Intraosseous infusion performed in the prehospital setting: South Carolina's six-year experience

Our data do not demonstrate that a prehospital intraosseous infusion protocol will improve the outcome of prehospital pediatric patients with cardiac arrest. The number of patients in our study is too small to allow us to draw a conclusion as to the effect of intraosseous infusion on altering survivability of pediatric cardiac arrest in the prehospital setting. More study is necessary to determine whether there might be a group of pediatric patients with cardiac arrest or hypovolemic shock who could potentially benefit in a prehospital setting from this procedure.     

Visual search times assessed without reaction times: A new method and an application to aging.

Considered several ways in which the interpretation of reaction time (RT) data might confound differences in visual search rates with non-search-related factors. To determine whether estimates of search rates for groups differing in age suffered this problem, estimates provided by the RT method with those obtained using a forced-choice method with limited-duration stimuli were compared. The forced-choice method provided faster estimates of search rates. The effects of age, the variable of interest, were comparable, but the difference between results obtained using the 2 methods suggests the need for caution in using the RT method. How the forced-choice method can be used, under appropriate circumstances, to provide an independent test of whether Ss are carrying out serial searchers and, if they are, to provide search rate estimates even from data obtained using only a single array size is discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ambulatory obstetrical care: strategies to reduce telephone liability

The telephone will become the centerpiece of ambulatory care services. As such, a pertinent aspect of office procedures will necessarily include a protocol to manage and document telephone calls. Encourage your office staff to use good telephone manners, as listed in Table 5. The net result should be a reduction in telephone liability risks and an enhanced reputation for your office.     

Quantifying the scanty science of prehospital emergency care

Research can produce false-positive results just as can diagnostic tests. Uncontrolled studies have a specificity of only 11%, versus 88% for randomized controlled trials (RCTs), which have been designed to minimize the bias of investigators toward a positive outcome. A search of all the scientific studies in Medicine since 1985 revealed 5,842 publications on prehospital EMS, but only 54 were RCTs (and therefore unlikely to produce false-positive results). By way of comparison, during the same time hundreds of RCTs have been conducted on major medical emergency conditions, and RCTs on even minor topics such as urticaria and constipation exceed the scientific database on all of EMS. Of the 54 EMS RCTs, 4 (7%) reported harm from the new therapy, and 74% reported no effect of the new therapy at all. Only 7 (13%) RCTs showing a positive outcome of the intervention were uncontradicted; of these only 1 examined a major outcome such as survival, and only 1 compared the intervention with a placebo and could therefore evaluate the efficacy of EMS itself. Because there is such a paucity of scientific support for EMS interventions and because monitoring of outcomes and adverse effects is so poor, a serious reexamination of EMS practice is indicated.     

Effect of the prehospital trauma life support program (PHTLS) on prehospital trauma care

BACKGROUND: Improvement in trauma patient outcome has been demonstrated after the implementation of the Prehospital Trauma Life Support (PHTLS) program in Trinidad and Tobago. This study was aimed at identifying prehospital care factors that may explain this improvement. METHODS: All patients transferred by ambulance to the major trauma referral hospital had assessment of airway control, oxygen use, cervical (C)-spine control, and hemorrhage control, as well as splinting of extremities during pre-PHTLS (July of 1990 to December of 1991; n = 332) and post-PHTLS periods (January of 1994 to June of 1995; n = 350). Pre-PHTLS data were compared with post-PHTLS data by chi 2 analysis with a p value < or = 0.05 being considered statistically significant. RESULTS: The frequency (%) increased in the post-PHTLS period for airway control (10 vs. 99.7%), C-spine control (2.1 vs. 89.4%), splinting of extremities (22 vs. 60.6%), hemorrhage control (16 vs. 96.9%), and oxygen use (6.6 vs. 89.5%) when no specific problem was identified. When a specific problem was identified in these areas, the post-PHTLS percentage also increased for airway control (16.2 vs. 100%), C-spine control (25 vs. 100%), splinting of extremities (33.9 vs. 100%), hemorrhage control (18 vs. 100%), and oxygen use (43.2 vs. 98.9%). CONCLUSIONS: Prehospital trauma care has changed after the introduction of the PHTLS program as indicated by more frequent airway control, use of oxygen, control of cervical (C)-spine and hemorrhage, as well as splinting of fractures. This finding was evident not only as a routine but particularly when a specific related problem was identified. This change in prehospital care could be responsible for the improved trauma patient outcome after PHTLS.     

Undergraduate education in primary care: the Rockford experience

Four years of experience with an undergraduate program in primary care in a new community-based medical school are described. Students are intimately involved over a two-and-a-half-year period in the delivery of primary care in rural and semi-rural community health centers. Despite problems of financing and, especially, faculty recruitment and development, the program has been enthusiastically endorsed by students and patients and appears to represent a viable new model for medical education.     

The role of facial response in the experience of emotion: A reply to Tourangeau and Ellsworth.

Replies to R. Tourangeau and P. C. Ellsworth (see record 1981-00499-001), who tested a hypothesis about the role of voluntarily innervated facial responses in the experience of emotion and disconfirmed that hypothesis. The present author's theory would also have predicted that their hypothesis would be disconfirmed. The value of the technique of voluntary simulation of facial responses for the study of innate affects is seriously questioned. (5 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A wake-up call: The experience of a mental health commissioner in times of change.

The experience and impressions of a state mental health commissioner are given to illustrate what it is like to head a health care agency and what a psychologist can accomplish in such a position. The author maintains that this is a time for mental health system reform, and that organized psychology must rise to the occasion, lest others define evolving health care roles. Specifically, psychologists are challenged to acknowledge the paradigm shift toward managed care, to take a lead role in developing performance and outcome measures, and to effectively address key sociopolitical issues. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The Brighton resuscitation ambulances: a continuing experiment in prehospital care by ambulance staff

Two ambulances from the existing fleet in Brighton and one in Hove are equipped with portable defibrillator-oscilloscope units. Selected attendants have been trained not only to defibrillate patients but also to perform endotracheal intubation and administer intravenous atropine and lignocaine for carefully defined indications. In the two years up to December 1975 the ambulances responded to 2253 calls which were considered possible emergencies. Retrospective analysis showed that half of these had been for patients with myocardial infarction, coronary insufficiency, or angina. The ambulances took a median time of five minutes to reach a patient. Attempts at resuscitation were made in 207 patients with circulatory arrest, of whom 160 had ventricular fibrillation. Coordinated rhythm was restored at least transiently in 66 patients, and 27 of them survived to leave hospital. Sixteen of the survivors had been in ventricular fibrillation before the arrival of the ambulance. The delay before admission to hospital was reduced: over 50% of patients carried in the ambulances were admitted within two hours of the onset of major symptoms. No extra ambulance staff have been employed for the scheme. The increased load on hospital services has been limited by encouraging a rational admission policy and also by early discharge.     

Ecologic ethics: a response for our times

To understand the ethics of our present time (macrocosmos), the patient-physician relationship (microcosmos complex) and its changes through history are analyzed. The patient-physician relationship is no longer between two individuals, it is plural and technified. An individualistic forms of ethic cannot answer the questions that arise from contemporary society. The power (political) of medical science has placed us at the threshold of a qualitative change, new that the human genome can be known and the very nature of the species can be modified. Man's destiny will depend on the way (ethic) he uses his knowledge. An ecological ethic could be the answer.     

Interventions to reduce decibel levels on patient care units

The University of Virginia Health System inpatient satisfaction survey identified noise as the most important irritant to surgical inpatients. Analysis of the level and pattern of noise on patient floors and intensive care units was done with baseline measurements followed by then two separate interventions: 1) education of nursing and physician staff 2) closing patient room doors. A decibel meter (M-27 Dosimeter) recorded the noise level over 24 hours. Patients doors were open in the initial measurements. Next, three 1-hour education sessions were conducted by a surgeon and nursing supervisor to review noise-reduction strategies with the staff. These included using pagers in vibrate mode, minimizing overhead announcements, and conducting nurse reports and physician teaching sessions in classrooms away from the nurses' station. Finally, the doors were closed except as visitors and staff entered the room. Little impact was seen from staff education. Closing patient doors on surgical floors decreased noise an average of 6.0 dB, a change that patients can readily perceive. Conversely, intensive care unit patients are exposed to more noise with closed doors, presumably because most noise emanates from equipment within the room. A policy of closing patient floor room doors may increase patient satisfaction.     

Competition and quality in health care: the UK experience

Intraindividual variability and the effects of menstrual cycle phase on CYP2D6 activity were evaluated by dextromethorphan phenotyping in 20 Caucasian normal volunteers. Dextromethorphan 30 mg was administered to 10 men every 14 days for 3 months, and to 10 premenopausal women during the mid-follicular and mid-luteal phases of each menstrual cycle for three complete cycles. Urinary dextromethorphan/dextrorphan molar ratios were obtained after an overnight urine collection. Ten women and nine men were extensive metabolizer phenotypes, and one man was a poor metabolizer phenotype (confirmed by genotyping). There was no difference in dextromethorphan metabolic ratios between the mid-follicular (mean +/- SD: 0.00728+/-0.00717) and mid-luteal (0.00745+/-0.00815) phases of the menstrual cycle (P = 0.88). Also, no significant difference was found in the intraindividual variability of the metabolic ratios between the two phases (P = 0.80). No statistically significant sex difference in CYP2D6 activity was found between men (0.00537+/-0.00431) and women (0.00737+/-0.00983) extensive metabolizers (P = 0.84). For all individuals, intraindividual variability in dextromethorphan ratios ranged from 12.1-136.6% with a median of 36.7%. Because hormonal fluctuations within the mid-follicular and mid-luteal phases of the menstrual cycle do not appear to affect CYP2D6 activity, pharmacokinetic or clinical investigations of CYP2D6 substrate activity may not require menstrual cycle phase stratification. Because baseline metabolic ratios may fluctuate an average of 37%, repeat baseline and treatment phenotyping assessments should be obtained for accurate determination of a given drug's effect on CYP2D6 activity when measured by dextromethorphan.     

Utilizing increased response effort to reduce chronic hand mouthing

The effects of increased response effort on levels of hand mouthing, leisure engagement, and adaptive elbow flexion were investigated with 2 individuals who had been diagnosed with profound disabilities. Arm restraints designed to alter the amount of physical effort necessary to engage in hand mouthing were used. Results indicated that the treatment strategy reduced levels of hand mouthing but produced only small to moderate reductions in levels of leisure engagement and adaptive elbow flexion. At follow-up, the effects of increased response effort on hand mouthing and leisure engagement were maintained for both participants; however, the restraints were associated with substantial reductions in adaptive elbow flexion for 1 participant.     

Fear and loathing on the managed care trail: A response to Pipal (1995).

Responds to the critique by J. E. Pipal (see record 1996-12808-001) of managed care. Pipal is criticized for hyperbole and negativity in her discussion, and it is suggested that professional and public-health objectives will be better served by an open and mutually respectful discussion that raises issues and seeks solutions to complex problems. It is argued that true managed care, featuring arrangements to regulate the costs, site, and utilization of mental health services in an ethically, fiscally, and clinically sound manner, would be a worthwhile goal. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clinical study of using aspirin at various times to reduce adverse reactions of alpha-IFN

The prevalence of problem drinking among medical and surgical in-patients in a general hospital was studied using the CAGE questionnaire. Almost a quarter (23.3%) of the in-patients had associated drinking problems which were more among medical than surgical in-patients. In a large majority of these patients, the associated problem drinking was not recognised by the treating medical professionals. Routine administration of instruments like CAGE which are brief and easy to use would contribute to the early detection and management of alcohol problems in the general hospital setting.     

Occupational exposure to HIV: experience at a tertiary care center

We examined our hospital-based occupational health clinic's experience with combination antiretroviral therapy for postexposure prophylaxis for human immunodeficiency virus (HIV). Over a 12-month period, 68 workers started postexposure prophylaxis: 23 with zidovudine and lamivudine and 45 with zidovudine, lamivudine, and indinavir. Fifty-one (75%) of the 68 workers starting postexposure prophylaxis reported one or more side effects. Side effects were more common among those taking three drugs. Many workers failed to complete the recommended 28-day regimen because of the side effects of the various treatments. The estimated mean cost for evaluations, prophylaxis, and monitoring of exposed workers was $669 per reported exposure. In our experience, major challenges in carrying out the current HIV postexposure prophylaxis guidelines include expeditious source testing, improved staff education and prevention measures, and scrupulous monitoring of workers taking combination antiretroviral drugs for postexposure prophylaxis, with consideration of alternate regimens for intolerant workers.