The rightness of emergency medicine.
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Emergency Medical Services↗
Biomedical subjects
John A Marx
Publications and source records attributed to John A Marx.
Nosocomial infection with vancomycin-dependent enterococci.
We report three patients infected with unique strains of vancomycin-dependent enterococci. Two were first infected by genetically identical strains of vancomycin-resistant enterococci (VRE). All three patients had much greater exposure to vancomycin and third-generation cephalosporins than did two control groups (patients infected with VRE and hospitalized patients without enterococcal infections). While antimicrobial pressure promotes nosocomial colonization by VRE, prolonged exposure to vancomycin may foster the transition from vancomycin resistance to dependence.
Anti-Bacterial Agents↗
FAST (focused assessment with sonography in trauma) accurate for cardiac and intraperitoneal injury in penetrating anterior chest trauma.
OBJECTIVE: To evaluate the FAST (focused assessment with sonography in trauma) examination for determining traumatic pericardial effusion and intraperitoneal fluid indicative of injury in patients with penetrating anterior chest trauma. METHODS: An observational prospective study was conducted over a 30-month period at an urban level I trauma center. FAST was performed in the emergency department by emergency physicians and trauma surgeons. FAST results were recorded before review of patient outcome as determined by 1 or more of the following: thoracotomy, laparotomy, pericardial window, cardiologic echocardiography, diagnostic peritoneal lavage, computed tomography, and serial examinations. RESULTS: FAST was undertaken in 32 patients with penetrating anterior chest trauma: 20 (65%) had stab wounds, and 12 (35%) had gunshot wounds. Sensitivity of FAST for cardiac injury (n = 8) in patients with pericardial effusion was 100% (95% confidence interval, 63.1%-100%); specificity was 100% (95% confidence interval, 85.8%-100%). The presence of pericardial effusion determined by FAST correlated with the need for thoracotomy in 7 (87.5%) of 8 patients (95% confidence interval, 47.3%-99.7%). One patient with a pericardial blood clot on cardiologic echocardiography was treated nonsurgically. FAST had 100% sensitivity for intraperitoneal injury (95% confidence interval, 63.1%-100%) in 8 patients with views indicating intraperitoneal fluid but without pericardial effusion, again with no false-positive results, giving a specificity of 100% (95% confidence interval, 85.8%-100%). This prompted necessary laparotomy in all 8. CONCLUSIONS: In this series of patients with penetrating anterior chest trauma, the FAST examination was sensitive and specific in the determination of both traumatic pericardial effusion and intraperitoneal fluid indicative of injury, thus effectively guiding emergent surgical decision making.
Ascites↗
Emergency department resuscitative procedures: animal laboratory training improves procedural competency and speed.
UNLABELLED: Certain resuscitative procedures can be lifesaving, but are performed infrequently by emergency medicine (EM) residents on human subjects. Alternative training methods for gaining procedural proficiency must be explored and tested. OBJECTIVE: To test whether animal laboratory training (ALT) is associated with sustained improvement in procedural competency and speed. METHODS: After watching an educational videotape of saphenous cutdown (SAPH), thoracotomy (THOR), and cricothyroidotomy (CRIC), EM residents were randomized to receive either a tutored ALT session on live anesthetized pigs (Group A) or no ALT session (Group B). Residents were tested six months later by performing procedures on live anesthetized pigs. Videotaped procedures were evaluated by blinded examiners for the number of critical steps, complications, and procedure times. RESULTS: Group A (n = 10) achieved a higher number of critical steps compared with Group B (n = 8) for SAPH (15.4 +/- 0.7 vs. 9.0 +/- 1.8, p = 0.03) and THOR (17.4 +/- 0.6 vs. 12.3 +/- 1.6, p = 0.009), but not CRIC (18.1 +/- 0.4 vs. 16.2 +/- 1.0, p = 0.1). Group A completed procedures in less time than Group B for SAPH (Wilcoxon chi(2) = 4.0, p = 0.04) and THOR (chi(2) = 4.4, p = 0.04), but not CRIC (chi(2) = 0.9, p = 0.3). There was no difference in the number of complications for any of the procedures. CONCLUSION: Residents with animal laboratory training six months prior to testing demonstrated improved procedural competency and speed in the performance of resuscitative procedures.
Adult↗