Genesys Regional Medical Center

BACKGROUND: Bevacizumab and the antimetabolites capecitabine and gemcitabine have been shown to improve outcomes when added to taxanes in patients with metastatic breast cancer. The primary aims of this trial were to determine whether the addition of capecitabine or gemcitabine to neoadjuvant chemotherapy with docetaxel, followed by doxorubicin plus cyclophosphamide, would increase the rates of pathological complete response in the breast in women with operable, human epidermal growth factor receptor 2 (HER2)-negative breast cancer and whether adding bevacizumab to these chemotherapy regimens would increase the rates of pathological complete response. METHODS: We randomly assigned 1206 patients to receive neoadjuvant therapy consisting of docetaxel (100 mg per square meter of body-surface area on day 1), docetaxel (75 mg per square meter on day 1) plus capecitabine (825 mg per square meter twice a day on days 1 to 14), or docetaxel (75 mg per square meter on day 1) plus gemcitabine (1000 mg per square meter on days 1 and 8) for four cycles, with all regimens followed by treatment with doxorubicin-cyclophosphamide for four cycles. Patients were also randomly assigned to receive or not to receive bevacizumab (15 mg per kilogram of body weight) for the first six cycles of chemotherapy. RESULTS: The addition of capecitabine or gemcitabine to docetaxel therapy, as compared with docetaxel therapy alone, did not significantly increase the rate of pathological complete response (29.7% and 31.8%, respectively, vs. 32.7%; P=0.69). Both capecitabine and gemcitabine were associated with increased toxic effects--specifically, the hand-foot syndrome, mucositis, and neutropenia. The addition of bevacizumab significantly increased the rate of pathological complete response (28.2% without bevacizumab vs. 34.5% with bevacizumab, P=0.02). The effect of bevacizumab on the rate of pathological complete response was not the same in the hormone-receptor-positive and hormone-receptor-negative subgroups. The addition of bevacizumab increased the rates of hypertension, left ventricular systolic dysfunction, the hand-foot syndrome, and mucositis. CONCLUSIONS: The addition of bevacizumab to neoadjuvant chemotherapy significantly increased the rate of pathological complete response, which was the primary end point of this study. (Funded by the National Cancer Institute and others; ClinicalTrials.gov number, NCT00408408.).

Burnout among physicians and physicians-in-training is well established as a potential threat to the health and well-being of health care providers and patients. However, there are myriad problems with current burnout research and its ongoing measurement that threaten the validity of the conclusions. For example, researchers have used differing ways of defining and measuring burnout. Those who have used the Maslach Burnout Inventory vary in recommended use of the instrument and cutoff scores. As a result, the authors suggest that the term "burnout" may be misused and recommend some reconsideration of the meaning of burnout. The measurement and discussion of burnout have strong implications for interventions and policy alike. In this article, the authors review the problems with burnout research and ask important questions about the future directions of research efforts. The authors recommend a consistent measurement approach and perhaps moving toward a focus on physician wellness from a positive psychology perspective.

Replacement of functional myocytes with crosslinked collagen as a result of tissue fibrosis is a final common pathway that is central to the progression of heart failure (HF), irrespective of etiology. In response to a variety of mechanical and neurohormonal stimuli, macrophages secrete galectin-3, which works as a paracrine and endocrine factor to stimulate additional macrophages, pericytes, myofibroblasts, and fibroblasts. The response to this signal is cellular proliferation and secretion of procollagen I. This protein is then irreversibly crosslinked to form collagen and result in cardiac fibrosis. With a commercially available assay, galectin-3 can now be measured in blood and has been found to aid in the prognosis of both systolic and nonsystolic HF. Measurement of galectin-3 before hospital discharge, on outpatient evaluation for suspected HF, and approximately twice per year for those with stable symptoms is supported by the evidence available at this time. Levels > 25.9 ng/mL, independent of symptoms, clinical findings, and other laboratory measures, predict a patient who is likely to have rapid progression of HF, resulting in hospitalization and death. In addition, a doubling in galectin-3 level over the course of 6 months, irrespective of baseline value, identifies a high-risk patient in whom additional care management efforts and advanced therapies could be warranted.

BACKGROUND: In patients with acute ST-elevation myocardial infarction (STEMI) who are undergoing percutaneous coronary intervention, current guidelines for reperfusion therapy recommend a door-to-balloon (DTB) time of less than 90 minutes. Considerable effort has focused on reducing DTB time with the assumption that a reduction in DTB time translates into a significant reduction in mortality; however, the clinical impact of this effort has not been evaluated. Therefore, our objective was to determine whether a decline in DTB time in patients with STEMI was associated with an improvement in clinical outcomes. METHODS: We assessed the yearly trend in DTB time for 8771 patients with STEMI who were undergoing primary percutaneous coronary intervention from 2003 to 2008 as part of the Blue Cross Blue Shield of Michigan Cardiovascular Consortium and correlated it with trends in in-hospital mortality. Patients were stratified according to risk of death using a mortality model to evaluate whether patient risk factors affect the relationship between DTB time and mortality. RESULTS: Median DTB time decreased each year from 113 minutes in 2003 to 76 minutes in 2008 (P < .001), and the percentage of patients who were revascularized with a DTB time of less than 90 minutes increased from 28.5% in 2003 to 67.2% in 2008 (P < .001). In-hospital mortality remained unchanged at 4.10% in 2003, 4.02% in 2004, 4.40% in 2005, 4.42% in 2006, 4.73% in 2007, and 3.62% in 2008 (P = .69). After the differences in baseline characteristics were adjusted for, there was no difference in the standardized mortality ratios (SMRs) across the study period (SMR, 1.00; 95% confidence interval [CI], 0.74-1.26 in 2003 compared with SMR, 0.95; 95% CI, 0.77-1.13 in 2008). CONCLUSIONS: There has been a dramatic reduction in median DTB time and increased compliance with the related national guideline. Despite these improvements, in-hospital mortality was unchanged over the study period. Our results suggest that a successful implementation of efforts to reduce DTB time has not resulted in the expected survival benefit.

Post-traumatic stress disorder (PTSD) is one of the few mental disorders in which the cause is readily identifiable. In this article, we review the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) diagnostic criteria, prevalence, and presentation of patients with PTSD in primary care. The purpose of this article is to review current literature regarding theory, etiology, and treatment effectiveness. Key findings in terms of neurobiological underpinnings with implications for future treatment are discussed. Recommendations regarding effective psychotherapy and pharmacotherapy, emerging treatment, and management issues in primary care settings are offered.

BACKGROUND: Stent thrombosis (ST) is an uncommon but serious complication of drug-eluting and bare metal stents. To assess drug-eluting stent ST in contemporary practice, we analyzed 2-year data from the 7492-patient ARRIVE registry. METHODS AND RESULTS: Patients were enrolled at the initiation of percutaneous coronary intervention with no inclusion/exclusion criteria beyond use of the paclitaxel-eluting TAXUS stent. Two-year follow-up was 94% with independent adjudication of major cardiac events. A second, autonomous committee adjudicated Academic Research Consortium (ARC) definite/probable ST. Cumulative 2-year ARC-defined ST was 2.6% (1.0% early ST [<30 days], 0.7% late ST [31 to 365 days], and 0.8% very late ST [>1 year]). Simple-use (single-vessel and single-stent) cases had lower rates than expanded use (broader patient/lesion characteristics, 2-year cumulative: 1.4% versus 3.3%, P<0.001; early ST: 0.4% versus 1.4%, P<0.001; late ST: 0.5% versus 0.8%, P=0.14; very late ST: 0.4% versus 1.0%, P=0.008). Within 7 days of ST, 23% of patients died; 28% suffered Q-wave myocardial infarction. Mortality was higher with early ST (39%) than late ST (12%, P<0.001) or very late ST (13%, P<0.001). Multivariate analysis showed anatomic factors increased early ST (lesion >28 mm, lesion calcification) and late ST (vessel <3.0 mm); biological factors increased very late ST (renal disease, prior brachytherapy). Although early ST (71.4%) and very late ST (23.1%) patients had dual antiplatelet therapy at the time of ST, premature thienopyridine discontinuation was a strong independent predictor of both. CONCLUSIONS: The relative risks of early and late ST differ. Knowledge of ST risk for specific subgroups may guide revascularization options until the completion of randomized trials in these broad populations.

PURPOSE: The purpose of this study was to biomechanically evaluate several configurations of the Krackow stitch and determine which configuration provided the best fixation with regard to load to failure and elongation. TYPE OF STUDY: Biomechanical study. METHODS: Thirty fresh-frozen porcine Achilles tendons were randomly assigned into 6 groups. For 3 of the groups, 1 suture was used (No. 5 Ethibond; Ethicon, Somerville, NJ) with 2, 4, or 6 Krackow locking loops. For the other 3 groups, 2 sutures (interlocking and at 90 degrees) with 2, 4, or 6 Krackow locking loops were used. Data were evaluated using analysis of variance. RESULTS: There were no statistical differences in peak load to failure and elongation among any of the 1-suture techniques regardless of the number of locking loops (2, 290 N; 4, 302 N; and 6, 298 N; standard deviation, 25.2, 9.0, and 28.6, respectively). Similarly, there were no statistical differences among any of the 2-suture techniques regardless of the number of locking loops (2, 534 N; 4, 492 N; and 6, 505 N; standard deviation, 42.0, 65.4, and 76.3, respectively). There was, however, a significant difference (P < .05) in peak load to failure between the 1-suture and the 2-suture groups. The mechanism of failure was suture rupture in all cases. CONCLUSIONS: Load to failure did increase with the addition of a second interlocking suture placed at 90 degrees to the first. CLINICAL RELEVANCE: Tendon fixation with gap formation or suture rupture is at risk of failure. This study identifies that increasing the number of sutures is more important than increasing the number of locking loops.

We report here a prospective study evaluating an alternative to the roentgenographic confirmation of "fine-bore" nasoenteral feeding tubes. Of 78 nasoenteral intubations in 46 patients using a Dobbhoff (Biosearch Medical Products) weighted enteral feeding tube, gastric aspirates were evaluated in 28. Auscultation was performed in all 78. Data was collected at initial placement prior to x-ray confirmation. Observers used color-coded pH paper to analyze gastric aspirate (pH < or = 4) and/or auscultation of the epigastrium to determine feeding tube position prior to x-rays. Auscultation alone was ineffective as a confirmatory test with only 6.3% specificity (p = 0.31). Aspiration to ascertain tube position was very accurate when pH < or = 4.0 (p = 0.0005) and when it was performed. A pH value of > 4 was not very helpful in predicting malposition (37%) especially when pH altering medications were used. Aspiration of contents was successful in 85% of patients. We conclude that when the pH of the nasogastric tube aspirate is < 4.0, x-ray films are not needed to prove the accuracy of tube placement. In other situations, a film is indicated since auscultation is inaccurate.

We report here a prospective study evaluating an alternative to the roentgenographic confirmation of “fine-bore” nasoen-teral feeding tubes. Of 78 nasoenteral intubations in 46 patients using a Dobbhoff (Biosearch Medical Products) weighted enteral feeding tube, gastric aspirates were evaluated in 28. Auscultation was performed in all 78. Data was collected at initial placement prior to x-ray confirmation. Observers used color-coded pH paper to analyze gastric aspirate (pH ± 4) and/or auscultation of the epigastrium to determine feeding tube position prior to x-rays. Auscultation alone was ineffective as a confirmatory test with only 6.3% specificity (p = 0.31). Aspiration to ascertain tube position was very accurate when pH ± 4.0 (p = 0.0005) and when it was performed. A pH value of >4 was not very helpful in predicting malposition (37%) especially when pH altering medications were used. Aspiration of contents was successful in 85% of patients. We conclude that when the pH of the nasogastric tube aspirate is <4.0, x-ray films are not needed to prove the accuracy of tube placement. In other situations, a film is indicated since auscultation is inaccurate.

The authors examined client outcome data to evaluate treatment effectiveness across counselor training level. They used a multitiered supervision model consisting of professional staff, interns, and practicum students. Clients ( N = 264) demonstrated significant improvement with no significant outcome differences between professional staff and supervised trainees. Limitations and future directions are discussed.

BACKGROUND: The objective of this study was to compare the utility of Thin-Prep (TP) cytologic preparation with that of Cell Block (CB) preparation in the diagnosis of thyroid lesions, mainly follicular epithelial lesions, by fine needle aspiration biopsy (FNAB). Feasibility of using the TP slides for immunocytochemical stains is also discussed. METHODS: A total of 126 consecutive cases of thyroid FNAB with TP slides and 128 consecutive cases of thyroid FNAB with CB slides were reviewed blindly by two cytopathologists. The presence of colloid, follicular cells, macrophages and lymphocytes/plasma cells were recorded and scored 0-4 on each case based on TP or CB slide review. The cytologic diagnoses were grouped as follows: cyst, colloid nodule, colloid nodule with cystic change, chronic thyroiditis, atypical/neoplastic and non-diagnostic. RESULTS: The TP slides had higher diagnostic rate than CB slides. The diagnostic yield was 68% of the TP slides whereas only 24% of the CB slides were diagnostic. Also, only 4 atypical/neoplastic lesions were diagnosed on the TP slides and the corresponding direct smears, while 5 cases of atypical/neoplastic lesions were diagnosed on the smears but could not be diagnosed on the corresponding CB slides. Additionally, the TP slides revealed cytologic features that were not observed on the direct traditional smears of the same case. CONCLUSION: In thyroid FNAB cases, TP slide preparation is superior to CB slide preparation and is more likely to have greater cellularity for diagnosis and detect atypical/neoplastic thyroid lesions, particularly those of follicular cell origin. Furthermore, TP slides appear to detect helpful diagnostic cytologic features and should be considered complementary to, rather than replacing, direct smears.

BACKGROUND: The diagnosis of chronic obstructive pulmonary disease (COPD) is usually made based on history and physical exam alone. Symptoms of dyspnea, cough, and wheeze are nonspecific and attributable to a variety of diseases. Confirmatory testing to verify the airflow obstruction is available but rarely used, which may result in substantial misdiagnoses of COPD. The aim of this study is to evaluate the use of confirmatory testing and assess the accuracy of the diagnosis. METHODS: From January 2011 through December 2013, 6,018 patients with COPD as a principal or leading diagnosis were admitted at a community teaching hospital. Of those, only 504 (8.4%) patients had spirometry performed during hospitalization. The studies were reviewed by two board-certified pulmonologists to verify presence of persistent airflow obstruction. Charts of these patients were then examined to determine if the spirometry results had changed the diagnosis or the treatment plan for these patients. RESULTS: Spirometry confirmed the diagnosis of COPD in 270 patients (69.2%) treated as COPD during their hospitalization. Restrictive lung disease was found to be present in 104 patients (26.6%) and normal in 16 patients (4.2%). Factors predictive of airflow obstruction included smoking status and higher pack-year history. Negative predictive factors included higher body mass index (BMI) and other medical comorbidities. These patients were significantly more likely to be misdiagnosed and mistreated as COPD. CONCLUSION: Up to a third of patients diagnosed and treated as COPD in the hospital may be inaccurately diagnosed as COPD based on confirmatory spirometry testing. Factors contributing to the inaccuracy of diagnosis include less smoking history, high BMI, and associated comorbidities.

Multicultural (MC) competence is considered a necessary skill for clinical and counseling psychologists; however, there is little to no research on the assessment of demonstrated multicultural counseling competence (DMCCC) of clinical psychology graduate students. In this study, we developed a MC assessment instrument to assess DMCCC of clinical psychology graduate students compared with MC-experienced psychologists. In addition, we assessed for differences between the endorsement of MC-appropriate strategies and actual use of these strategies in clinical practice, both by MC-experienced psychologists and clinical psychology students. Results revealed significant differences between the DMCCC of clinical psychology graduate students and MC-experienced psychologists. Significant differences also emerged between endorsement of strategies as multiculturally appropriate and likelihood of actual use of these strategies. Findings suggest that future training and competence models should incorporate participants' ability to not only identify multiculturally appropriate strategies but also use these strategies in therapy.

BACKGROUND: It is unclear how well the long-term safety and effectiveness of drug-eluting stents observed in tightly defined randomized controlled trials (RCT) translates to expanded use in routine practice. METHODS: The FDA-mandated TAXUS Express(2) ARRIVE 1 postmarket registry was designed to consecutively enroll patients receiving > or = 1 TAXUS stent in low-, medium-, and high-volume US sites (n = 50). All cardiac events plus an additional 20% sample of records were monitored and all endpoints were independently adjudicated. RESULTS: Detailed follow-up data through 2 years were compiled for 2,487 patients (95%). Simple-use (on-label) ARRIVE 1 patients (35%) had outcomes similar to 4 pooled TAXUS RCTs for death (3.5% vs. 3.4%, respectively, P = 0.78), Q-wave myocardial infarction (QWMI, 0.7% vs. 0.9%, P = 0.72), and stent thrombosis (ST, 2.2% vs. 1.2%, P = 0.12), but lower target vessel revascularization (7.8% vs. 13.4%, P < 0.0001). Compared with simple-use, cases representing expanded use to treat broader patient/lesion characteristics showed higher 2-year rates for death (7.4% vs. 3.5%, respectively, P = 0.0003), target lesion revascularization (9.4% vs. 5.8%, P = 0.0031), and ST (3.4% vs. 2.2%, P = 0.061, concentrated early in the first year). CONCLUSIONS: By including methods usually found in RCT, ARRIVE 1 captured a broad spectrum of disease treated in standard practice with high levels of ascertainment of clinical outcomes. In the more complicated cases, expectedly higher adverse event rates were seen compared to that found in the simple-use cases or pivotal RCT. These results have now been included in the Directions for Use, to aid in physician and patient decision-making.

OBJECTIVE: To retrospectively compare the diagnostic accuracy and cytomorphologic features of thyroid lesions on ThinPrep (TP) (Cytyc Corporation, Boxborough, Massachusetts, U.S.A.) monolayer preparations with those of the conventional smear (CS) method on fine needle aspiration biopsy (FNAB). STUDY DESIGN: Slides of 145 TP and 145 CS consecutive cases of thyroid FNAB were retrospectively reviewed for the following features: amount and architecture of follicular cells, nuclear and cytoplasmic details, amount and quality of colloid, background blood, cyst fluid and macrophages, and lymphocytes and plasma cells. These were semiquantitatively scored 0-4 for each parameter. RESULTS: The TP slides more often had higher cellularity with flat clusters, while CS slides more often had 3-dimentional clusters. The CS slides displayed better morphology and more preserved follicular cells with intact cytoplasm and crisper nuclei, while TP slides revealed shrunken cells with fragmented cytoplasm and dark, often-naked nuclei. The amount of colloid was generally more abundant on the CS slides, while it appeared as small, dense droplets (thick colloid) or as folded tissue paper-like material (thin, watery colloid) on the TP slides. The CS more often had a bloody background obscuring the cells, while the TP slides had a clear background. Simple thyroid cysts were more often detected on TP than CS slides by the presence of cyst fluid and macrophages. The 2 methods had almost similar diagnostic rates for chronic thyroiditis (11% TP vs. 12% CS) and atypical/neoplastic lesions (3.4% each). The 2 methods had similar diagnostic correlation for colloid nodules (49% TP vs. 45.5% CS), but the nondiagnostic rate was lower in TP (24%) than CS slides (31%). CONCLUSION: Although there are cytomorphologic differences between the TP and CS methods, including better cellular preservation and details on CS, the TP method shows a lower nondiagnostic rate, similar diagnostic rate for chronic thyroiditis and atypical/neoplastic lesions, and slightly better diagnostic rate for colloid nodules. The 2 methods complement each other, and we strongly recommend that they both be performed on all thyroid FNAB cases.

INTRODUCTION: The Focused Abdominal Sonography in Trauma (FAST) scan is used to detect free fluid in the peritoneal cavity, or pericardium, to quickly assess for injuries needing immediate surgical intervention. Mass-casualty incidents (MCIs) are settings where paramedics must make triage decisions in minutes. The Simple Triage and Rapid Transport (START) system is used to prioritize transport. The FAST scan can be added to the triage of critical patients, and may aid in triage. METHODS: This was a single-blinded, randomized control trial. Ten paramedics with field experience were trained with an ultrasound machine in the performance of the FAST scan. Two weeks were allowed to pass before testing to simulate the time between training of standard procedures and their implementation. On test day, five peritoneal dialysis patients with instilled dialysis fluid and five matched control patients were placed in a room in a random order where the paramedics performed FAST scans on each patient. The paramedics were assessed by declaring positive or negative for each evaluation, as well as being timed for the total exercise. RESULTS: Of the ninety tests (one paramedic dropped out due to family emergency), the paramedics had a mean accuracy of 60% and median of 62% (range 40%-80%). There was a statistically significant higher false-positive rate of 59% than false-negative rate of 41% (P < .01). Sensitivity was 67% with a specificity of 56%. Average time taken was 1,218 seconds (121.8 seconds per patient) with a range of 735-1,701 seconds and a median of 1,108 seconds. CONCLUSION: In this simulation study, paramedics had difficulty performing FAST scans with a high degree of accuracy. However, they were more apt to call a patient positive, limiting the likelihood for false-negative triage.

Sickle cell leg ulcers (SCLUs) are a common complication of sickle cell disease (SCD). Patients who develop ulcers appear to have a more severe haemolysis-associated vasculopathy than individuals who do not develop them, and manifest other complications such as priapism and pulmonary hypertension. SCLUs are slow to heal and often recur, affecting both the emotional and physical well-being of patients. Here we summarise what is known about the pathophysiology of SCLUs, describe available treatment options and propose a treatment algorithm.

BACKGROUND: Thoracic trauma accounts for 10%-15% of all trauma admissions. Rib fractures are the most common injury following blunt thoracic trauma. Epidural analgesia improves patient outcomes but is not without problems. The use of continuous intercostal nerve blockade (CINB) may offer superior pain control with fewer side effects. This study's objective was to compare the rate of pulmonary complications when traumatic rib fractures were treated with CINB vs epidurals. METHODS: A hospital trauma registry provided retrospective data from 2008 to 2013 for patients with 2 or more traumatic rib fractures. All subjects were admitted and were treated with either an epidural or a subcutaneously placed catheter for continuous intercostal nerve blockade. Our primary outcome was a composite of either pneumonia or respiratory failure. Secondary outcomes included total hospital days, total ICU days, and days on the ventilator. RESULTS: 12.5% (N=8) of the CINB group developed pneumonia or had respiratory failure compared to 16.3% (N=7) in the epidural group. No statistical difference (P=0.58) in the incidence of pneumonia or vent dependent respiratory failure was observed. There was a significant reduction (P=0.05) in hospital days from 9.72 (SD 9.98) in the epidural compared to 6.98 (SD 4.67) in the CINB group. The rest of our secondary outcomes showed no significant difference. CONCLUSION: This study did not show a difference in the rate of pneumonia or ventilator-dependent respiratory failure in the CINB vs epidural groups. It was not sufficiently powered. Our data supports a reduction in hospital days when CINB is used vs epidural. CINB may have advantages over epidurals such as fewer complications, fewer contraindications, and a shorter time to placement. Further studies are needed to confirm these statements.

Theoretical models of binge eating and eating disorders include both transdiagnostic and eating disorder-specific risk factors. Negative urgency (i.e., the tendency to act impulsively when distressed) is a critical transdiagnostic risk factor for binge eating, but limited research has examined interactions between negative urgency and disorder-specific variables. Investigating these interactions can help identify the circumstances under which negative urgency is most strongly associated with binge eating. We examined whether prominent risk factors (i.e., appearance pressures, thin-ideal internalization, body dissatisfaction, dietary restraint) specified in well-established etiologic models of eating disorders moderate negative urgency-binge eating associations. Further, we investigated whether phenotypic moderation effects were due to genetic and/or environmental associations between negative urgency and binge eating. Participants were 988 female twins aged 11-25 years from the Michigan State University Twin Registry. Appearance pressures, thin-ideal internalization, and body dissatisfaction, but not dietary restraint, significantly moderated negative urgency-binge eating associations, with high levels of these risk factors and high negative urgency associated with the greatest binge eating. Twin moderation models revealed that genetic, but not environmental, sharing between negative urgency and binge eating was enhanced at higher levels of these eating disorder-specific variables. Future longitudinal research should investigate whether eating disorder risk factors shape genetic influences on negative urgency into manifesting as binge eating. (PsycINFO Database Record

INTRODUCTION: The world's new social environment dictates the need for preparedness should a disaster occur. One caveat in the realm of disaster preparedness is the vertical evacuation of hospital patients. Little data regarding the evacuation of patients are available, and the consequences of not being prepared could be devastating. Therefore, if the vertical evacuation of critically ill patients was thrust upon a community hospital, the response of emergency services and ancillary staff is largely unknown. METHODS: The vertical evacuation of 12 simulated critically ill patients from the fourth floor of a newly constructed and vacant critical care unit was undertaken by local fire fighters, on-staff nursing, residents, and ancillary staff, all under the direction of the hospital Emergency Management Committee. Four randomly selected groups of firefighters, two teams consisting of three personnel and two teams of four personnel, were timed and had vital signs assessed prior to ascending to the fourth floor to retrieve a patient and upon each subsequent decent. Each team, dressed in full turnout gear, retrieved three patients. Each simulated patient was fashioned with mock endotracheal tube, intravenous lines, monitor, and a Pleurovac was attached in three of the four patients. Vital signs were analyzed for significant changes or patterns due to exertion and or stress during the drill. Evaluations were distributed to all participants upon completion of the drill. RESULTS: Mean values for the vital signs of the members of each team showed minimal increases from baseline to completion with the exception of heart rate. A decrease in systolic blood pressure was present in both of the four member teams. Subjective evaluation by the firefighters, indicated a "minimal" increase in exertion. Mean extraction time was 14.7 minutes. Patient transfer and evacuation was completed without complication to the patients or staff. Only one firefighter requested a replacement. Completed evaluations indicated above average or outstanding performance on organization, commitment, security, and care. Comments included statements regarding equipment management during transport, better communication, stairwell width, difficulty with ventilating intubated patients, improvement of evacuation time, and organization as drill progressed; three member teams, spatially, worked better than four. CONCLUSION: This drill reflected an impressive level of preparedness by firefighters, nurses, and ancillary staff both physically and organizationally. Should a vertical evacuation of critically ill patients be necessary, a four firefighter extraction team and accompanying nurse and respiratory therapist would be able to evacuate one patient at a rate of 3.75 minutes per floor.