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Biomedical subjects

Michael A Frakes

Publications and source records attributed to Michael A Frakes.

15 recordsLinked to original sources
PubMed2006

Efficacy of fentanyl analgesia for trauma in critical care transport.

INTRODUCTION: Pain relief is one of the most important interventions for out-of-hospital patient care providers. This paper documents the need for and benefits from the administration of fentanyl to trauma patients during critical care transport. METHODS: We underwent a retrospective review of the transport charts of 100 trauma patients who received fentanyl analgesia during transport and who were able to use a numeric response scale to rate their pain from 0 to 10. RESULTS: Mean initial pain report was 7.6 +/- 2.2 units, relieved to 3.7 +/- 2.8 units by a mean total fentanyl dose of 1.6 +/- 0.8 microg/kg (P < .001). Neither initial pain level nor pain relief differed between male and female patients, but did differ between patients originating at the site of injury and those transferred between hospitals. Fentanyl dose correlated poorly with the magnitude of pain relief (r = 0.22), but a dose greater than 2 microg/kg provided more relief than lower doses (5.1 +/- 2.1 vs 3.6 +/- 2.4, P < .02). CONCLUSION: Fentanyl analgesia from these critical care transport teams provided significant pain relief to trauma patients. Pain reduction was greater for patients who received more than 2.0 microg/kg of fentanyl.

Adolescent↗
PubMedDate not supplied

Clinical features of patients intubated by a flight team.

INTRODUCTION: Little information exists about the clinical features of patients intubated by a flight program and the relationships of those factors with flight team intervention. METHODS: Prospective analysis was conducted of consecutive patients intubated by a helicopter flight team. RESULTS: The flight team intubated 11.1% of patients transported. Scene origin and trauma diagnosis were associated with flight team intubation (P <.01). The diagnosis distribution differed between scene and interfacility groups (P <.01), with a trauma diagnosis more common in scene patients and a medical diagnosis more common on interfacility flights. The most common clinical indicator for intubation on both scene and interfacility flights was mental status change. The distribution of indicators, however, also varied with patient origin (P <.01). CONCLUSION: The flight team most commonly intubated patients who originated at the scene, suffered traumatic injury, and had altered mental status. Both the diagnosis distribution and primary clinical indicator for intubation varied with patient origin.

Air Ambulances↗
PubMedDate not supplied

EMS certification requirements for flight nurses.

INTRODUCTION: Emergency medical technician (EMT) or paramedic (EMTP) certification requirements for flight nurses (FNs) providing on-scene patient care vary. We surveyed those requirements and evaluated the relationships between flight team composition or program location and FN EMS certification. METHODS: Telephone survey of all 184 rotor-wing programs responding with a nurse to scenes RESULTS: The overall EMS training requirement for FNs was: none-57.6%, EMT-21.7%, EMTP-14.7%, local credential (not EMT or EMTP)-6.0%. Second team members were EMTP, RN, physician, or respiratory therapist (RRT). Overall, team configuration related significantly to FN EMS certification (P =.01). FN/EMTP and FN/RRT teams were individually significant (P <.01), with FN/EMTP teams tending not to require certification and all FN/RRT teams tending toward a certification requirement. Neither FN/FN nor FN/physician pairings related significantly with FN EMS certification requirements. Regional patterns emerged to both crew configuration and FN EMS certification requirements. CONCLUSION: Most flight programs do not require FN EMT/EMTP certification. Team configuration and geography are related to those requirements.

Air Ambulances↗
PubMedDate not supplied

Shift length and on-duty rest patterns in rotor-wing air medical programs.

INTRODUCTION: Air medical teams provide around-the-clock critical care, a pattern at risk of inducing performance-altering fatigue from circadian disruption and sleep deprivation. Safety is an essential issue in the air medical industry, but little data are available on shift length and on-duty rest practices. We report the results of a survey concerning those practices and analyze the relationships to crew duty practices by program model (hospital-operated, vendor-operated, independent, or public safety), base location, flight volume, and job requirements. METHODS: A survey was mailed to 182 Association of Air Medical Services-member rotor-wing air medical programs in the United States that complete scene flights with a flight nurse. One-hundred-twenty-nine programs (70.9%) returned anonymous surveys, all of which were used for data analysis. Results were analyzed with descriptive and nonparametric statistics. RESULTS: All pilots work shifts between 10 and 14 hours. For medical team members the shift distribution is: </= 8 hours, 0.4%; 9 to 12 hours, 44.2%; 12 to 16 hours, 7.0%; 17 to 24 hours, 45%; > 24 hours, 3.5%. An independent association exists between shift length greater than 12 hours and each of the following: flight volume per-aircraft under 731 flights/year, program model other than hospital operated, and nonhospital base (Fisher's exact test with Bonferroni correction, P < .01 for each). All pilots are allowed on-duty rest on both day and night shifts. On-duty rest is permitted for 67.4% of medical team members: 18.2% only at night, and 49.2% at any time of day. The presence of any period of on-duty crew rest is significantly associated with nonhospital base, program model other than hospital-operated, and shift length exceeding 12 hours (Fisher's exact test with Bonferroni correction, P < .01 for each). The presence of a nonflight clinical assignment while on flight duty is associated with a prohibition against on-duty rest (Fisher's exact test with Bonferroni correction, P < .05). CONCLUSION: Notable differences arose between on-duty work and rest patterns for pilots and medical team members. Medical team members generally work longer shifts than pilots do, with shifts exceeding 12 hours as the most common staffing pattern. Medical team members also have less access to on-duty rest than do pilots. Traditional hospital-operated programs are more likely to use shorter shifts and prohibit on-duty rest for the medical teams, whereas vendor-operated, independent, or public safety programs are more likely to use longer shifts and permit on-duty rest. As the industry works toward a unified approach to mitigating the impact of fatigue on safe operation, variable practices based on job description and program style may be a factor.

Air Ambulances↗
PubMedDate not supplied

Off-duty preparation for overnight work in rotor wing air medical programs.

INTRODUCTION: Air medical teams provide around-the-clock critical care, risking performance-altering fatigue from circadian disruption and sleep deprivation. Although safety is an essential issue in the air medical industry, there is little understanding of off-duty preparation for overnight shifts. METHODS: An anonymous survey was distributed to pilots and medical team members at participating programs with variable program, staffing, and shift models. Eighty responses from crewmembers working 12-hour night shifts (12N) were analyzed with appropriate t-tests and nonparametric tests. RESULTS: 12N crewmembers sleep significantly less in off-duty periods than before night shifts: 7.3 +/- 1.2 hours versus 4.8 +/- 1.9 hours (P < 0.01). Preshift sleep does not differ between crewmembers permitted on-duty rest and those for whom it is prohibited. 34.1% of 12N crewmembers permitted on-duty rest say they report to work planning to sleep. The minimum preshift sleep reported by 12N crewmembers before any shift in the past month averaged 2.4 +/- 2.3 hours, with 36.3% having worked overnight in the past month with no sleep before their shift On-duty rest permission was not a significant factor. Fifty-five percent of 12N crewmembers report outside employment (OE) in addition to their flight position. 12N crewmembers with OE averaged significantly less preshift sleep than those without OE: 4.4 +/- 2.1 hours versus 5.3 +/- 1.6 hours (P < 0.05). 54.5% of 12N crewmembers with OE described reporting to a flight shift within 8 hours of leaving their other job at least once within the past month. OE was more common when the flight program permitted on-duty rest (P < 0.01). CONCLUSION: Air medical team members report for 12N shifts with a significant sleep debt that does not differ between crewmembers permitted on-duty rest and those with on-duty rest prohibitions. More than half of flight team members surveyed have OE and many report for flight duty within 8 hours of leaving their other job. 12N shift crewmembers are at a particularly high risk for the consequences of fatigue. This is an important consideration as the industry develops on-duty rest guidelines to optimize safe operations.

Air Ambulances↗
PubMedDate not supplied

Sedative use in patients receiving neuromuscular blocking agents from a helicopter flight team.

INTRODUCTION: Cognitive awareness under general anesthetic may occur in up to 0.2% of patients, with approximately twice the risk in chemically paralyzed patients. Patients in emergency and critical care areas frequently receive neuromuscular blocking agents (NMBA), but a recent survey indicated that only 90% to 96% of critical care nurses routinely provide concurrent sedative medications to those patients. We sought to determine the potential for awake paralysis in patients transported by helicopter critical care transport teams and to evaluate for associations with clinical factors. METHODS: A retrospective review was performed of the rotor-wing transport records of 103 consecutive patients receiving NMBAs and without cardiac arrest during their care. Using hospital-approved pharmacological references, independent reviewers determined whether individual patients were likely to be under the effects of sedative medications during their period of neuromuscular blockade. Descriptive statistics are reported, and the chi-square test was used to evaluate relationships. RESULTS: The sample population was 70.9% male, 89.3% adult, 53.4% trauma/surgical, 66% interhospital, and 88.3% normotensive (SBP>90 mm Hg). Clinically, 91.3% of patients were judged as probably to have been under the effects of some sedative during their period of paralysis. There was not a significant association between the use of sedatives and any of the factors studied: sex, age, diagnosis, site of origin, flight nurse experience, or systolic blood pressure. Patients most commonly received benzodiazepine alone (70.2%), followed by benzodiazepine+opioid (23.4%), opioid alone (5.3%), and propofol (1.1%). Medication choice was also unrelated to any of the clinical factors studied. DISCUSSION: Awake paralysis is difficult to detect but is a serious practice complication. In anesthesia practice, 96% of such cases were considered substandard care, even with prompt recognition and management. Flight nurses administer sedatives at rates similar to other critical care nurses but not to all chemically paralyzed patients. We were unable to identify clinical correlations with medication use or omission. Additional phenomenological and quantifiable evaluations of consciousness during the transport of chemically paralyzed patients would be valuable studies. CONCLUSION: Patients receiving NMBAs during transport by helicopter flight teams are at risk for awareness during paralysis. Both practice development and research efforts in this area would be useful.

Adolescent↗
PubMedDate not supplied

Sleep debt and outside employment patterns in helicopter air medical staff working 24-hour shifts.

INTRODUCTION: Twenty-four hour availability creates physiological and psychological challenges for air medical teams. The 24-hour shift (24H) is a common staffing pattern in the air medical community. We report sleep dept and pre-duty activity patterns for 24H medical staff members at helicopter air medical transport programs. METHODS: An anonymous survey collecting self-reported sleep quantities for off-duty, immediate pre-duty, and on-duty periods, along with self-reported outside employment patterns, was distributed to medical team members at cluster sample of 10 rotor wing air medical programs selected by stratified random sample to ensure geographic and operational diversity. Both matched-sample comparisons of sleep quantities in different phases of the duty-cycle and independent-sample comparisons between staff with and without outside employment had 80% power to detect a difference in means of 60 minutes at a 0.05 two-sided significance level using the appropriate t-test. Descriptive statistics are also reported; means are reported with the standard deviation. RESULTS: A total of 138 surveys were returned (69.0%) and the 133 (66.5%) that were fully completed were utilized for analysis. 24H crewmembers average nearly the same amount of sleep in 24 hour periods on both duty and non-duty days (6.9 +/- 1.3 v. 6.4 +/- 1.8 hours, p = NS, range 3 - 10 for duty days and 4 - 10 for non-duty days). On duty, they average 1.1 +/- 1.3 hours of sleep in the first half of their shifts (range 0 to 5) and 5.3 +/- 1.4 hours in the overnight portion (range 2 - 9). The lowest amount of on-duty sleep reported in the past 30 days ranged from 0 to 6 hours, averaging 1.9 +/- 1.7 hours. The minimum pre-duty sleep reported by 24H crewmembers prior to any shift in the past month averaged 4.6 +/- 1.6 hours (range 0-8), with 3.8% having reported in the past month with no sleep before their 24-hour shift. Outside employment (OE) in addition to the flight position was common for 24H crewmembers (81.1% of respondents). Pre-duty sleep did not differ significantly between 24H crewmembers with and without OE, but 16.3% of surveyed 24H crewmembers with OE had reported for flight duty within eight hours of leaving OE within the past 30 days. CONCLUSION: In the programs surveyed, 24H crewmembers completed an average duty cycle with little sleep debt and were unlikely to be sleepless prior to reporting for a shift. OE is common for 24H medical staff and some personnel report for flight duty within eight hours of leaving an OE position. As the industry considers the impact of fatigue on operational safety, shift length, on-duty rest, and outside employment will be important considerations.

Air Ambulances↗
PubMedDate not supplied

Evaluation and management of the patient with LeFort facial fractures.

Fractures of the maxillary facial bones, also described as LeFort fractures, are potentially disfiguring and potentially lethal injuries that require careful examination and expectant management skills. This review article provides an overview of facial anatomy, fracture patterns, patient assessment, and the specific management of patients with LeFort fractures.

Airway Obstruction↗
PubMedDate not supplied

Flight team management of in-place endotracheal tubes.

INTRODUCTION: Unintended misplacement or removal of the endotracheal tube (ETT) complicates the care of up to 18% of intubated patients. This project analyzed the incidence of such complications in patients transported by a flight program. METHODS: 9-month analysis of all intubated patients transported by the flight team. RESULTS: 340/926 patients transported were intubated. One extubation was unplanned and no patients were delivered to the receiving hospital with an esophageal or endobronchial ETT placement. After initial examination, 19/241 ETTs placed before flight team arrival were repositioned. Rates of misplacement on arrival at the receiving hospital and of unplanned extubation were significantly lower than those reported in the EMS or critical care literature. CONCLUSION: Flight teams have very low rates of unplanned extubation or undetected ETT misplacement when transporting intubated patients.

Adolescent↗
PubMedDate not supplied

An overview of Medicare reimbursement regulations for advanced practice nurses.

The federal government spends nearly 15% of the budget on Medicare services annually, and advanced practice nurses are eligible for reimbursement from that pool. The regulations governing reimbursement are complex because of the social, political, and financial pressures involved in their development. Although economic viability and due diligence considerations make it incumbent on advanced practice nurses to understand the rules, the profession, as a whole, has knowledge deficits in this area. The essentials of regulatory development and structure are reviewed and considerations for optimizing reimbursement are described.

Government Regulation↗