Contribution of air medical personnel to the airway management of injured patients

INTRODUCTION: Air medical services are being pressured to demonstrate their value. Airway management is the first priority of care when treating injured patients in the prehospital setting. Injured patients with decreased Glasgow Coma Scale (GCS) are candidates for advanced airway procedures and air medical transport. RESEARCH QUESTION: The purpose of this study was to determine the extent of air medical crews' contributions to the airway management of the injured patient in the prehospital setting. METHOD: A study of adult (age > 12 years) injured patients encountered in a field setting, whose GCS on the arrival of the air medical crew was < or = 8, was conducted for 21 months (Feb. 1, 1991-Oct. 31, 1992). RESULTS: During the study period, 174 patients who met the criteria were transported by the air medical crew. All but one received advanced airways including oral tracheal intubation, nasal tracheal intubation or cricothyrotomy. Of those, 68 (39%) of these procedures were completed by ground personnel (ground group), and 105 (61%) were completed by the air medical personnel (air group). The mean GCS for the ground group was 3.69 and for the air group was 4.69. The distributions were significantly different (Wilcoxon Rank Test p = 0.0002). Nineteen percent (13/68) of the patients whose airways were successfully managed by the ground personnel had a GCS of 5 to 8, as did 44% (46/105) of the air group's patients. The groups' patients were not significantly different in age or sex distribution. CONCLUSION: Properly trained air medical personnel positively contribute to the prehospital care of injured patients by establishing definitive airways in patients with higher GCSs.     

8.5 French peripheral intravenous access during air medical transport of the injured patient

Introduction: This study describes a simple approach to peripheral large-bore intravenous (IV) access for the injured patient.Method: Retrospective chart review of patients identified by concurrent transport registry who received peripheral 8.5 F IV access during air medical transport for injury. The transport program consists of four remote-based BK-117 helicopters staffed by a nurse/paramedic crew. A peripheral 8.5 F IV access was obtained by protocol using guidewire technique over an existing peripheral IV. Crew education consisted of a combination of didactic and hands-on experience updated periodically on an ongoing basis.Results: From July 1991 through March 1995, 23 injured patients transported to a single Level I trauma center received a peripheral 8.5 F introducer. The patients averaged 30.9 years of age and were primarily male (78.3%) with blunt injuries (87%). Initial trauma score averaged 9.8; injury severity score averaged 24.6. All patients had at least one additional IV line; 21 of 23 patients were endotracheally intubated. Ground times averaged 19 minutes, flight time averaged 22.1 minutes, and in-flight fluids averaged 2239 ml or 101 ml per minute of flight. Complications associated with prehospital IV access did not occur.Conclusion: Peripheral 8.5 F access through a guidewire technique of an existing IV provides a rapid, simple approach to large-bore IV access in the injured patient transported by air.     

Current practice regarding reading previous films in the NHS Breast Screening Programme

Purpose: To evaluate current practice regarding reading previous films in the NHS Breast Screening Programme (NHSBSP) and review the imaging literature.Method: All NHSBSP units were sent a postal questionnaire. Each was asked whether they always read with previous films on the viewer? Those that answered, ‘yes’ were asked which films they display medio-lateral oblique (MLO), cranio-caudal (CC), or both?Results: Ninety-five of 101 centres replied to our postal questionnaire. Ninety-three of the 95 that replied are currently reading previous mammograms as part of their routine practice. Two units said previous mammograms are viewed only selectively. Forty-seven of the 93 that read with previous films display MLO views only. Forty-six of the 93 read both MLO and CC views if these are available.Conclusion: Consistent with ‘best practice’, most breast screening units in the NHSBSP display previous films when reading screening mammograms.     

Motivation and satisfaction among polyclinic volunteers at the 2002 Winter Olympic and Paralympic Games

Background: The Olympic and Paralympic Games rely heavily on volunteers to provide many essential services, including medical care of athletes.

Objective: This preliminary investigation sought to characterise the motivational influences and factors responsible for the satisfaction of Olympic and Paralympic healthcare volunteers.

Methods: The 2002 Winter Games polyclinic healthcare volunteers were asked to complete a questionnaire designed to elicit information about their motives for volunteering and the factors that contributed to their satisfaction with their volunteer experience.

Results: There was no significant difference in the motivation or satisfaction summary scores based on event worked. There was a strong positive correlation between motivation and satisfaction. Physician respondents had a lower mean motivation score than did non-physician volunteers.

Conclusions: There were no significant motivational differences between Olympic and Paralympic volunteers, but there were several differences noted between physician and non-physician volunteers. The 2002 polyclinic volunteers appear to have been motivated by a complex process best described as "enlightened self interest," and all were generally well satisfied with their experience. These results may assist organisers of future Games in selecting appropriately motivated volunteer personnel and creating rewarding work environments for them.

     

A new technique of surface anatomy MR scanning of the brain: its application to scalp incision planning

BACKGROUND AND PURPOSE: Surface anatomy scanning (SAS) is an established technique for demonstrating the brain's surface. We describe our experience in applying SAS with superposition of MR venograms to preoperative scalp incision planning. METHODS: In 16 patients, scalp incision planning was done by placing a water-filled plastic tube at the intended incision site when we performed SAS using half-Fourier single-shot fast spin-echo sequences. Two-dimensional phase-contrast MR angiograms were obtained to demonstrate the cortical veins and then superimposed upon the SAS images. The added images were compared with surgical findings using a four-point grading scale (0 to 3, poor to excellent). RESULTS: In each case, neurosurgeons could easily reach the lesion. Surgical findings correlated well with MR angiogram-added SAS images, with an average score of 2.56. CONCLUSION: Our simple technique is a useful means of preoperatively determining brain surface anatomy and can be used to plan a scalp incision site.     

Learning styles of radiographers

Purpose: The purpose of the study was to determine how radiographers learn and to explore how this may affect professional learning.Method: Twenty copies of Kolb’s Learning Style Inventory 1985 were distributed to each of a random sample of 31 hospitals in one health region. The response rate was 84% (n=26) of hospitals yielding a useable questionnaire return of 224.Results: On the continuum representing perception of information 75% (n=169) of respondents scored higher on the learning attribute of abstract conceptualisation than concrete experience. Twenty percent (n=45) scored higher on concrete experience than abstract conceptualisation. Five percent (n=10) had equal scores. On the continuum representing processing of information 73% (n=164) scored higher on the learning attribute of active experimentation than reflective observation. Twenty-four percent (n=53) scored higher on reflective observation than active experimentation and 3% (n=7) had equal scores. The calculation of the learning attribute preferences led to determination of learning style. Thirty-three percent were found to be convergers, 33% assimilators, 21% accommodators and 13% divergers.Conclusions: The weaker learning attributes are concrete experience and reflective observation and therefore in general radiographers miss drawing out the full potential of all the learning experience has to offer. The predominant learning style score was converger and assimilator (66%) demonstrating strength in practical application of ideas and ability to create theoretical models respectively. The information obtained may be used to help radiographers optimise their life long learning and also to facilitate a closer match of teaching styles to those of the learners.     

Development of prehospital medical classification criteria

INTRODUCTION: A trauma classification system (TCS) is widely used by many prehospital personnel to provide advanced activation of trauma teams. Specific criteria serve to notify specialty departments and enhance communication between prehospital and emergency department (ED) personnel. Because the TCS has worked so well, a medical classification criteria tool (MCCT) was developed to consistently notify EDs of medical patients' acuity, enhance communication, and provide a smooth transfer of care. METHOD: MCCT development included establishment of tool validity by experts; retrospective chart review to determine consistency and accuracy of classification; and a pilot test of the MCCT at three hospitals. After the pilot, satisfaction surveys were distributed to receiving hospitals to determine tool effectiveness, ease of use, and enhanced transition of care. RESULTS: Of the receiving staff surveyed, 97% found the tool easy to understand; 82% thought the MCCT enabled them to effectively prepare for patients; 62% perceived consistency in classification by the helicopter staff. The flight crew had a 100% positive response regarding ease of MCCT use; 36% noted a positive change in preparation for medical patients' transfer of care. CONCLUSION: The MCCT enhances communication and is useful in preparation and transition of patient care from prehospital to the hospital environment. Advanced notification of patient illness severity may enhance care and affect overall outcome.     

Injury history as a risk factor for incident injury in youth soccer

Objectives: To determine if athletes with a self reported history of previous injury have a higher incident injury rate than athletes without a self reported injury history.

Methods: A prospective cohort study of Classic League soccer players playing at the level under 12 through under 18. Injury history forms were mailed to all registering Classic League soccer players in the North Carolina Youth Soccer Association during 1997–2000 (n = 7000); 1483 (19%) returned the baseline questionnaire and were followed up for injuries.

Results: There were 5139 player-seasons of follow up and an estimated 171 957 athlete-exposures. More than half self reported an injury history (59.7%). Overall, the unadjusted incidence rate was 4.6 (95% confidence interval (CI) 4.3 to 4.9) incident injuries per 1000 athlete-exposures. Multivariate generalised Poisson regression modelling indicated that players with one previous injury had a twofold greater risk of incident injury (IRR = 2.6; 95% CI 2.0 to 3.3), and those with two or more previous injuries had a threefold greater risk of incident injury (IRR = 3.0; 95% CI 2.3 to 3.8) compared with athletes with no previous injuries.

Conclusions: Injury history was associated with an increased injury rate. This suggests that, even in these youth soccer players, those with an injury history may be at higher risk.

     

Ectopic pregnancy in uncommon implantation sites

The majority of ectopic pregnancies are located within the fallopian tube. Nevertheless, pregnancies have been reported to implant in the cervix, ovary, interstitial tubal segment, and at various intra-abdominal sites. The diagnosis and treatment of these unusual implantation sites presents a challenge for clinical as well as radiological diagnosis and there is a tendency to overlook its possibility. In this study, we attempt to summarize the current data regarding diagnosis and optimal treatment of these unusual ectopic pregnancies from our experience with six unusual types of ectopic pregnancies from the Women Hospital, Doha, Qatar.     

Subjective functional assessments and the return to competitive sport after anterior cruciate ligament reconstruction

Objectives: To examine (a) return to competitive sport within 12 months of anterior cruciate ligament (ACL) reconstruction, (b) maintenance of competitive participation at follow up, and (c) the relation of the level of sports activity and competitive participation at follow up to subjective functional assessments. Also to address the incidence of continued competitive participation despite notable functional problems with the operated knee at 12 months and follow up.

Methods: All patients were competitive athletes before injury and had undergone ACL reconstruction by the transtibial endoscopic technique with either a bone-patellar tendon-bone or a multiple looped hamstring autograft. Evaluation was carried out a mean of 43 months (range 24–73) after surgery by a postal questionnaire in which the Cincinnati sports activity scale (CSAS) and Cincinnati sports function scales were presented in conjunction with closed questions on change in competitive level and the presence of complaints.

Results: Of 109 selected patients, 77 (71%) responded. At follow up, 62 of 77 patients (81%) reported that they had returned to competition within 12 months of surgery. Within the same time frame, 55 of the above 62 patients (89%) also claimed to have returned to the level at which they were competing before injury (or higher). At follow up, 30 of the above 55 patients (54%) reported to still be competing at this high level. Twelve of the above 55 patients (22%) also admitted to major problems with the operated knee at that time. The overall incidence of patients competing despite major functional impairment in the operated knee was 13 of 62 (21%) at 12 months and six of 47 (13%) at follow up. Thirty eight patients (49%) were active in sport at least four times a week at follow up (CSAS level 1), and, using Spearman's rank correlation between CSAS scores and total sports function scores, r was calculated to be 0.44. Competitive and male patients had higher total sports function scores at follow up than non-competitive (p = 0.005) and female (p = 0.02) patients respectively.

Conclusions: The reported return to competition at the previous level, both within 12 months and at follow up, was high but as expected considering the standard of treatment, patient selection, and study exclusion criteria. Patients with few functional complaints maintained a high level of sporting activity, even after discontinuing competitive participation.

     

应用80kV管电压降低主动脉CT造影射线剂量初探

目的 探讨80kV管电压256层螺旋CT主动脉造影降低射线剂量的可行性。方法 对62例疑似主动脉疾病的患者进行主动脉CT造影成像,分为常规管电压扫描组(120kV扫描组)和低管电压扫描组(80kV扫描组),每组31例。然后对两组图像信号噪声比、对比度噪声比和有效剂量进行评估。结果 120与80kV2个扫描组的图像信号噪声比分别为(35.92±5.04)和(33.95±8.30),对比度噪声比分别为(30.32±4.78)和(28.71±7.96),差异均无统计学意义(t =1.131、0.964, P >0.05)。而二组的有效剂量分别为(14.28±0.96)和(9.72±0.81)mSv,差异有统计学意义 (t =20.12, P <0.001)。 结论 同120kV管电压比较,80kV管电压主动脉CT造影在没有降低图像质量的情况下,射线剂量降低约31.9%,同时降低造影剂剂量50%。     

A comparison study of chest tube thoracostomy: air medical crew and in-hospital trauma service

Chest tube thoracostomy (CTT) is not frequently performed by non-physician-staffed air medical crews (AMC) due to concern regarding safety, efficiency and training requirements. This study compared two groups of patients requiring CTT, one group with insertion performed by an AMC and the other by a physician trauma service (TS) in the emergency department on patient arrival. The CTT of 172 patients managed at a Level I trauma center between October 1988 and September 1990 were reviewed. Seventy-two patients were managed by the AMC and received CTT in a prehospital setting; the air medical personnel placed the chest tube cleanly in all cases. Chest tubes placed by AMC were removed within 48 hours of transport to minimize infection risk. One hundred patients requiring CTT in the hospital setting were randomly selected from the trauma registry during a similar time span. The study compared the patients' Injury Severity Scores (ISS), and trauma scores, any placement complications and the overall mortality. While the AMC often treated patients with higher acuity, as reflected by ISS and trauma scores and overall higher mortality, the rate of complications between CTT performed by AMC and TS was similar. Appropriately trained AMC can safely perform CTT without putting patients at increased risk.     

Mortalité et stock en fer chez 514 anciens coureurs cyclistes de haut niveau

Aims. – To study mortality and body iron stores in former elite road cyclists.Synthesis of facts. – Mortality and body iron stores were studied in 514 former elite cyclists. Mortality. Twenty-seven deaths (5%) were recorded compared to 38 (7,4%) in a control group. Iron stores. Hyperferritinemia was found in 13% of cyclists and associated with both the metabolic syndrome and previous iron supplementation, especially through parenteral route and in the youngest subjects.Conclusion. – Middle-term mortality of former elite cyclists is unmodified. Previous iron supplementation may be responsible of persisting and long-term damaging iron excess.     

A 12-year experience with prehospital cricothyrotomies

Introduction: Maintaining cricothyrotomy skills is difficult for air medical crewmembers because the procedure is performed infrequently. The purposes of this study were to review our program's experience with cricothyrotomies and use this pilot study to guide an industry-wide study. Methods: We conducted a retrospective review of all cricothyrotomies performed by our flight crew during the past 12 years. The flight logs were reviewed for patient demographics, scene information, clinical data, and procedure data. Results: During this period, 8833 patients were transported: 1589 required intubation (18%), and eight of the 1589 required a cricothyrotomy (0.5%). Five nurses (14% of the total employed during the study) and one physician attempted this procedure. All patients had at least one intubation attempt before the cricothyrotomy (average 3.6, range 1-6 attempts). Six (75%) patients had airway edema, four (50%) had an unstable trachea, and one patient (12.5%) had an airway obstruction. Five (62.5%) of the cricothyrotomy attempts were successful. The remaining three patients were managed with bag-valve mask ventilation. Three patients arrived at the receiving hospital with a perfusing rhythm. Conclusion: Cricothyrotomy, rarely performed by our flight crews, is successful in 62.5% of cases. These preliminary data suggest current training practices should be re-evaluated. An industrywide survey is planned to determine the optimal training program.     

个人辐射防护用品防护质量检测结果与评价

目的 通过有效监测个人防护用品防护质量,探讨促进个人防护用品的研制和开发,以保障放射工作人员的健康与安全.方法 应用标准铅片迭代法测量个人防护用品和材料的铅当量厚度,用"mm Pb"表示.共检测了77件产/样品,其中铅橡胶板37件,各类个人防护制品27件,包括防护服12件、防护帽4件、防护围脖5件、防护手套4件和防护面罩2件;其中铅玻璃眼镜13件.结果 铅橡胶板比铅当量分别在0.20～0.39 mm Pb/mm之间,铅橡胶板比铅当量在0.25 mmPb/mm以下有6件,不符合相关标准的要求.个人防护制品和铅玻璃眼镜检测结果表明,实测铅当量均大于标称铅当量.结论 国产和进口的个人辐射防护材料及用品的防护质量是可靠的,但介入防护手套的防护质量有待于提高和改进.

Abstract：

Objective To monitor the protective qualities of personal protective appliances and to ensure the health and safety of radiological working personnel.Methods The lead-equivalent thickness of personal protective appliances and materials was measured by means of standard lead slices.The lead equivalent thickness represents in terms of mm Pb.Results 77 pieces of products and samples were measured altogether.The results indicate that the specific lead equivalents of lead-rubber plates were between 0.20-0.39 mm Pb/mm for 37 pieces of lead-rubber plates and the values of 6 pieces of samples were less than 0.25 mm Pb/mm,which did not accord with the requirement of the relational standard.27 pieces of personal protection appliances were measured altogether.They were 12 pieces of protective clothes,4 pieces of protective headgears,5 pieces of protective neckpieces,4 pieces of protective gloves and 2 pieces of protective masks.13 pairs of lead-glass spectacles among them were measured altogether.The measured results for personal protective appliances and lead-glass spectacles showed that actually measured lead-equivalent were higher than the nominal lead-equivalent.Conclusions The protective qualities are reliable for personal protection materials and appliances to be made in home and imported abroad.But the protective qualities of interventional protection gloves should be improved and made them better.     

An evaluation of pulmonary atelectasis and its re-expansion: hyperpolarized 3He MRI in the Yorkshire pig

Rationale and Objectives. Atelectasis, the collapse of small airways, is a significant clinical problem. We use hyperpolarized (HP) ³He magnetic resonance imaging (MRI), or HP ³He MRI, to describe atelectasis in the normal Yorkshire pig, the pig with atelectasis, and the pig with re-expansion of atelectasis. We compare HP ³He MRI findings with depictions of atelectasis by proton MRI.Materials and Methods. During end-expiration in the anesthetized and paralyzed Yorkshire pig (n = 6), HP ³He gas produced by the optical pumping spin-exchange method, was delivered via an endotracheal tube. For two separate groups, atelectasis was either induced by Fogarty-catheter occlusion balloon inflation (n = 3), or lateral chest wall administration of sodium hydroxide (NaOH) (n = 3). MRI was performed at time zero, at 5, 9, 13, 15, and 19 minutes after atelectasis production, 30 minutes after balloon deflation, and 10 and 30 minutes after recruitment of atelectatic areas with increased tidal volumes and added positive end-expiratory pressure. High-resolution, cross-sectional MR images were procured, and comparison was made with the traditional proton MRI.Results. Atelectatic areas by HP ³He MRI were easily distinguishable in both subject groups, and correlated with those located by proton MR. HP ³He MR images showed absence of ventilation, whereas proton MR images depicted dense, white areas. Re-expansion of atelectasis was well delineated by HP ³He MRI.Conclusion. HP ³He MRI may overcome many of the shortcomings of other well-established radiographic methods. HP ³He MRI is a novel, informative method for describing atelectasis and its re-expansion.     

Implementing a Novel Through-Glass Chest Radiography Technique for COVID-19 Patients: Image Quality,Radiation Dose Optimization,and Practical Considerations

Rationale and objectives: The novel coronavirus (COVID-19) pandemic has presented many logistical challenges, including unprecedented shortages of personal protective equipment (PPE). A technique of obtaining portable chest radiographs (pCXR) through glass doors or windows to minimize technologist-patient contact and conserve PPE has gained popularity, but remains incompletely evaluated in the literature. Our goal was to quickly implement this technique and evaluate image quality and radiation dose. Materials and methods: An infographic and video were developed to educate nurses and technologists on the through-glass pCXR technique. Imaging parameters were optimized using a phantom and scatter radiation was measured. Three reviewers independently evaluated 100 conventionally obtained and 100 through-glass pCXRs from March 13, 2020 to April 30, 2020 on patients with suspected COVID-19, using criteria for positioning and sharpness/contrast on a 1 (confident criteria not met) to 5 (confident criteria met) scale. Imaging parameters, including deviation index (DI) were recorded for all radiographs. Results: The through-glass method was rapidly adopted and conserved one isolation gown per interaction. Although there was a statistically significant difference in the positioning (P value 0.018) and sharpness/contrast (P value 0.016), the difference in mean ratings was small: 4.82 vs 4.65 for positioning and 4.67 vs 4.50 (conventional vs modified) for sharpness/contrast. Scatter radiation was measured using a thorax phantom and found to be acceptable for the patient and nearby personnel. Standard deviation was higher for the DI for the through-glass technique (2.8) compared to the conventional technique (1.8), although the means were similar. Conclusion: The through-glass technique was quickly implemented, producing diagnostic quality chest radiographs while conserving PPE and reducing risks to radiology staff. There was more variability with imaging technique and DI using the through-glass technique, likely due to technologist uncertainty regarding technical modifications. Further work to reduce this variation is necessary to optimize quality and dose.