TRIAD II: Do Living Wills Have an Impact on Pre-Hospital Lifesaving Care?

Background: Living wills accompany patients who present for emergent care. To the best of our knowledge, no studies assess pre-hospital provider interpretations of these instructions. Objectives: Determine how a living will is interpreted and assess how interpretation impacts lifesaving care. Design setting: Three-part survey administered at a regional emergency medical system educational symposium to 150 emergency medical technicians (EMTs) and paramedics. Part I assessed understanding of the living will and do-not-resuscitate (DNR) orders. Part II assessed the living will's impact in clinical situations of patients requiring lifesaving interventions. Part III was similar to part II except a code status designation (full code) was incorporated into the living will. Results: There were 127 surveys completed, yielding an 87% response rate. The majority were male (55%) and EMTs (74%). The average age was 44 years and the average duration of employment was 15 years. Ninety percent (95% confidence interval [CI] 84.6–95.4%) of respondents determined that, after review of the living will, the patient's code status was DNR, and 92% (95% CI 86.5–96.6%) defined their understanding of DNR as comfort care/end-of-life care. When the living will was applied to clinical situations, it resulted in a higher proportion of patients being classified as DNR as opposed to full code (Case A 78% [95% CI 71.2–85.6%] vs. 22% [95% CI 14.4–28.8%], respectively; Case B 67% [95% CI 58.4–74.9%] vs. 33% [95% CI 25.1–1.6%], respectively; Case C 63% [95% CI 55.1–71.9%] vs. 37% [95% CI 28.1–44.9%]), respectively. With the scenarios presented, this DNR classification resulted in a lack of or a delay in lifesaving interventions. Incorporating a code status into the living will produced statistically significant increases in the provision of lifesaving care. In Case A, intubation increased from 15% to 56% (p < 0.0001); Case B, defibrillation increased from 40% to 59% (p < 0.0001); and Case C, defibrillation increased from 36% to 65% (p < 0.0001). Conclusions: Significant confusion and concern for patient safety exists in the pre-hospital setting due to the understanding and implementation of living wills and DNR orders. This confusion can be corrected by implementing clearly defined code status into the living will.     

Childhood cancer survivors exposed to total body irradiation are at significant risk for slipped capital femoral epiphysis during recombinant growth hormone therapy

Background

Childhood cancer survivors treated with cranial or total body irradiation (TBI) are at risk for growth hormone deficiency (GHD). Recombinant growth hormone (rhGH) therapy is associated with slipped capital femoral epiphysis (SCFE). We compared the incidence of SCFE after TBI versus cranial irradiation (CI) in childhood cancer survivors treated with rhGH.

Procedure

Retrospective cohort study (1980–2010) of 119 survivors treated with rhGH for irradiation‐induced GHD (56 TBI; 63 CI). SCFE incidence rates were compared in CI and TBI recipients, and compared with national registry SCFE rates in children treated with rhGH for idiopathic GHD.

Results

Median survivor follow‐up since rhGH initiation was 4.8 (range 0.2–18.3) years. SCFE was diagnosed in 10 subjects post‐TBI and none after CI (P < 0.001). All 10 subjects had atypical valgus SCFE, and 7 were bilateral at presentation. Within TBI recipients, age at cancer diagnosis, sex, race, underlying malignancy, age at radiation, and age at initiation of rhGH did not differ significantly between those with versus without SCFE. The mean (SD) age at SCFE diagnosis was 12.3 (2.7) years and median duration of rhGH therapy to SCFE was 1.8 years. The SCFE incidence rate after TBI exposure was 35.9 per 1,000 person years, representing a 211‐fold greater rate than reported in children treated with rhGH for idiopathic GH deficiency.

Conclusions

The markedly greater SCFE incidence rate in childhood cancer survivors with TBI‐associated GHD, compared with rates in children with idiopathic GHD, suggests that cancer treatment effects to the proximal femoral physis may contribute to SCFE. Pediatr Blood Cancer 2013;60:1766–1771. © 2013 Wiley Periodicals, Inc.     

Comparison of 21 vs. 25 mm Gastrojejunostomy in the Gastric Bypass Procedure - Early Results

Background: Many bariatric surgeons consider a small gastrojejunostomy stoma critical to the success of gastric bypass. Methods:We retrospectively compared a 21 vs. 25 mm gastrojejunostomy in 50 patients undergoing gastric bypass for morbid obesity. Results: 31 patients were constructed with a 21mm EEA, group I, and 19 with a 25 mm, group II. Average percent of excess body weight lost was 61%, 65%, and 64% at 12, 15, and 18 months followup in the group I patients, vs. 61%, 67%, and 69% in the group B patients. Differences were not significant. Complaints of nausea, vomiting, and/or dysphagia were similar between the groups. Conclusion:The choice of a 21 or 25 mm gastrojejunostomy does not appear to alter the success of gastric bypass surgery and can be based upon surgeon preference.