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Biomedical subjects

Lawrence H Brown

Publications and source records attributed to Lawrence H Brown.

At least 19 recordsLinked to original sources
PubMed2006

Emergency department treatment of viral gastritis using intravenous ondansetron or dexamethasone in children.

OBJECTIVES: To compare the efficacy of intravenous ondansetron or dexamethasone compared with intravenous fluid therapy alone in children presenting to the emergency department with refractory vomiting from viral gastritis who had failed attempts at oral hydration. METHODS: This double-blind, randomized, controlled trial was performed in a tertiary care pediatric emergency department. Children aged 6 months to 12 years presenting with more than three episodes of vomiting in the past 24 hours, mild/moderate dehydration, and failed oral hydration were included. Patients with other medical causes were excluded. Subjects were randomized to dexamethasone 1 mg/kg (15 mg maximum), ondansetron 0.15 mg/kg, or placebo (normal saline [NS], 10 mL). All subjects also received intravenous NS at 10-20 mL/kg/hr. Oral fluid tolerance was evaluated at two and four hours. Those not tolerating oral fluids at four hours were admitted. Discharged patients were evaluated at 24 and 72 hours for vomiting and repeat health care visits. The primary study outcome was hospitalization rates between the groups. Data were analyzed using chi-square test, Kruskal-Wallis test, Mantel-Haenszel test, and analysis of variance, with p < 0.05 considered significant. RESULTS: A total of 166 subjects were enrolled; data for analysis were available for 44 NS-treated patients, 46 ondansetron-treated patients, and 47 dexamethasone-treated patients. Hospital admission occurred in nine patients (20.5%) receiving placebo (NS alone), two patients (4.4%) receiving ondansetron, and seven patients (14.9%) receiving dexamethasone, with ondansetron significantly different from placebo (p = 0.02). Similarly, at two hours, more ondansetron-treated patients (39 [86.6%]) tolerated oral hydration than NS-treated patients (29 [67.4%]; relative risk, 1.28; 95% confidence interval = 1.02 to 1.68). There were no differences in number of mean episodes of vomiting or repeat visits to health care at 24 and 72 hours in the ondansetron, dexamethasone, or NS groups. CONCLUSIONS: In children with dehydration secondary to vomiting from acute viral gastritis, ondansetron with intravenous rehydration improves tolerance of oral fluids after two hours and reduces the hospital admission rate when compared with intravenous rehydration with or without dexamethasone.

Antiemetics↗
PubMed2006

Can stock rotation effectively mitigate EMS medication exposure to excessive heat and cold?

The United States Pharmacopeia recently published a general chapter specifically addressing on-ambulance storage of medications, including a suggestion for stock rotation. This study describes the effectiveness of a simple stock rotation strategy in mitigating EMS medication exposure to excessive heat and cold. Previously collected on-ambulance temperature data from 5 US cities were randomly resampled to generate model exposures of 2 days to 6 months duration. The temperature measurements for every other 24-hour period were then set at 20 degrees C to model the rotation of medications into a controlled environment. For each model, we then determined consistency with the official United States Pharmacopeia definition of controlled room temperature. Without stock rotation, excessive heat occurred in 39.9% of the model exposures. With stock rotation, exposures to excessive heat occurred in less than 1% of northern city models and in 2.9% of the central US models. Stock rotation did not reduce heat exposures in the models for southern cities.

Ambulances↗
PubMed2006

Patient perceptions of emergency physicians: the gender gap still exists.

This study examines whether female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians. A convenience sample of adult patients seen while a trained observer was on duty in an academic Emergency Department constituted the study population. After the first physician contact, the observer asked the patient if a physician had seen the patient yet. The observer recorded the physician's sex, the patient's response, sex, age, and race. The frequencies that male and female physicians were recognized as physicians were compared. For the 184 physician-patient contacts evaluated, 98/105 (93.3%) of males were recognized as physicians and 62/79 (78.5%) of females were recognized as physicians. Females were significantly less likely than males to be recognized as physicians (chi-square, p = 0.003). Female emergency physicians are less likely than male emergency physicians to be recognized by patients as physicians.

Adult↗
PubMed2005

Medication storage in the EMS environment: understanding the science and meeting the standards.

In most systems, current EMS medication storage practices are not consistent with USP standards. Exposure to excessive heat and excessive cold are both common. Although the clinical implications of noncompliant storage remain unclear, it's in the best interest of patients to do everything possible to meet the standards. To help in this effort, USP has generated EMS-specific guidance for medication storage. Most of the strategies for achieving compliance with USP standards are relatively simple and inexpensive. All EMS systems should develop a plan for medication storage that strives to achieve compliance with the USP standards, and reevaluate that plan on a regular basis.

Drug Storage↗
PubMed2004

Conducting research using the emergency exception from informed consent: the Public Access Defibrillation (PAD) Trial experience.

BACKGROUND: The Public Access Defibrillation (PAD) Trial, a prospective, multicenter, randomized clinical trial comparing two prehospital resuscitation strategies, was conducted under the regulations for exception from informed consent (21CFR50.24) in 24 communities in North America. These regulations place additional requirements for human subject protection on investigators and Institutional Review Boards (IRBs), including conducting community consultation (CC) and public disclosure (PD). OBJECTIVE: To describe the IRB approval process at study sites and the number and types of community consultation and public disclosure activities conducted. METHODS: The 24 study sites in the United States and Canada submitted IRB applications, CC and PD plans, and a structured report on IRB process and investigator perceptions to the Clinical Trial Center at the University of Washington. RESULTS: The primary IRBs for all 24 trial sites and a total of 101 IRBs approved the study. The median interval from submission to approval was 108 days (IQR 43-196), and the mean number of revisions was two (range 0-7). Investigators conducted nearly 12,000 activities to achieve CC and PD; activities varied greatly from site to site in both type and quantity. CONCLUSION: The length of time to obtain IRB approval and the extent of community consultation and public disclosure varied greatly among trial sites in meeting the current regulations for conducting emergency research with exception from informed consent. This suggests that more specific guidance may be useful and that determination of effective strategies for community consultation and public disclosure is needed.

Cardiopulmonary Resuscitation↗
PubMed2003

National EMS research agenda: proceedings of the implementation symposium.

The National EMS Research Agenda identified eight recommendations for improving the conduct of emergency medical services (EMS) research in the United States. EMS leaders from across the country attended a two-day symposium to discuss implementation of the Research Agenda recommendations. The participants suggested specific methods to move the recommendations forward. These included improving training opportunities for EMS researchers, stimulating increases in available funding sources, facilitating the integration of research into practice, and crafting alterations within the regulatory environment. Participants felt that EMS must be more broadly integrated into the public health continuum. Federal agencies, states, local governments, charitable foundations, and corporations are asked to examine their practices to increase opportunities for participation in EMS research programs at all stages of the process.

Emergency Medical Services↗
PubMed2002

The emergency medicine rotation: a unique experience for medical students.

The objective of this study was to determine if an Emergency Medicine (EM) rotation for medical students offers a unique educational opportunity, and to document those experiences. Thirty-three medical students at one teaching hospital recorded in a computer database information about their patient encounters during EM and Internal Medicine (IM) rotations. Data collected included the types of patients seen, the level of participation in patient care and decision making, and procedures performed. A total of 2740 patient encounters were recorded, 1564 EM and 1176 IM. Students on EM rotations were more likely than students on IM rotations to be involved in the initial evaluation (93.1% vs. 47.0%, respectively), diagnosis (93.5% vs. 44.7%, respectively), and decision making (93.3% vs. 43.5%, respectively); they were also more likely to perform procedures (31.7% vs. 8.5%, respectively). There were significant differences in the patient populations and disease processes encountered on the two rotations as well.

Clinical Clerkship↗
PubMed2002

Falls from rooftops after heavy snowfalls: the risks of snow clearing activities.

Many patients present to emergency departments as a result of falling from a roof while shoveling snow. This study was undertaken to determine whether the frequency of such falls increases after large snowfalls, and to describe associated injuries. We reviewed the records of all patients presenting with cause of injury codes (E-codes) related to a fall: (E882, E881, and E884.9). We compared the frequency with which snow-shoveling related falls from roofs occurred on days with and without snowfalls greater than 12 inches. Fifty-nine patients met inclusion criteria. Patients were more likely to fall from a roof while shoveling snow on days with greater than 12 inches of snow accumulation than on days with less than 12 inches of snow accumulation (12/14 v 2/45, P <.001). Injuries included spinal fractures, extremity fractures, and head injury. These results suggest a need for public service campaigns emphasizing the risks of roof shoveling.

Accidental Falls↗
PubMedDate not supplied

Out-of-hospital medication storage temperatures: a review of the literature and directions for the future.

The United States Pharmacopeia (USP) National Formulary prescribes the packaging, storage, and distribution of medications. Most of the medications commonly used by emergency medical services (EMS) are intended for storage at "controlled room temperature." The USP definition of controlled room temperature is multifaceted and complex, and cannot be easily described as a simple range of acceptable temperatures, or even as an average temperature. The out-of-hospital environment is notoriously uncontrolled, and one of the uncontrolled aspects of that environment is temperature. This report reviews and summarizes the past 15 years of published research relating to out-of-hospital medication temperature exposures. Although the evidence is clear that EMS medication storage is not consistent with the USP definition of controlled room temperature, the impact of EMS medication storage on medication stability and potency remains unclear. Further research is needed to determine the true extent of the EMS medication storage problem, and to develop and validate appropriate solutions.

Drug Stability↗
PubMedDate not supplied

The value of EMS experience when applying to medical school?

INTRODUCTION: This study explores the value of Emergency Medical Services (EMS) experience for students applying to medical school. METHODS: Surveys were sent to 67 medical schools in the eastern United States and Canada. Using a five-point Likert scale, the survey asked the respondent to rate the amount of consideration given to Emergency Medical Technician (EMT) or paramedic experience when making admissions decisions (1 = very little to 5 = strong), and to describe the influence of that experience (1 = very negative to 5 = very positive). RESULTS: Usable responses were received from 21 schools. The median rating for the consideration given to EMS experience was "some consideration" for both EMT and paramedic experience, with 85.7% of respondents assigning that rating or higher. The median rating for the influence of that experience was "somewhat positive" for both EMT and paramedic experience. Only 14.3% of the returned surveys rated EMS experience as "neutral", and no respondent reported EMS experience as a "negative". CONCLUSION: EMS experience receives at least some consideration during the admissions process at most of the responding institutions in the United States and Canada. Experiences at either the EMT or Paramedic level are viewed similarly. None of the responding institutions viewed EMS experience negatively.

Canada↗
PubMedDate not supplied

Changes in physical examination caused by use of spinal immobilization.

UNLABELLED: The standard of care for patients following blunt trauma includes midline palpation of vertebrae to rule out fractures. Previous studies have demonstrated that spinal immobilization does cause discomfort. OBJECTIVE: To determine whether spinal immobilization causes changes in physical exam findings over time. METHODS: This was a single-blinded, prospective study at a tertiary care university teaching hospital. Twenty healthy volunteers without previous back pain or injuries, 13 male and seven female, were fully immobilized for one hour, with a cervical collar and strapped to a long wooden backboard. Midline palpation of vertebrae to illicit pain was performed at 10-minute intervals. In addition, the participants were asked to rate neck and back pain on a scale from 1 to 10 (1 for no pain, and 10 for unbearable pain), to see whether subjective pain from immobilization correlated with tenderness to palpation. RESULTS: Three patients had point tenderness of cervical vertebrae within 40 minutes. Five patients developed point tenderness of vertebrae by 60 minutes. Eighteen of 20 participants complained of increasing discomfort over time. The median initial pain scale was 1 (range 1-1), in contrast to 4 (range 1-9) at 60 minutes, p < 0.05. CONCLUSION: This study shows that over time, standard immobilization causes a false-positive exam for midline vertebral tenderness. In order to reduce this high false-positive rate for midline vertebral tenderness, the authors recommend that, initially on arrival to the emergency department, immediate evaluation occur of all immobilized patients. Furthermore, backboards should be modified to reduce patient discomfort to prevent the iatrogenically induced midline vertebral tenderness, thereby reducing subsequent false-positive examinations.

Adult↗
PubMedDate not supplied

National prevalence of palliative care protocols in emergency medical services.

OBJECTIVES: There are approximately 500,000 hospice patients in the United States. While hospice patients may desire only palliative care, they often access the emergency medical services (EMS) system, unaware that many EMS systems do not have specific palliative care protocols. This study was undertaken to determine the prevalence of palliative care protocols among EMS agencies in the United States, and to estimate the percentage of the U.S. population covered by such protocols. METHODS: A survey requesting information about out-of-hospital palliative care protocols was mailed to the EMS agencies serving the 200 most populous U.S. cities. After four weeks a follow-up telephone call was made to those agencies that had not yet responded. The number of agencies with a palliative care protocol was determined, and the populations served by those agencies with and without palliative care protocols were calculated. RESULTS: Responses were received from 121 (60.5%) of the cities. Only seven (5.8%) of the responding cities' EMS agencies had a palliative care protocol. The population of cities covered by a palliative care protocol was just under 3 million, or slightly more than 6% of the 47.2 million people living in the responding cities. CONCLUSIONS: Most of the U.S. population is not served by an EMS agency with specific palliative care protocols. Until more EMS systems enact specific palliative care protocols, physicians treating the terminally ill should educate patients and families about appropriate use of the EMS system, and that EMS professionals may be required to provide more than supportive care.

Clinical Protocols↗
PubMedDate not supplied

Public safety answering point readiness for wireless E-911 in New York State.

OBJECTIVE: To determine the level of wireless enhanced 911 readiness among New York's primary public safety answering points. METHODS: This descriptive study utilized a simple, single-page survey that was distributed in August 2001, with telephone follow-up concluding in January 2002. Surveys were distributed to directors of the primary public safety answering points in each of New York's 62 counties. Information was requested regarding current readiness for providing wireless enhanced 911 service, hardware and software needs for implementing the service, and the estimated costs for obtaining the necessary hardware and software. RESULTS: Two directors did not respond and could not be contacted by telephone; three declined participation; one did not operate an answering point; and seven provided incomplete responses, resulting in usable data from 49 (79%) of the state's public safety answering points. Only 27% of the responding public safety answering points were currently wireless enhanced 911 ready. Specific needs included obtaining or upgrading computer systems (16%), computer-aided dispatch systems (53%), mapping software (71%), telephone systems (27%), and local exchange carrier trunk lines (42%). The total estimated hardware and software costs for achieving wireless enhanced 911 readiness was between 16 million and 20 million dollars. CONCLUSIONS: New York's primary public safety answering points are not currently ready to provide wireless enhanced 911 service, and the cost for achieving readiness could be as high as 20 million dollars.

Cell Phone↗
PubMedDate not supplied

Location of cardiac arrests in the public access defibrillation trial.

BACKGROUND: The Public Access Defibrillation (PAD) Trial found an overall doubling in the number of out-of-hospital cardiac arrest (CA) survivors when a lay responder team was equipped with an automated external defibrillator (AED), compared with cardiopulmonary resuscitation (CPR) alone. OBJECTIVES: To describe the types of facilities that participated in the trial and to report the incidence of CA and survival in these different types of facilities. METHODS: In this post-hoc analysis of PAD Trial data, the physical characteristics of the participating facilities and the numbers of presumed CAs, treatable CAs, and survivors are reported for each category of facilities. RESULTS: There were 625 presumed CAs at 1,260 participating facilities. Just under half (n = 291) of the presumed CAs were classified as treatable CAs. Treatable CAs occurred at a rate of 2.9 per 1,000 person-years of exposure; rates were highest in fitness centers (5.1) and golf courses (4.8) and lowest in office complexes (0.7) and hotels (0.7). Survival from treatable CA was highest in recreational complexes (0.5), public transportation sites (0.4), and fitness centers (0.4) and lowest in office complexes (0.1) and residential facilities (0.0). CONCLUSIONS: During the PAD Trial, the exposure-adjusted rate of treatable CA was highest in fitness centers and golf courses, but the incidence per facility was low to moderate. Survival from treatable cardiac arrest was highest in recreational complexes, public transportation facilities, and fitness centers.

Age Distribution↗
PubMedDate not supplied

The National EMS Research strategic plan.

One of the eight major recommendations put forth by the National EMS Research Agenda Implementation Project in 2002 was the development of an emergency medical services (EMS) research strategic plan. Using a modified Delphi technique along with a consensus conference approach, a strategic plan for EMS research was created. The plan includes recommendations for concentrating efforts by EMS researchers, policy makers, and funding resources with the ultimate goal of improving clinical outcomes. Clinical issues targeted for additional research efforts include evaluation and treatment of patients with asthma, acute cardiac ischemia, circulatory shock, major injury, pain, acute stroke, and traumatic brain injury. The plan calls for developing, evaluating, and validating improved measurement tools and techniques. Additional research to improve the education of EMS personnel as well as system design and operation is also suggested. Implementation of the EMS research strategic plan will improve both the delivery of services and the care of individuals who access the emergency medical system.

Emergency Medical Services↗