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Biomedical subjects

A L Kellermann

Publications and source records attributed to A L Kellermann.

At least 19 recordsLinked to original sources
PubMed1992

Suicide in the home in relation to gun ownership.

BACKGROUND: It has been suggested that limiting access to firearms could prevent many suicides, but this belief is controversial. To assess the strength of the association between the availability of firearms and suicide, we studied all suicides that took place in the homes of victims in Shelby County, Tennessee, and King County, Washington, over a 32-month period. METHODS: For each suicide victim (case subject), we obtained data from police or the medical examiner and interviewed a proxy. Their answers were compared with those of control subjects from the same neighborhood, matched with the victim according to sex, race, and age range. Crude and adjusted odds ratios were calculated with matched-pairs methods. RESULTS: During the study period, 803 suicides occurred in the two counties, 565 of which (70 percent) took place in the home of the victim. Fifty-eight percent (326) of these suicides were committed with a firearm. After excluding 11 case subjects for various reasons, we were able to interview 80 percent (442) of the proxies for the case subjects. Matching controls were identified for 99 percent of these subjects, producing 438 matched pairs. Univariate analyses revealed that the case subjects were more likely than the controls to have lived alone, taken prescribed psychotropic medication, been arrested, abused drugs or alcohol, or not graduated from high school. After we controlled for these characteristics through conditional logistic regression, the presence of one or more guns in the home was found to be associated with an increased risk of suicide (adjusted odds ratio, 4.8; 95 percent confidence interval, 2.7 to 8.5). CONCLUSIONS: Ready availability of firearms is associated with an increased risk of suicide in the home. Owners of firearms should weigh their reasons for keeping a gun in the home against the possibility that it might someday be used in a suicide.

Adult↗
PubMed1992

Physician staffing in the emergency departments of public teaching hospitals: a national survey.

STUDY HYPOTHESIS: To evaluate factors influencing emergency physician staffing patterns in an important subset of US hospitals. DESIGN: Survey of emergency department directors and hospital administrators. PARTICIPANTS: Member institutions of the National Association of Public Hospitals and the Council of Teaching Hospitals. MEASUREMENTS: Of 498 hospitals enrolled, two mailings and telephone follow-up yielded 277 replies (56% response rate). To adjust for differences in ED size and volume, levels of staffing were converted to full-time equivalents (FTEs) per 10,000 annual ED visits. RESULTS: Responding institutions included 160 private and 115 public hospitals, 74 of which were Veterans Administration hospitals. Formal medical school affiliation was noted by 86% of responding institutions, and 82 (30%) supported emergency medicine residency programs. Full-time attending emergency physician staffing varied widely, from less than one to more than three FTEs per 10,000 visits; however, mean levels of staffing at public hospitals did not differ significantly from private institutions (2.7 +/- 1.6 vs 2.5 +/- 3.1, respectively; P = .50). Three of four hospitals reported using part-time emergency physician attending but only 33% used nurse practitioners or physicians' assistants. Two thirds of responding hospitals used rotating house officers-in-training. Of note, hospitals that supported emergency medicine residency programs reported significantly higher levels of staffing by housestaff (2.2 +/- 1.8 vs 1.0 +/- 1.2 FTEs/10,000 visits; P less than .0004), but levels of total staffing by full- and part-time attending physicians were virtually identical (2.69 +/- 1.6 vs 2.67 +/- 2.6 FTEs/10,000 visits; respectively; P = .95). Marked variability in levels and patterns of ED staffing at public and teaching hospitals currently exists, but the differences are not explained by hospital ownership. The reasons for such variations and their implications for patient care must be explored.

Data Collection↗
PubMed1992

Men, women, and murder: gender-specific differences in rates of fatal violence and victimization.

To study the potential differences that distinguish homicides involving women as victims or offenders from those involving men, we analyzed Federal Bureau of Investigation Uniform Crime Reports data on homicides that occurred in the United States between 1976 and 1987. Only cases that involved victims aged 15 years or older were included. Persons killed during law enforcement activity and cases in which the victim's gender was not recorded were excluded. A total of 215,273 homicides were studied, 77% of which involved male victims and 23% female victims. Although the overall risk of homicide for women was substantially lower than that of men (rate ratio [RR] = 0.27), their risk of being killed by a spouse or intimate acquaintance was higher (RR = 1.23). In contrast to men, the killing of a woman by a stranger was rare (RR = 0.18). More than twice as many women were shot and killed by their husband or intimate acquaintance than were murdered by strangers using guns, knives, or any other means. Although women comprise more than half the U.S. population, they committed only 14.7% of the homicides noted during the study interval. In contrast to men, who killed nonintimate acquaintances, strangers, or victims of undetermined relationship in 80% of cases, women killed their spouse, an intimate acquaintance, or a family member in 60% of cases. When men killed with a gun, they most commonly shot a stranger or a non-family acquaintance.(ABSTRACT TRUNCATED AT 250 WORDS)

Family↗
PubMed1991

Too sick to wait.

Explore the source record for details and available documents.

Emergency Service, Hospital↗
PubMed1991

Critical decision making: managing the emergency department in an overcrowded hospital.

Hospital and emergency department overcrowding is a serious and growing problem nationwide. Although EDs are organized around the goals of rapid patient assessment, stabilization, and prompt admission to the hospital, an increasing number are being required to hold admitted floor and critical care patients for extended periods due to lack of vacant inpatient beds. Provision of acceptable patient care under such circumstances requires a fundamental reordering of ED priorities and procedures. Overcrowding is the result of inadequate funding for emergency health care services during a period of increasing demand. The initial focus of management strategies to resolve this problem is the inpatient area and includes evaluation of length of stay, "intent to discharge" policies, flexible bed designations, restriction of in-house transfers, and the use of "over-census beds." If in-hospital management strategies fail, modifications in ED management may include staffing contingency plans, definition of physician responsibility, inpatient charts, revised pharmacy formulary, new floor plans, and modified accounting systems. Successful resolution of hospital and ED overcrowding may be the greatest challenge facing emergency medicine today.

Bed Conversion↗
PubMed1990

Firearm regulations and rates of suicide. A comparison of two metropolitan areas.

To investigate a possible association between firearm regulations and suicide, we compared the incidence of suicide from 1985 through 1987 in King County, Washington, with that in the Vancouver metropolitan area, British Columbia, where firearm regulations are more restrictive. The risk of death from suicide was not found to differ significantly between King County and the Vancouver area (relative risk, 0.97; 95 percent confidence interval, 0.87 to 1.09). The rate of suicide by firearms, however, was higher in King County (relative risk, 2.34; 95 percent confidence interval, 1.90 to 2.88), because the rate of suicide by handguns was 5.7 times higher there. The difference in the rates of suicide by firearms was offset by a 1.5-fold higher rate of suicide by other means in the Vancouver area. Persons 15 to 24 years old had a higher suicide rate in King County than in the Vancouver area (relative risk, 1.38; 95 percent confidence interval, 1.02 to 1.86). Virtually all the difference was due to an almost 10-fold higher rate of suicide by handguns in King County. We conclude that restricting access to handguns might be expected to reduce the suicide rate in persons 15 to 24 years old, but that it probably would not reduce the overall suicide rate.

Adolescent↗
PubMed1990

Validating survey responses to questions about gun ownership among owners of registered handguns.

While survey-based data on firearm ownership are essential for epidemiologic studies of the relation between gun ownership and injuries, the validity of respondent answers to questions about gun ownership has not been confirmed. In order to assess the accuracy of interview data about firearms, in June to August 1987, the authors attempted to contact residents of 75 homes in the cities of Memphis, Tennessee and Seattle, Washington listed as the address of the owner of a recently registered handgun. Despite problems with inaccurate registration data, contact was ultimately made with 55 households, 35 of which consented to a general interview that included a series of questions about gun ownership. Respondents in 31 of these 35 households (88.6%) readily acknowledged that one or more guns were kept in their home. Respondents in three of the remaining four households (8.6%) stated that guns were recently kept in their homes but were no longer kept there. Only one respondent (2.9%) denied categorically that guns of any kind were kept in her home. The authors conclude that, at least among registered gun owners, respondent answers to questions about gun ownership are generally valid and that survey data of this type can be utilized with confidence.

Adult↗
PubMed1990

Inhaled albuterol and oral prednisone therapy in hospitalized adult asthmatics. Does aminophylline add any benefit?

STUDY OBJECTIVE: To determine the efficacy of intravenous aminophylline in the treatment of adult patients hospitalized for exacerbation of asthma. DESIGN: Randomized, double-blind, placebo-controlled trial throughout the study. SETTING: University Hospital Clinical Research Center. PATIENTS: Forty-four patients admitted from the emergency room with a primary diagnosis asthma; 39 patients completed the study. INTERVENTIONS: Patients received either intravenous aminophylline or placebo in addition to frequent nebulized albuterol; prednisone 0.5 mg/kg body weight every 6 h orally; and supplemental oxygen. Aminophylline infusion rates were adjusted to achieve serum theophylline concentrations of 10 to 20 micrograms/ml. Changes were made in placebo infusion rates to maintain the double blind design. MEASUREMENTS AND RESULTS: Forced expiratory volume in 1 s (FEV1) and other spirometric measurements every 8 h by a blinded investigator or trained respiratory therapist. Subjective patient response and duration of hospitalization were compared. No difference in spirometric measurements was observed between the two groups at any time point. On admission to the study, FEV1 in the placebo group was 41.5 (+/- 2.9) percent predicted and in the aminophylline group 34.7 (+/- 2.3) percent predicted (p = 0.08). At discharge, FEV1 was 70.4 (+/- 2.9) percent predicted in the placebo group and 63.7 (+/- 2.8) percent predicted in the theophylline group (p = 0.10). There was no difference in subjective patient rating or duration of hospitalization between the two groups (placebo 1.95 days and aminophylline 1.78 days, p = 0.51). CONCLUSIONS: Our results suggest that aminophylline therapy does not add significant benefit to other standard therapies in hospitalized adult asthmatic patients. Because of the risks and cost of aminophylline treatment in the hospital setting, further research is needed to determine if there are subgroups of adult asthmatics who may benefit from the addition of aminophylline to other standard optimal therapies.

Acute Disease↗
PubMed1990

Patient 'dumping' post-COBRA.

To gauge the impact of the new federal patient transfer provisions following the federal Combined Budget Reconciliation Act of 1985 (COBRA), we monitored all emergency interhospital transfers to a public hospital emergency department in the Memphis, Tennessee area during three identical time periods: June 1 to August 31 of 1986, 1987, and 1988. A high number of transfers in the summer of 1986 diminished only slightly in summer 1987 (following implementation of COBRA). Far greater reductions occurred in summer 1988, when overcrowding forced our hospital to refuse most transfers. In contrast to changes in hospital policy, COBRA alone had little effect in this area.

Emergency Service, Hospital↗
PubMed1989

Dispatcher-assisted cardiopulmonary resuscitation. Validation of efficacy.

Dispatcher-delivered telephone instruction in cardiopulmonary resuscitation (CPR) has been proposed to increase rates of bystander CPR in cases of out-of-hospital cardiac arrest. We tested the efficacy of a previously developed CPR message using a recording mannikin in a high stress, simulated cardiac arrest scenario. Community volunteers were unaware they would perform CPR until immediately before each trial. Performance of volunteers without prior CPR training (group A, n = 65) who received telephone instruction was compared with that of previously trained volunteers (group B, n = 43) who received the same message. Performances of both groups were also compared with a third group (group C, n = 43) composed of previously trained volunteers who did not receive the message. Quality of CPR was graded by three CPR instructors using explicit criteria. Printout strips from the recording mannikins were also analyzed. Evaluators were unaware of the training status of volunteers. The three groups were of comparable sex, race, and educational level, but group C was significantly younger than groups A and B (31.7 vs. 37.7 years, p less than 0.001). Because of the time required for telephone instruction, groups A and B started chest compressions a mean of 4.0 minutes after collapse compared with 1.2 minutes for group C (p less than 0.0001). We found that the previously untrained volunteers of group A performed CPR of an overall quality comparable to that performed by previously trained members of group C. Group A performed chest compressions significantly better than group C (p less than 0.02) but had greater problems performing effective ventilations.(ABSTRACT TRUNCATED AT 250 WORDS)

Emergencies↗
PubMed1988

Handgun regulations, crime, assaults, and homicide. A tale of two cities.

To investigate the associations among handgun regulations, assault and other crimes, and homicide, we studied robberies, burglaries, assaults, and homicides in Seattle, Washington, and Vancouver, British Columbia, from 1980 through 1986. Although similar to Seattle in many ways, Vancouver has adopted a more restrictive approach to the regulation of handguns. During the study period, both cities had similar rates of burglary and robbery. In Seattle, the annual rate of assault was modestly higher than that in Vancouver (simple assault: relative risk, 1.18; 95 percent confidence interval, 1.15 to 1.20; aggravated assault: relative risk, 1.16; 95 percent confidence interval, 1.12 to 1.19). However, the rate of assaults involving firearms was seven times higher in Seattle than in Vancouver. Despite similar overall rates of criminal activity and assault, the relative risk of death from homicide, adjusted for age and sex, was significantly higher in Seattle than in Vancouver (relative risk, 1.63; 95 percent confidence interval, 1.28 to 2.08). Virtually all of this excess risk was explained by a 4.8-fold higher risk of being murdered with a handgun in Seattle as compared with Vancouver. Rates of homicide by means other than guns were not substantially different in the two study communities. We conclude that restricting access to handguns may reduce the rate of homicide in a community.

British Columbia↗
PubMed1988

Utilization and yield of drug screening in the emergency department.

Emergency qualitative tests for drugs are commonly ordered during evaluation of cases of suspected drug overdose. We prospectively compared the utilization and yield of drug screens based on urine and of identical tests of gastric contents under actual clinical conditions in a busy metropolitan emergency department. During the 4.5-month study period, physicians ordered drug screening in 405 of 582 (70%) study cases. Screens of both types of body fluid were ordered in only 95 cases (16%), suggesting study physicians regarded these tests to be functionally equivalent. Drug screens of gastric fluid were favored in cases involving acute ingestion and in medically complicated cases requiring gastric lavage. Urine drug screens were favored in clinically stable cases with primarily thought or behavior disorders. In the 95 cases for which both drug screens were ordered, gastric screens in 18 cases detected 20 drugs not detected by urine drug screening. Urine screening, on the other hand, identified 74 drugs not found on gastric screening in 48 cases. Gastric drug screening also performed poorly in comparison to quantitative serum drug levels. Seventeen false-positive urine or gastric screens were noted as well. Despite significant technical limitations, physicians frequently order drug screens in our emergency department. Qualitative drug screening of gastric fluid may prove useful in cases involving acute ingestion, but samples of urine and serum must also be submitted for analysis if optimal test performance is to be achieved.

Acute Disease↗
PubMed1988

In-hospital resuscitation following unsuccessful prehospital advanced cardiac life support: 'heroic efforts' or an exercise in futility?

From our emergency department logbook we identified 281 consecutive patients transported to the Regional Medical Center at Memphis following failed prehospital advanced cardiac life support (ACLS). Medical records were obtained for 240 cases (85.4%). Initial cardiac rhythms in the ED included ventricular fibrillation or pulseless ventricular tachycardia (29%), electromechanical dissociation (18%), and asystole (51%). Thirty-two patients (13.3%) were successfully resuscitated in the ED, but only four (1.7%) survived to hospital discharge. Two patients had good neurologic outcomes; both degenerated to cardiac arrest shortly prior to arrival in the ED. The remaining two survivors were discharged to nursing homes with severe neurologic deficits. Of the 41 cases for whom no medical records could be found, 39 were noted in our logbook to have died in the ED. No record of subsequent hospital admission could be found for the other two. Both are presumed to have died. Failure to respond to prehospital ACLS predicts nonsurvival and may warrant cessation of efforts in the field. Future programs and research efforts in the management of out-of-hospital cardiac arrest should be focused on optimal provision of prehospital care prior to the onset of irreversible deterioration.

Emergencies↗