mean Injury Severity Score was higher (17 +/- 11.1) versus 10.8 +/- 8.4 (p < 0.001). A trend toward increased survival was observed among patients transported by helicopter with a higher Injury Severity Score. Statistical significance was achieved only for patients with a Trauma Score between 5 and 12 and Injury Severity Score between 21 and 30. CONCLUSION: The large majority of trauma patients transported by both helicopter and ground ambulance have low injury severity measures. Outcomes were not uniformly better among patients transported by helicopter. Only a very small subset of patients transported by helicopter appear to have any chance of improved survival based on their helicopter transport. This study suggests that further effort should be expended to try to better identify patients who may benefit from this expensive and risky mode of transport.     

False allegations of satanic abuse: case studies from the witch panic in R?ttvik 1670-71

OBJECTIVE: Nonemergency ambulance transports (NETs) represent a substantial proportion of all ambulance transports. Recently, the medical necessity of a substantial number of NETs has been questioned. The purpose of the study was threefold: 1) to formulate criteria for NET using a multidisciplinary panel; 2) to develop a structured implicit review instrument (SIRI) for the evaluation of NET from the criteria formulated; and 3) to evaluate the reliability and validity of the SIRI. Previously, a validated instrument has not been available to assess NET appropriateness. METHODS: Using a modified Delphi process and scale development techniques, a panel of ten multidisciplinary health care professionals determined criteria for NET and developed a SIRI consisting of two dimensions: 1) ambulation status and 2) medical care requirements. A convenience sample of 50 cases (occurring January through May 1996) were retrospectively reviewed by individual panel members and two panels, and categorized as either: 1) definitely appropriate NET; 2) possibly appropriate NET; 3) patient did not require ambulance transport; 4) patient required emergency transport; and 5) indeterminate. Reliability of the SIRI was assessed using percent agreement among individual panels and weighted kappa for the two panels. Interitem consistency of the SIRI was measured by Cronbach's alpha. Criterion validity was assessed by comparing percent agreements between the SIRI and Medicare reimbursement guidelines. RESULTS: Percent agreement among individual panel members was 62%. Percent agreement among the two panels was 74%, with a kappa of 0.43. Cronbach's alpha for individual panel member item response ranged from 0.647 to 0.960. Percent agreement with Medicare reimbursement guidelines was 92%. CONCLUSION: Consensus criteria and an associated SIRI were developed for determining the appropriateness of NETs. Further research is needed to build on the validity and reliability of this instrument.     

Legislation relevant to perinatal care

The legislative process is one route to follow in the attempt to change and improve perinatal care. Payment by the State Crippled Children's Service for medical care of certain costly high-risk neonatal conditions, only to qualified specialists and in centers meeting acceptable standards has had a snowball effect on upgrading neonatal care in this state. Not only has a large network of neonatal care centers and infant transport systems been developed, but there has been a rush especially on the part of nurses, to get special training in neonatal care. This has included not only the care of the sick neonate, but a look at newborn evaluation and resuscitation in the delivery and newborn areas. It is expected that this same center development and education and training process will now be extended to obstetrical care, as there is renewed interest in special care for high-risk mothers because of Assembly Bill 1326. The new hospital perinatal regulations mandate improvement of care in community hospitals where the majority of deliveries take place. The emphasis is on a larger and better educated staff, more concern with patients rights, and provision of a more humanistic family centered care as well as continual evaluation of maternal and neonatal outcome. The greatest limitation has been lack of Health Department staff to provide adequate consultation and surveillance of these services for compliance with the new laws. There has been an approximate 10 per cent reduction in the number of hospitals with maternity services- from 416 in 1968 to 369 today. While much of this consolidation may have been due to the fall in birth rate, these regulations have also contributed to the process. Most important of all, these laws have kept perinatal care constantly in the consciousness of California health care providers and consumers.     

Regionalization of critical care medicine: task force report of the American College of Critical Care Medicine

OBJECTIVES: To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies. DATA SOURCES: Pertinent literature in the English language. STUDY SELECTION: One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services. DATA EXTRACTION: Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought. DATA SYNTHESIS: Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue. CONCLUSIONS: Regionalization of critical care medicine probably is beneficial and the concept should be explored.     

The case of myoepithelioma of the parotid gland

STUDY OBJECTIVE: To determine whether the environment of a moving ambulance affects the ability of our-of-hospital care providers to auscultate breath sounds. METHODS: Out-of-hospital care providers assessed breath sounds with a previously described breath-sounds model in a quiet environment (control) and in a moving ambulance. The setting was a nonurban emergency medical services system and an interhospital transport agency based at a 600-plus-bed tertiary care center. The participants were physicians, transport nurses, and advanced life support EMS providers routinely involved in the emergency out-of-hospital treatment and transportation of the ill and injured. The accuracy with which participants identified the presence or absence of breath sounds in the two environments was compared with the use of the chi 2 test, with the alpha-value set at .05. RESULTS: The accuracy of breath-sounds assessment in the control environment was 96% (251 of 260); the sensitivity was 96% and the specificity 97%. The accuracy of breath-sounds assessment in the experimental environment was 54% (140 of 260); the sensitivity was .09% and the specificity 98%. Participants were significantly less likely to hear breath sounds in the moving ambulance than in the quiet room (P < .001). CONCLUSION: Assessment of breath sounds is hampered by the environment of a moving ambulance.     

Institutional influences on the primary cesarean section rate in Utah, 1992 to 1995

OBJECTIVES: Our purpose was to evaluate institutional and organizational influences on cesarean section rates in Utah and to adjust such rates for differences in patient acuity. STUDY DESIGN: Data on cesarean section rates were derived from the Utah Hospital Discharge Database and adjusted for patient acuity by correcting raw cesarean rates for those patients undergoing cesarean section meeting regional gestational age transport criteria. RESULTS: When analyzed by means of 1-way analysis of variance, the following factors had a significant negative correlation (P < .05) with cesarean section rate: presence of a newborn intensive care unit and maternal-fetal medicine subspecialists, presence on the medical staff of obstetrician-gynecologist(s) as opposed to family physicians only, delivery volume >1500/y, urban location, and 24-hour in-house anesthesiology. When cesarean rates were corrected for acuity, facilities with maternal-fetal medicine specialists and a newborn intensive care unit had significantly lower rates (P < .001) and more uniform rates than otherwise similar institutions. CONCLUSIONS: More medically sophisticated physicians and institutions have lower cesarean rates when patient acuity is taken into account.     

Safe handling of cytotoxic drugs

Guidelines for the handling of cytotoxic drugs and related waste in health care establishments have recently been developed by the WorkCover Authority of NSW in collaboration with the New South Wales College of Nursing. Competencies for accreditation of staff involved in the reconstitution, storage, transport, administration and management of waste related to cytotoxic drug use have also been developed.     

Extraction of Hoechst 33342 from the cytoplasmic leaflet of the plasma membrane by P-glycoprotein

In this paper, we show that P-glycoprotein contains two distinct sites for drug binding and transport, and that, unexpectedly, these sites interact in a positively cooperative manner. The kinetics of transport of rhodamine 123 and Hoechst 33342 in isolated P-glycoprotein-rich plasma membrane vesicles from Chinese hamster ovary CH(R)B30 cells were followed by continuous fluorescence monitoring. Each substrate stimulated P-glycoprotein-mediated transport of the other. Colchicine and quercetin stimulated rhodamine 123 transport and inhibited Hoechst 33342 transport. In contrast, anthracyclines such as daunorubicin and doxorubicin stimulated Hoechst 33342 transport and inhibited rhodamine 123 transport. Vinblastine, actinomycin D, and etoposide inhibited transport of both dyes. The results are consistent with a functional model of P-glycoprotein containing at least two positively cooperative sites (H site and R site) for drug binding and transport. This model is consistent with earlier observations of competitive and non-competitive effects of P-glycoprotein substrates and chemosensitizers. Such a two-site model may be fundamental to multidrug transport by P-glycoprotein, and it may be a feature common to other ATP-dependent transporters belonging to the ATP-binding cassette superfamily.     

Emergency treatment of stroke patients--what does the primary health care do?

Has new evidence concerning acute care for stroke patients changed medical practice in primary health care in Norway? What type of wards are currently used when stroke patients are admitted to hospital? These questions are discussed on the basis of data from telephone interviews with chief medical officers in a representative sample of 77 Norwegian local administrative areas (municipalities). 60% of the medical officers state that admission practices are more liberal now than five years ago. Less severe cases are admitted to hospital more often. 34% claim that there has been no change, and 1% report that the practice is stricter now than before. According to our informants, routines for transport, managing TIA and managing nursing home patients with acute stroke vary. 26% of all stroke patients have access to stroke units. In most cases (59%) an ordinary medical ward is the only option.     

Hypoxic changes in metabolism and effectiveness of therapy of surgical sepsis in children

Examinations of 64 children with surgical sepsis, 12 of whom developed multiorgan insufficiency, showed that reduced oxygen transport and hypoxic changes of metabolism aggravate the endogenous intoxication. Hence, normalization of gas exchange and liquidation of oxygen debt by means of artificial ventilation of the lungs performed according to modern schemes becomes an important and obligatory component of intensive care for grave surgical sepsis.     

Traumatic uveitis: the problem of pathogenetic therapy

Inhalative nitric oxide (NO) has recently been included in the therapeutic armament for the treatment of ARDS. We evaluated the effect of inhalative NO on hemodynamic and oxygen transport parameters in 30 internal intensive care patients suffering from ARDS. All patients received a pulmonary artery catheter. Hemodynamics were assessed prior to NO therapy and after 1, 6, 12, and 24 h. 80% (n = 24) of the patients were classified as therapy responders. The median NO dose was 15 ppm (range 5 to 40 ppm). The PaO2/FiO2--ratio increased significantly after initiation of NO (p = 0.0002) while the pulmonary shunt fraction (Qs/Qt) decreased significantly (p = 0.0019). All other measured or calculated parameters including arterial and pulmonary arterial blood pressure remained unchanged. No negative effects of the therapy could be observed. Inhalative NO improves oxygenation in most intensive care patients with ARDS and thus offers the possibility to reduce invasiveness of mechanical ventilation.     

Primary care within the VA: the firm model

Many of the VA medical centers are reorganizing total care across a continuum that includes outpatient, inpatient, long-term, and home based care, into interdisciplinary firms. The goals of reorganization are to improve patient access to care and continuity of care, to improve housestaff education by assigning a specific panel of patients for the residents to follow longitudinally in a variety of situations supervised by the same mentors, and to enhance research in primary care issues. Preliminary results show increased patient satisfaction and improvements in both quality of care and increased efficiency in its delivery. Many large health care organizations might be expected to reorganize care delivery around a similar interdisciplinary team concept.     

论国有大中型企业的铁路运输

我国绝大多数的国有大中型企业,尤其是特大型企业,其外部运输方式主要为铁路运输。铁路运输是一种现代化运输方式,具有运输能力大,运送速度较快,运输距离长、安全程度高、运输准时方便、运输成本低廉以及受气候条件影响较小等特点,而国有大中型企业特别是钢铁厂、炼铜厂,需要运输的量较大,货源较稳定,因此,其外部运输大多数采用铁路运输的方式。如,一个钢铁厂每年生产1t钢便产生6t的铁路运量。笔者所在的江西铜业公司贵溪冶炼厂,在国内同行业铜产量第一,在世界排名第3位,它每生产1t铜需要产生5t的铁路运量。2012年年产铜103.48万t,产生铁路运量511万t,有部份管道运输与公路运输,铁路运输占企业的绝大部分。从数字表明,研究国有大中型企业的铁路运输,对企业或铁路部门都有具有十分重大的意义。     

Equipment for germ-free caesarean section and baby care

A germ-free isolator system was designed and constructed. It permits a sterile caesarean section and rearing of an infant under germ-free conditions. The system includes a plastic surgical and rearing isolator and two supply isolators; one of the supply isolators served as a transport mobile unit of staff participating in the sterile caesarean section and in the postnatal care of the germ-free newborn underwent to a special training and all of them were able to meet the high requirements of this work. The surgery itself was without complications. The newborn was absolutely sterile up to the age of 1 month; afterwards the infant was gradually colonized with selected strains of bacteria and thus prepared for conventialization. In the course of this work further possibilities of application of gnotobiological techniques in pediatrics were proposed (e.g. care of premature, high-risk neonates).     

The competition of molybdate and sulphate ions for a transport system in the ovine small intestine

The transport of molybdate and sulphate by segments of ovine small intestine in vitro was examined and kinetic constants derived for the late ileum where transport was highest. Sulphate inhibited the uptake of molybdate, probably by competition for sites on a common transport system. The significance of the results with respect to the problem of molybdate toxicity in animals is discussed, and related to the known protective effect of sulphate.     

Models for the active transport of cations...the steady-state analysis

We summarise the progress that has been made in the analysis of active transport models, at the steady-state level. The two general classes of such model, counter-and co-transport, can be treated by a kinetic analysis which makes no assumptions as to the symmetry or asymmetry of the systems nor as to the presence of any particular rate-limiting steps. Precisely the same formalism is obeyed for primary active transport as for secondary active transport. Both are merely a generalisation of facilitated diffusion, in that they follow directly from accepted properties of carrier models. How affinities of such carriers for their substrates affect the efficiency of active transport is discussed and it is shown that in a number of cases, the affinity changes that the carrier demonstrates arise from inherent properties of the free carrier and not from any "high energy" properties of the chemical reactants. Methods of obtaining the kinetic parameters of the system from experimental data are reviewed, together with methods for testing and characterising the different transport models.