Resurrection Medical Center

OBJECTIVE: To determine whether emergency physicians (EPs) with goal-directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. METHODS: Prospective, observational study at an urban teaching ED with >100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five-view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. RESULTS: Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p < 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 +/- 10% vs. 48 +/- 17%, p < 0.001). CONCLUSIONS: Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.

BACKGROUND: Advanced practitioners including nurse practitioners and physician assistants are contributing to care for critically ill patients in the intensive care unit through their participation on the multidisciplinary team and in collaborative physician practice roles. However, the impact of nurse practitioners and physician assistants in the intensive care unit setting is not well known. OBJECTIVES: To identify published literature on the role of nurse practitioners and physician assistants in acute and critical care settings; to review the literature using nonquantitative methods and provide a summary of the results to date incorporating studies assessing the impact and outcomes of nurse practitioner and physician assistant providers in the intensive care unit; and to identify implications for critical care practice. METHODS: We conducted a systematic search of the English-language literature of publications on nurse practitioners and physician assistants utilizing Ovid MEDLINE, PubMed, and the Cumulative Index of Nursing and Allied Health Literature databases from 1996 through August 2007. INTERVENTIONS: None. RESULTS: Over 145 articles were reviewed on the role of the nurse practitioner and physician assistant in acute and critical care settings. A total of 31 research studies focused on the role and impact of these practitioners in the care of acute and critically ill patients. Of those, 20 were focused on nurse practitioner care, six focused on both nurse practitioner and physician assistant care, and five were focused on physician assistant care in acute and critical care settings. Fourteen focused on intensive care unit care, and 17 focused on acute care including emergency room, trauma, and management of patients with specific acute care conditions such as stroke, pneumonia, and congestive heart failure. Most studies used retrospective or prospective study designs and nonprobability sampling techniques. Only two randomized control trials were identified. The majority examined the impact of care on patient care management (n = 17), six focused on comparisons of care with physician care, five examined the impact of models of care including multidisciplinary and outcomes management models, and three assessed involvement and impact on reinforcement of practice guidelines, education, research, and quality improvement. CONCLUSIONS: Although existing research supports the use of nurse practitioners and physician assistants in acute and critical care settings, a low level of evidence was found with only two randomized control trials assessing the impact of nurse practitioner care. Further research that explores the impact of nurse practitioners and physician assistants in the intensive care unit setting on patient outcomes, including financial aspects of care is needed. In addition, information on successful multidisciplinary models of care is needed to promote optimal use of nurse practitioners and physician assistants in acute and critical care settings.

Objective: To determine whether emergency physicians (EPs) with goal‐directed training can use echocardiography to accurately assess left ventricular function (LVF) in hypotensive emergency department (ED) patients. Methods: Prospective, observational study at an urban teaching ED with &gt;100,000 visits/year. Four EP investigators with prior ultrasound experience underwent focused echocardiography training. A convenience sample of 51 adult patients with symptomatic hypotension was enrolled. Exclusion criteria were a history of trauma, chest compressions, or electrocardiogram diagnostic of acute myocardial infarction. A five‐view transthoracic echocardiogram was recorded by an EP investigator who estimated ejection fraction (EF) and categorized LVF as normal, depressed, or severely depressed. A blinded cardiologist reviewed all 51 studies for EF, categorization of function, and quality of the study. Twenty randomly selected studies were reviewed by a second cardiologist to determine interobserver variability. Results: Comparison of EP vs. primary cardiologist estimate of EF yielded a Pearson's correlation coefficient R = 0.86. This compared favorably with interobserver correlation between cardiologists (R = 0.84). In categorization of LVF, the weighted agreement between EPs and the primary cardiologist was 84%, with a weighted kappa of 0.61 (p &lt; 0.001). Echocardiographic quality was rated by the primary cardiologist as good in 33%, moderate in 43%, and poor in 22%. The EF was significantly lower in patients with a cardiac cause of hypotension vs. other patients (25 ± 10% vs. 48 ± 17%, p &lt; 0.001). Conclusions: Emergency physicians with focused training in echocardiography can accurately determine LVF in hypotensive patients.

BACKGROUND: The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. OBJECTIVES: The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. METHODS: This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. RESULTS: In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions. CONCLUSIONS: The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.

BACKGROUND: In 2021, we showed an increased risk associated with COVID-19 in pregnancy. Since then, the SARS-CoV-2 virus has undergone genetic mutations. We aimed to examine the effects on maternal and perinatal outcomes of COVID-19 during pregnancy, and evaluate vaccine effectiveness, when omicron (B.1.1.529) was the variant of concern. METHODS: INTERCOVID-2022 is a large, prospective, observational study, involving 41 hospitals across 18 countries. Each woman with real-time PCR or rapid test, laboratory-confirmed COVID-19 in pregnancy was compared with two unmatched women without a COVID-19 diagnosis who were recruited concomitantly and consecutively in pregnancy or at delivery. Mother and neonate dyads were followed until hospital discharge. Primary outcomes were maternal morbidity and mortality index (MMMI), severe neonatal morbidity index (SNMI), and severe perinatal morbidity and mortality index (SPMMI). Vaccine effectiveness was estimated, adjusted by maternal risk profile. FINDINGS: We enrolled 4618 pregnant women from Nov 27, 2021 (the day after WHO declared omicron a variant of concern), to June 30, 2022: 1545 (33%) women had a COVID-19 diagnosis (median gestation 36·7 weeks [IQR 29·0-38·9]) and 3073 (67%) women, with similar demographic characteristics, did not have a COVID-19 diagnosis. Overall, women with a diagnosis had an increased risk for MMMI (relative risk [RR] 1·16 [95% CI 1·03-1·31]) and SPMMI (RR 1·21 [95% CI 1·00-1·46]). Women with a diagnosis, compared with those without a diagnosis, also had increased risks of SNMI (RR 1·23 [95% CI 0·88-1·71]), although the lower bounds of the 95% CI crossed unity. Unvaccinated women with a COVID-19 diagnosis had a greater risk of MMMI (RR 1·36 [95% CI 1·12-1·65]). Severe COVID-19 symptoms in the total sample increased the risk of severe maternal complications (RR 2·51 [95% CI 1·84-3·43]), perinatal complications (RR 1·84 [95% CI 1·02-3·34]), and referral, intensive care unit (ICU) admission, or death (RR 11·83 [95% CI 6·67-20·97]). Severe COVID-19 symptoms in unvaccinated women increased the risk of MMMI (RR 2·88 [95% CI 2·02-4·12]) and referral, ICU admission, or death (RR 20·82 [95% CI 10·44-41·54]). 2886 (63%) of 4618 total participants had at least a single dose of any vaccine, and 2476 (54%) of 4618 had either complete or booster doses. Vaccine effectiveness (all vaccines combined) for severe complications of COVID-19 for all women with a complete regimen was 48% (95% CI 22-65) and 76% (47-89) after a booster dose. For women with a COVID-19 diagnosis, vaccine effectiveness of all vaccines combined for women with a complete regimen was 74% (95% CI 48-87) and 91% (65-98) after a booster dose. INTERPRETATION: COVID-19 in pregnancy, during the first 6 months of omicron as the variant of concern, was associated with increased risk of severe maternal morbidity and mortality, especially among symptomatic and unvaccinated women. Women with complete or boosted vaccine doses had reduced risk for severe symptoms, complications, and death. Vaccination coverage among pregnant women remains a priority. FUNDING: None.

DNA content and cell proliferation were measured by flow cytometry on paraffin-embedded Stage B2 or C colorectal adenocarcinomas from 694 patients enrolled in adjuvant trials conducted by the North Central Cancer Treatment Group. Patients with diploid tumors had a higher survival rate than those with nondiploid tumors (P less than 0.001). The proliferation index (the sum of the percent of cells in S-phase plus those in G2M phase) was also a strong prognostic factor (P less than 0.001). The ploidy and proliferation data were combined, and the patients in the favorable group (diploid and low proliferative index) had a 5-year survival of 74% compared with 54% for the unfavorable group (high proliferative index or nondiploid, P less than 0.001). This grouping was prognostic for survival in B2 (P less than 0.001), C (P = 0.013), colon (P less than 0.001), and rectal (P = 0.026) patient subsets. This study indicates that cell kinetic parameters are important and independent prognostic factors for Stages B2 and C colorectal cancer.

BACKGROUND: Exercise has many benefits for survivors of breast cancer, yet only half of this population regularly exercise. Fear has been identified as a barrier to exercise for people with neuromusculoskeletal conditions but has been minimally explored in women with breast cancer. OBJECTIVES: The purposes of this study were: (1) to investigate factors that affected decisions about physical activity and exercise in survivors of breast cancer and (2) to determine whether fear was a factor. DESIGN: This investigation was a grounded-theory qualitative study. Qualitative data were triangulated with data from 2 quantitative scales that measured participants' beliefs about exercise and their activity levels. METHODS: Thirty-four survivors of breast cancer in 8 focus groups participated in semistructured interviews that were recorded, transcribed, and coded. Concept maps created for each group were merged to develop themes. Beliefs about physical activity and exercise were assessed with the Decisional Balance Scale. The Rapid Assessment of Physical Activity was used to assess behaviors regarding physical activity and exercise before and after the breast cancer diagnosis. RESULTS: Participants generally believed that exercise was beneficial (Decisional Balance Scale score: X=28.1 [of a maximum score of 44], SD=7.6, range=10-43). Participants decreased the amount of physical activity or exercise during treatment but increased the amount of exercise beyond prediagnosis levels after treatment (Rapid Assessment of Physical Activity score: median=6, range=2-7). Three prominent themes described participants' behaviors regarding physical activity or exercise: values and beliefs about exercise, facilitators and barriers that were both similar to those affecting the general population and cancer specific, and lack of or inaccurate information about safe exercise. CONCLUSIONS: Survivors who were active were not afraid to exercise. However, concern about lymphedema and knowledge about safe and effective exercise programs influenced choices regarding physical activity and exercise.

The role of acute care nurse practitioners (ACNPs) has developed in capacity. More than 3500 advanced practice nurses have been certified as ACNPs, and the number of practice settings where these professionals work is continually expanding. Beginning in 1996, a series of surveys were conducted of nurse practitioners seeking national certification as ACNPs. What started as an attempt to gather information on the role of ACNPs evolved into a national 5-year longitudinal survey of ACNP practice. The cumulative results of the project are reported, and how the role of the ACNP was established in advanced practice nursing is discussed.

OBJECTIVE: To define sources of job satisfaction and stress among emergency physicians and assess self-projected career longevity. DESIGN: A survey containing questions regarding emergency medicine (EM) practice satisfaction was mailed to 1,317 diplomates of the American Board of Emergency Medicine (ABEM). Specific sources of practice satisfaction and dissatisfaction, self-reported burnout or impairment, and plans for remaining in the specialty were assessed. Data were compared between two groups of physicians, namely, those residency-trained in EM and those attaining certification through the practice or special category tracts. RESULTS: Of the physicians returning the survey, 25.2% stated that they felt burned out or impaired and 23.1% planned to leave the practice of EM within five years. Perceptions of burnout/impairment and plans to stop practice were associated with less overall practice satisfaction but were not significantly different between the two groups of physicians. Burnout/impairment was linked with psychiatric, drug, or alcohol problems and the feeling that EM had contributed to that problem. CONCLUSION: This study confirms the relatively high levels of projected attrition in EM and supports the perception that stress and burnout are associated with the specialty. Differences in job satisfaction and stress between those ABEM diplomates who were residency-trained in EM and those who became eligible for the board examination through practice or special-category eligibility appear minor.

OBJECTIVE: To determine whether transfer from a long-term care facility (LTCF) is a risk factor for colonization with Klebsiella pneumoniae carbapenemase (KPC)-producing Enterobacteriaceae upon acute care hospital admission. DESIGN: Microbiologic survey and nested case-control study. SETTING: Four hospitals in a metropolitan area (Chicago) with an early KPC epidemic. PATIENTS: Hospitalized adults. METHODS: Patients transferred from LTCFs were matched 1∶1 to patients admitted from the community by age (± 10 years), admitting clinical service, and admission date (± 2 weeks). Rectal swab specimens were collected within 3 days after admission and tested for KPC-producing Enterobacteriaceae. Demographic and clinical information was extracted from medical records. RESULTS: One hundred eighty patients from LTCFs were matched to 180 community patients. KPC-producing Enterobacteriaceae colonization was detected in 15 (8.3%) of the LTCF patients and 0 (0%) of the community patients ([Formula: see text]). Prevalence of carriage differed by LTCF subtype: 2 of 135 (1.5%) patients from skilled nursing facilities without ventilator care (SNFs) were colonized upon admission, compared to 9 of 33 (27.3%) patients from skilled nursing facilities with ventilator care (VSNFs) and 4 of 12 (33.3%) patients from long-term acute care hospitals (LTACHs; [Formula: see text]). In a multivariable logistic regression model adjusted for a propensity score that predicted LTCF subtype, patients admitted from VSNFs or LTACHs had 7.0-fold greater odds of colonization (ie, odds ratio; 95% confidence interval, 1.3-42; [Formula: see text]) with KPC-producing Enterobacteriaceae than patients from an SNF. CONCLUSIONS: Patients admitted to acute care hospitals from high-acuity LTCFs (ie, VSNFs and LTACHs) were more likely to be colonized with KPC-producing Enterobacteriaceae than were patients admitted from the community. Identification of healthcare facilities with a high prevalence of colonized patients presents an opportunity for focused interventions that may aid regional control efforts.

OBJECTIVE: To determine the current state of bedside emergency physician-performed ultrasonography in terms of prevalence, training, quality assurance, and reimbursement at emergency medicine residency programs. METHODS: The link to a 10-question Web-based survey was e-mailed to ultrasound/residency directors at 122 emergency medicine residency programs in the United States. RESULTS: The overall response rate was 84%. Ninety-two percent of programs reported 24-hour emergency physician-performed ultrasonography availability. Fifty-one percent of programs reported that a credentialing/privileging plan was in place at their hospital, and 71% of programs had a quality assurance/image review procedure in place. Emergency medicine specialty-specific guidelines of 150 ultrasonographic examinations and 40 hours of didactic instruction were met by 39% and 22% of residencies, respectively, although only 13.7% of programs were completing the 300 examinations recommended by the American Institute of Ultrasound in Medicine. Sixteen programs (16%) reported that they were currently billing for emergency physician-performed ultrasonography; of those not billing, 10 (12%) planned to bill within 1 year, and 32 (37%) planned to bill at some point in the future. CONCLUSIONS: Performance and training in emergency physician-performed ultrasonography at academic medical centers continues to increase. The number of emergency medicine residency programs meeting specialty-specific guidelines has more than doubled in the last 4 years, but only a small number are meeting American Institute of Ultrasound in Medicine guidelines. Although only 16% of programs reported that they were currently billing for emergency physician-performed ultrasonography, most had plans to bill in the future.

A standardized activities of daily living evaluation that has acceptable psychometric qualities, can relate discrete component skills to functional performance, includes culture-relevant test items, is standardized on culture-specific samples, and is free of cultural bias is needed to evaluate diverse cultural populations. The Assessment of Motor and Process Skills (AMPS) (Fisher, 1990a) offers a unique solution. The AMPS consists of 35 motor and process skill items assumed to represent two universal taxonomies that are free of cultural bias. The study described in this paper focused on the 20 process skill items of the AMPS process skills scale. To test the hypothesis that the AMPS process skills scale is suitable for cross-cultural applications, a translation of the AMPS was calibrated on a group of 20 Taiwanese subjects. The validity and reliability of the AMPS process skills scale were examined when applied to this sample. Examination of reliability included the extent to which rater scoring remained stable over time. The results revealed that the AMPS process skills scale has high intrarater reliability and is valid when applied to young nondisabled Taiwanese subjects. The results suggested that the AMPS could be applied to Taiwanese samples. However, further investigation is needed to determine whether Taiwanese activities can be calibrated onto the same scale as North American activities to make a single cross-cultural AMPS.

Haff disease, rhabdomyolysis after ingesting certain types of fish, was first reported in 1924 in Europe. There have been a limited number of cases reported in the United States. We present the case of a patient who presents with symptoms of rhabdomyolysis after eating cooked buffalo fish purchased at a suburban grocery market. [West J Emerg Med. 2014;15(6):664-666]

OBJECTIVES: To assess the feasibility of a brief comprehensive case-finding program for detecting functional, cognitive, and social impairments among elderly ED patients and to estimate the prevalence of unknown, undetected, or untreated impairments elderly patients may have. METHODS: A multicenter prospective study conducted at five private and public hospital EDs in five different communities across the country. Patients aged 60 years and older released to their homes during 52 randomly selected evening and weekend shifts between February 1 and April 30, 1993, were eligible for the case-finding program. They were evaluated by medical students who received special training (instructional videotape, supervised examinations, and conference calls) in the administration of a standardized 17-item protocol that included an interview and simple tests of function. The patients' physicians were notified of the screening results and were asked to return a one-month follow-up questionnaire. The physicians answered whether the presumed problem had been confirmed and whether a treatment plan for a new problem had been developed. RESULTS: Patient acceptance of the case-finding program was good; 252 of 338 eligible patients (75%) agreed to participate, and 281 conditions were detected for 242 screened patients (96%). The most frequently reported problems were with: performing the activities of daily living (79%); vision (55%); lack of influenza vaccination (54%); home environment (49%); mental status (46%); general health (41%); falls (40%); and depression (36%). The physicians returned questionnaires for 153 patients (63%); 76 patients (50%) were evaluated at follow-up visits, during which 47 newly identified problems (62%) were confirmed and treatment plans were developed for 25 problems (53%) among 21 patients. A mean time of 17.7 +/- 10.2 minutes was required to complete the screen. CONCLUSIONS: A brief comprehensive case-finding program for functional, cognitive, and social impairment among elderly ED patients is feasible. The screening uncovered a significant amount of morbidity among older patients visiting EDs.

Abstract Background The purpose of this study was to determine factors that impact recurrence and long‐term survival of head and neck adenoid cystic carcinoma (ACC). Methods We conducted a retrospective review of 87 patients with head and neck ACC who were evaluated between 1992 and 2009. Staining for Ki‐67, p53, α‐estrogen receptor (αER), and progesterone receptor (PR) was performed. Results Forty men (46%) and 47 women (54%) were included in this study. Median follow‐up for patients was 98 months. Five‐year recurrence‐free and overall survival (OS) rates were 56% and 81%, respectively. Ki‐67 and p53 expression was observed in 5 (6%) and 2 (2%) patients, respectively. αER and PR were all negative. The most important determinants of disease‐free survival (DFS) were perineural invasion (PNI; p = .001) and female sex ( p = .027). Disease site (major vs minor salivary gland) was the only predictor of worse OS on multivariate analysis. Conclusion Perineural invasion, female sex, and disease site were the most consistent predictors of poor outcome in head and neck ACC. © 2014 Wiley Periodicals, Inc. Head Neck 36: 1705–1711, 2014

Anticoagulation is the mainstay of medical treatment, prevention and reduction of recurrent venous thromboembolism, stroke prevention in patients with non-valvular atrial fibrillation, and it reduces the incidence of recurrent ischemic events and death in patients with acute coronary syndrome. Options for anticoagulation have been steadily increasing. Physicians need to be aware of the clinical profile of anticoagulation agents, reversal agents and treatment strategies in the face of major bleeding.

OBJECTIVES: Emergency ultrasound (EUS) has been recognized as integral to the training and practice of emergency medicine (EM). The Council of Emergency Medicine Residency-Academy of Emergency Ultrasound (CORD-AEUS) consensus document provides guidelines for resident assessment and progression. The Accredited Council for Graduate Medical Education (ACGME) has adopted the EM Milestones for assessment of residents' progress during their residency training, which includes demonstration of procedural competency in bedside ultrasound. The objective of this study was to assess EM residents' use of ultrasound and perceptions of the proposed ultrasound milestones and guidelines for assessment. METHODS: This study is a prospective stratified cluster sample survey of all U.S. EM residency programs. Programs were stratified based on their geographic location (Northeast, South, Midwest, West), presence/absence of ultrasound fellowship program, and size of residency with programs sampled randomly from each stratum. The survey was reviewed by experts in the field and pilot tested on EM residents. Summary statistics and 95% confidence intervals account for the survey design, with sampling weights equal to the inverse of the probability of selection, and represent national estimates of all EM residents. RESULTS: There were 539 participants from 18 residency programs with an overall survey response rate of 85.1%. EM residents considered several applications to be core applications that were not considered core applications by CORD-AEUS (quantitative bladder volume, diagnosis of joint effusion, interstitial lung fluid, peritonsillar abscess, fetal presentation, and gestational age estimation). Of several core and advanced applications, the Focused Assessment with Sonography in Trauma examination, vascular access, diagnosis of pericardial effusion, and cardiac standstill were considered the most likely to be used in future clinical practice. Residents responded that procedural guidance would be more crucial to their future clinical practice than resuscitative or diagnostic ultrasound. They felt that an average of 325 (301-350) ultrasound examinations would be required to be proficient, but felt that number of examinations poorly represented their competency. They reported high levels of concern about medicolegal liability while using EUS. Eighty-nine percent of residents agreed that EUS is necessary for the practice of EM. CONCLUSIONS: EM resident physicians' opinion of what basic and advanced skills they are likely to utilize in their future clinical practice differs from what has been set forth by various groups of experts. Their opinion of how many ultrasound examinations should be required for competency is higher than what is currently expected during training.

ObjectiveOutdoor-related activity has been on the rise in recent years, and hiking and backpacking are among those activities with the largest growth in participation. As the number of participants with varying experience increases, it is expected that there will be an increase in injuries related to these activities. Little empirical data exist related to outdoor injury types and rates. Our objectives were to determine incidence and frequency of injuries related to outdoor activity and requiring emergency medical system (EMS) activation at a national park.MethodsThis retrospective study examines injuries within Yellowstone National Park. Subjects were selected from a database containing all EMS calls within Yellowstone National Park from calendar year 2003 through 2004. Data collected included age, gender, type of injury, location, activity at the time of injury, and EMS response.ResultsThere were 306 injuries reviewed. The mean age of patients was 40.9 years (SD: 23.0), and the group comprised 49.0% males. Emergency medical system transport was not required in 59.2% of injuries, and of those transported, 58.4% of patients required basic life support only. Of all injuries, 77.4% involved soft tissue, including lacerations. Hiking and walking accounted for 38.0% of all injuries, and 56.0% of those injuries involved the lower extremity. Only 8.8% of the injuries involved fractures and/or dislocations.ConclusionsIn this study of EMS responses at a national park, the majority of injuries sustained were minor in nature. More than one third of injuries occurred while patients were hiking or walking, and most of those injuries involved the lower extremity. These results will help optimize resource planning in the national park setting. Outdoor-related activity has been on the rise in recent years, and hiking and backpacking are among those activities with the largest growth in participation. As the number of participants with varying experience increases, it is expected that there will be an increase in injuries related to these activities. Little empirical data exist related to outdoor injury types and rates. Our objectives were to determine incidence and frequency of injuries related to outdoor activity and requiring emergency medical system (EMS) activation at a national park. This retrospective study examines injuries within Yellowstone National Park. Subjects were selected from a database containing all EMS calls within Yellowstone National Park from calendar year 2003 through 2004. Data collected included age, gender, type of injury, location, activity at the time of injury, and EMS response. There were 306 injuries reviewed. The mean age of patients was 40.9 years (SD: 23.0), and the group comprised 49.0% males. Emergency medical system transport was not required in 59.2% of injuries, and of those transported, 58.4% of patients required basic life support only. Of all injuries, 77.4% involved soft tissue, including lacerations. Hiking and walking accounted for 38.0% of all injuries, and 56.0% of those injuries involved the lower extremity. Only 8.8% of the injuries involved fractures and/or dislocations. In this study of EMS responses at a national park, the majority of injuries sustained were minor in nature. More than one third of injuries occurred while patients were hiking or walking, and most of those injuries involved the lower extremity. These results will help optimize resource planning in the national park setting.

Reports of fidaxomicin treatment for patients with multiple recurrent Clostridium difficile infections ([mrCDI] ie, more than 2 CDI episodes) indicate symptomatic response to this agent, but 50% have subsequent mrCDI episodes. In an effort to improve outcomes in patients with mrCDI we used novel regimens of fidaxomicin based on strategies used with vancomycin. Of 8 patients who received a 10-day chaser of fidaxomicin given twice daily after a course of vancomycin, 3 (38%) experienced a subsequent recurrence. Two (18%) of 11 patients who completed a 14- to 33-day course of fidaxomicin in a tapering dose experienced a recurrence, both of whom received additional antibiotics before that recurrence. The median symptom-free interval (SFI) after fidaxomicin taper was greater than the median SFI after the most effective prior regimen for those patients (257 days [interquartile range, 280] vs 25 days [interquartile range, 30], respectively; P = .003). A fidaxomicin chaser or taper regimen may be effective in patients with mrCDI, but the number of patients treated is small, and randomized comparative data are not available.

INTRODUCTION: Pain is a common symptom evaluated by emergency medical services (EMS) providers. Hospital pain management programs began in the early 1990s based on a multidisciplinary approach and principles of total quality improvement. To date, these programs have had limited exposure in the prehospital setting. OBJECTIVES: To evaluate the effects of a pain management educational intervention (EI) for paramedic caregivers. METHODS: All ambulance providers from ten urban and suburban fire departments and two private ambulance companies participated in a three-hour EI during a quality improvement project. A survey was performed prior to the EI and repeated one month after the EI. A two-month collection of EMS runs for pain complaints was performed prior to the EI and repeated one month after the EI. Data analysis was performed using descriptive statistics and chi-square tests. RESULTS: The authors reviewed 397 surveys and 439 EMS runs for pain. Overall, after the EI, paramedics' knowledge of basic pain management principles increased from 57.3% to 74.9% (17.5%; 95% confidence interval (CI): 14.9%-20.2%; p < 0.001). Paramedics' utilization of nonpharmacologic pain therapies improved by 32.2% (95% CI: 25.3%-39.2%; p < 0.001), but there was no significant change in the use of pain medication (20.2% to 24.5%). There were 51.0% (95% CI: 44.1%-57.9%; p < 0.001) improvement in documentation of pain severity, 24% (95% CI: 21.2%-26.8%; p < 0.001) improvement in documentation of pain characteristics, and 13% (95% CI: 7.4%-18.7%; p < 0.001) improvement in pain reassessment following intervention. CONCLUSION: As a result of a three-hour educational intervention, paramedics had an increased understanding of pain principles, were more likely to provide prehospital nonpharmacologic pain therapy, and were more likely to document the results of their interventions.