Publication date: Available online 7 June 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Chelsea A. Pelletier, Masae Miyatani, Lora Giangregorio, B. Catharine Craven
ObjectivesTo describe the frequency and utility of clinically relevant spinal cord injury (SCI)-specific and general population thresholds for obesity and sarcopenic obesity; to describe the fat and lean soft tissue distributions based on neurological level of injury (NLI) and ASIA Impairment Scale (AIS).DesignCross-sectional.SettingTertiary SCI rehabilitation hospital.Participants136 adult men (n = 100) and women (n = 36) with chronic [mean (±SD) 15.6±11.3 years post injury] tetraplegia (n = 66) or paraplegia (n = 70).InterventionsNot applicable.Main Outcome MeasuresBody composition was assessed with anthropometrics and whole body dual-energy X-ray absorptiometry (DXA). Muscle atrophy was quantified using a sarcopenia threshold of appendicular lean mass index (ALMI; males: ≤7.26kg/m2, females: ≤5.5kg/m2). Obesity was defined by percentage body fat (males: ≥25%; females: ≥35%), visceral adipose tissue (VAT; ≥130cm2) and SCI-specific obesity thresholds (BMI ≥22kg/m2; waist circumference ≥94cm). Sarcopenic obesity was defined as the presence of both sarcopenia and obesity. Groups were compared based on impairment characteristics using an ANCOVA.ResultsSarcopenic obesity was prevalent in 41.9% of the sample. ALMI was lower among participants with motor-complete (6.2±1.3 kg/m2) versus motor-incomplete (7.5±1.6kg/m2) injuries (p<0.01). Whole body fat was greater among participants with tetraplegia (28.8±11.2kg) versus paraplegia (24.1 ± 8.7kg; p<0.05). Compared to general population guidelines (20.6%), SCI-specific BMI thresholds identified all of the participants with obesity (77.9%) based on percentage body fat (72.1%).ConclusionsThe observed frequency of sarcopenic obesity in this sample of individuals with chronic SCI is very high, and identification of obesity and sarcopenic obesity is dissimilar when using SCI-specific versus general population criteria.
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Τρίτη 7 Ιουνίου 2016
Sarcopenic Obesity in Adults with Chronic Spinal Cord Injury: A Cross-Sectional Study
Rare case of eyeball rupture following oculocardiac reflex during anaesthesia
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The half-life of infusion fluids: An educational review
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Anaesthesia and orphan disease: rocuronium and sugammadex in the anaesthetic management of a parturient with Becker's myotonia congenita
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District Administrator - Emergence Services Consulting Inc.
Newly-created position provides executive leadership in the managing the contract with EMS providers for a special district.
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Optimizing the management of disabling spasticity following spinal cord damage – The Ability Network – an international initiative
Publication date: Available online 7 June 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Anthony S. Burns, Indira Lanig, Klemen Grabljevec, Peter Wayne New, Djamel Bensmail, Per Ertzgaard, Anand Vishwanath Nene
Optimizing the treatment of disabling spasticity in persons with spinal cord damage is hampered by a lack of consensus regarding the use of acceptable definitions of spasticity and disabling spasticity, and the relative absence of decision tools such as clinical guidelines and concise algorithms to support decision-making within the broader clinical community. Many people with spinal cord damage are managed outside specialist centers and variations in practice result in unequal access to best practice despite equal need. In order to address these issues, the Ability Network - an international panel of clinical experts - was initiated to develop management algorithms to guide and standardize the assessment, treatment and evaluation of outcomes of persons with spinal cord damage and disabling spasticity. To achieve this, consensus was sought on common definitions through facilitated, in-person meetings. To guide patient selection, an in-depth review of the available tools was performed and expert consensus sought to develop an appropriate instrument. Literature reviews are guiding the selection and development of tools to evaluate treatment outcomes (body functions, activity, participation and quality of life), as perceived by people with spinal cord damage and disabling spasticity, their caregivers and clinicians. Using this approach, the Ability Network aims to facilitate treatment decisions that take into account the following - the impact of disabling spasticity on health status, patient preferences, treatment goals, tolerance for adverse events, and in cases of totally dependent persons, caregiver burden.
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The quest for the holy volume therapy
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District Administrator - Emergence Services Consulting Inc.
Newly-created position provides executive leadership in the managing the contract with EMS providers for a special district.
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Ethics in practice: is it futile to talk about ‘futility’?
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Customer Integration Manager - MedStar Mobile Healthcare
SUMMARY: Responsible for developing, implementing and managing MedStar's external and internal customer integration efforts; including, but not limited to, customer experience, customer relations, complaint resolution and integration of the customer's expectations into MedStar's current or future service delivery strategies. The specific external customers who are the focus of this ...
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Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany
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Anaesthesia and orphan disease: primary autosomal recessive microcephaly-10 caused by a mutation in the ZNF335 gene
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Inflammatory stimuli acutely modulate peripheral taste function
Inflammation-mediated changes in taste perception can affect health outcomes in patients, but little is known about the underlying mechanisms. In the present work, we hypothesized that proinflammatory cytokines directly modulate Na+ transport in taste buds. To test this, we measured acute changes in Na+ flux in polarized fungiform taste buds loaded with a Na+ indicator dye. IL-1β elicited an amiloride-sensitive increase in Na+ transport in taste buds. In contrast, TNF-α dramatically and reversibly decreased Na+ flux in polarized taste buds via amiloride-sensitive and amiloride-insensitive Na+ transport systems. The speed and partial amiloride sensitivity of these changes in Na+ flux indicate that IL-1β and TNF-α modulate epithelial Na+ channel (ENaC) function. A portion of the TNF-mediated decrease in Na+ flux is also blocked by the TRPV1 antagonist capsazepine, although TNF-α further reduced Na+ transport independently of both amiloride and capsazepine. We also assessed taste function in vivo in a model of infection and inflammation that elevates these and additional cytokines. In rats administered systemic lipopolysaccharide (LPS), CT responses to Na+ were significantly elevated between 1 and 2 h after LPS treatment. Low, normally preferred concentrations of NaCl and sodium acetate elicited high response magnitudes. Consistent with this outcome, codelivery of IL-1β and TNF-α enhanced Na+ flux in polarized taste buds. These results demonstrate that inflammation elicits swift changes in Na+ taste function, which may limit salt consumption during illness.
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Biophysical constraints on lateral inhibition in the olfactory bulb
The mitral cells (MCs) of the mammalian olfactory bulb (OB) constitute one of two populations of principal neurons (along with middle/deep tufted cells) that integrate afferent olfactory information with top-down inputs and intrinsic learning and deliver output to downstream olfactory areas. MC activity is regulated in part by inhibition from granule cells, which form reciprocal synapses with MCs along the extents of their lateral dendrites. However, with MC lateral dendrites reaching over 1.5 mm in length in rats, the roles of distal inhibitory synapses pose a quandary. Here, we systematically vary the properties of a MC model to assess the capacity of inhibitory synaptic inputs on lateral dendrites to influence afferent information flow through MCs. Simulations using passivized models with varying dendritic morphologies and synaptic properties demonstrated that, even with unrealistically favorable parameters, passive propagation fails to convey effective inhibitory signals to the soma from distal sources. Additional simulations using an active model exhibiting action potentials, subthreshold oscillations, and a dendritic morphology closely matched to experimental values further confirmed that distal synaptic inputs along the lateral dendrite could not exert physiologically relevant effects on MC spike timing at the soma. Larger synaptic conductances representative of multiple simultaneous inputs were not sufficient to compensate for the decline in signal with distance. Reciprocal synapses on distal MC lateral dendrites may instead serve to maintain a common fast oscillatory clock across the OB by delaying spike propagation within the lateral dendrites themselves.
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Macaque retinal ganglion cell responses to visual patterns: harmonic composition, noise, and psychophysical detectability
The goal of these experiments was to test how well cell responses to visual patterns can be predicted from the sinewave tuning curve. Magnocellular (MC) and parvocellular (PC) ganglion cell responses to different spatial waveforms (sinewave, squarewave, and ramp waveforms) were measured across a range of spatial frequencies. Sinewave spatial tuning curves were fit with standard Gaussian models. From these fits, waveforms and spatial tuning of a cell's responses to the other waveforms were predicted for different harmonics by scaling in amplitude for the power in the waveform's Fourier expansion series over spatial frequency. Since higher spatial harmonics move at a higher temporal frequency, an additional scaling for each harmonic by the MC (bandpass) or PC (lowpass) temporal response was included, together with response phase. Finally, the model included a rectifying nonlinearity. This provided a largely satisfactory estimation of MC and PC cell responses to complex waveforms. As a consequence of their transient responses, MC responses to complex waveforms were found to have significantly more energy in higher spatial harmonic components than PC responses. Response variance (noise) was also quantified as a function of harmonic component. Noise increased to some degree for the higher harmonics. The data are relevant for psychophysical detection or discrimination of visual patterns, and we discuss the results in this context.
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Predicting binaural responses from monaural responses in the gerbil medial superior olive
Accurate sound source localization of low-frequency sounds in the horizontal plane depends critically on the comparison of arrival times at both ears. A specialized brainstem circuit containing the principal neurons of the medial superior olive (MSO) is dedicated to this comparison. MSO neurons are innervated by segregated inputs from both ears. The coincident arrival of excitatory inputs from both ears is thought to trigger action potentials, with differences in internal delays creating a unique sensitivity to interaural time differences (ITDs) for each cell. How the inputs from both ears are integrated by the MSO neurons is still debated. Using juxtacellular recordings, we tested to what extent MSO neurons from anesthetized Mongolian gerbils function as simple cross-correlators of their bilateral inputs. From the measured subthreshold responses to monaural wideband stimuli we predicted the rate-ITD functions obtained from the same MSO neuron, which have a damped oscillatory shape. The rate of the oscillations and the position of the peaks and troughs were accurately predicted. The amplitude ratio between dominant and secondary peaks of the rate-ITD function, captured in the width of its envelope, was not always exactly reproduced. This minor imperfection pointed to the methodological limitation of using a linear representation of the monaural inputs, which disregards any temporal sharpening occurring in the cochlear nucleus. The successful prediction of the major aspects of rate-ITD curves supports a simple scheme in which the ITD sensitivity of MSO neurons is realized by the coincidence detection of excitatory monaural inputs.
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Local and global contributions to hemodynamic activity in mouse cortex
Imaging techniques such as functional magnetic resonance imaging seek to estimate neural signals in local brain regions through measurements of hemodynamic activity. However, hemodynamic activity is accompanied by large vascular fluctuations of unclear significance. To characterize these fluctuations and their impact on estimates of neural signals, we used optical imaging in visual cortex of awake mice. We found that hemodynamic activity can be expressed as the sum of two components, one local and one global. The local component reflected presumed neural signals driven by visual stimuli in the appropriate retinotopic region. The global component constituted large fluctuations shared by larger cortical regions, which extend beyond visual cortex. These fluctuations varied from trial to trial, but they did not constitute noise; they correlated with pupil diameter, suggesting that they reflect variations in arousal or alertness. Distinguishing local and global contributions to hemodynamic activity may help understand neurovascular coupling and interpret measurements of hemodynamic responses.
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Motor control differs for increasing and releasing force
Control of the motor output depends on our ability to precisely increase and release force. However, the influence of aging on force increase and release remains unknown. The purpose of this study, therefore, was to determine whether force control differs while increasing and releasing force in young and older adults. Sixteen young adults (22.5 ± 4 yr, 8 females) and 16 older adults (75.7 ± 6.4 yr, 8 females) increased and released force at a constant rate (10% maximum voluntary contraction force/s) during an ankle dorsiflexion isometric task. We recorded the force output and multiple motor unit activity from the tibialis anterior (TA) muscle and quantified the following outcomes: 1) variability of force using the SD of force; 2) mean discharge rate and variability of discharge rate of multiple motor units; and 3) power spectrum of the multiple motor units from 0–4, 4–10, 10–35, and 35–60 Hz. Participants exhibited greater force variability while releasing force, independent of age (P < 0.001). Increased force variability during force release was associated with decreased modulation of multiple motor units from 35 to 60 Hz (R2 = 0.38). Modulation of multiple motor units from 35 to 60 Hz was further correlated to the change in mean discharge rate of multiple motor units (r = 0.66) and modulation from 0 to 4 Hz (r = –0.64). In conclusion, these findings suggest that force control is altered while releasing due to an altered modulation of the motor units.
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Enhancer syntax compensates for binding affinity [Genetics]
Transcriptional enhancers are short segments of DNA that switch genes on and off in response to a variety of intrinsic and extrinsic signals. Despite the discovery of the first enhancer more than 30 y ago, the relationship between primary DNA sequence and enhancer activity remains obscure. In particular, the importance...
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Spliceosomal intronogenesis [Genetics]
The presence of intervening sequences, termed introns, is a defining characteristic of eukaryotic nuclear genomes. Once transcribed into pre-mRNA, these introns must be removed within the spliceosome before export of the processed mRNA to the cytoplasm, where it is translated into protein. Although intron loss has been demonstrated experimentally, several...
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How to tune an enhancer [Genetics]
Every cell's genome contains two main classes of functional DNA. The best understood type of DNA sequence, which was also the first to be discovered, is that which encodes RNA and protein products via the near-universal "genetic code" (1). A more mysterious but equally important class of functional DNA is...
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Firefighter/ EngineerEMT - Santa Clara County Fire Department
SANTA CLARA COUNTY FIRE DEPARTMENT 14700 WINCHESTER BOULEVARD LOS GATOS, CALIFORNIA 95032 http://www.sccfd.org Updated: June 02, 2016 Classification: Firefighter/Engineer EMT The Santa Clara County Fire Department (SCCFD) is recruiting for the position of Firefighter/Engineer EMT. NTN will be administering the required test, which must be completed by 1700 hours on July 28, 2016. The application must ...
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Development of a SCAR marker associated with salt tolerance in durum wheat ( Triticum turgidum ssp. durum ) from a semi-arid region
Abstract
Durum wheat (Triticum turgidum ssp. durum) is one of the main species of cultivated wheat. In arid and semi-arid areas, salinity stress reduces durum wheat productivity. This study used 26 durum wheat accessions from semi-arid regions in Tunisia to analyze plant tolerance to salt stress. Salt stress was experimentally applied by regularly submerging pots in NaCl solution. The salt tolerance trait index (STTI) and salt tolerance index (STI) of various growth parameters were used as criteria to select for salt tolerance. Analysis of genetic relationships was carried out to determine the genetic distance between durum wheat accessions. Based on simple sequence repeats analysis, a molecular marker for salt stress resistance in durum wheat was developed. Salt-treated plants had reduced morphological traits compared to control plants. Most STTIs in all genotypes were below 100 %. Based on STI, 8 accessions were found to be salt-resistant, 16 were salt-moderate, two were salt-susceptible. Analysis of the genetic relationships among 28 Tunisian durum wheat accessions revealed that landraces of the same nominal type are closely related. Of the 94 SSR primers investigated, three were selected and used to design sequence characterized amplified region (SCAR) primers. One SCAR primer pair, KUCMB_Xgwm403_2, produced a 207 bp band that was present in salt-resistant durum wheat lines but absent in salt-susceptible lines. The results suggest that KUCMB_Xgwm403_2 could be a potential genetic tag for salt-tolerant durum wheats.
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Intralipid in acute caffeine intoxication: a case report
Abstract
Caffeine is arguably the most widely used stimulant drug in the world. Here we describe a suicide attempt involving caffeine overdose whereby the patient's severe intoxication was successfully treated with the prompt infusion of Intralipid. A 19-year-old man was found in an agitated state at home by the volunteer emergency team about 1 h after the intentional ingestion of 40 g of caffeine (tablets). His consciousness decreased rapidly, followed quickly by seizures, and electrocardiographic monitoring showed ventricular fibrillation. Advanced life support maneuvers were started immediately, with the patient defibrillated 10 times and administered 5 mg epinephrine in total and 300 + 150 mg of amiodarone (as well as lidocaine and magnesium sulfate). The cardiac rhythm eventually evolved to asystole, necessitating the intravenous injection of epinephrine to achieve the return of spontaneous circulation. However, critical hemodynamic instability persisted, with the patient's cardiac rhythm alternating between refractory irregular narrow complex tachycardia and wide complex tachycardia associated with hypotension. In an attempt to restore stability we administered three successive doses of Intralipid (120 + 250 + 100 mg), which successfully prevented a severe cardiovascular collapse due to a supra-lethal plasma caffeine level (>120 mg/L after lipid emulsion). The patient survived without any neurologic complications and was transferred to a psychiatric ward a few days later. The case emphasizes the efficacy of intravenous lipid emulsion in the resuscitation of patients from non-local anesthetic systemic toxicity. Intralipid appears to act initially as a vehicle that carries the stimulant drug away from heart and brain to less well-perfused organs (scavenging mechanism) and then, with a sufficient drop in the caffeine concentration, possibly as a tonic to the depressed heart.
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Dominant and Non-dominant Leg Activities in Young Adults
2016-06-07T07-19-04Z
Source: International Journal of Therapies and Rehabilitation Research
SWATI AVINASH BHISE, NALINI KISHOR PATIL.
Lower extremity function is mainly weight bearing and walking. There is no particular activity in which one foot has to perform more activity than other. However the notion of foot or leg dominance may not be as obvious and it might require to be viewed in a different perspective considering the roles of the legs in different tasks such mobility and stability. The purpose of this study was to determine whether a difference in activities exists between the dominant and non-dominant legs in young adults. Method:-Observational - Cross sectional study design. Thirty left handed healthy college-age (20.46 ± 1.92 years) subjects with comparable group of Thirty Right handed healthy college-age (20.8 ± 2.5 years) subjects were participated in the study. Activities were given to both groups for to check for the hand & leg dominance. Conclusion:-Leg dominance seems to be function of the type of activity a subject is required to perform. When the task is manipulative in nature, most subjects will use the dominant leg in activities like side walking and obstacle walking but when the task involves stabilization such as standing on one leg, squatting and hopping on one leg then more than 60-70% adults prefers Lt Leg in spite of any leg dominant. 60% of the subjects in the study used the non- dominant leg as well as dominant leg to perform the task comfortably.
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The effects of traditional strengthening exercises versus functional task training on pain, balance and functional mobility in knee osteoarthritis
2016-06-07T07-19-04Z
Source: International Journal of Therapies and Rehabilitation Research
Krishna Kumar Singh, Madhusudan Tiwari.
The effects of traditional strengthening exercises versus functional task training on pain, balance and functional mobility in knee osteoarthritis Krishna Kumar Singh*, Madhusudan Tiwari** *Professor & Principal, Jaipur Physiotherapy College, Maharaj Vinayak Global University, Jaipur Rajasthan, India. **Associate Professor & Dean, Faculty of Physiotherapy, Mahatma Gandhi University of Medical Sciences & Technology, Jaipur, Rajasthan, India. Email- madhusudan1977@gmail.com, Mobile No. 8290964159, (Corresponding Author). ABSTRACT Objectives: To investigate the efficacy of functional task training in decreasing pain, and increasing functional mobility in Osteoarthritis Knee. Study design: Comparative case control study. Methodology: Forty individuals with a diagnosis of OA Knee were selected directly from Physiotherapy outpatient door of Jaipur Physiotherapy College, MVGU, Jaipur. These individuals were randomly assigned into two groups: FTT Group [Functional task Training (n = 20)] and TE Group [Traditional Exercise (n = 20)]. FTT Group Functional tasks included sit to stand box lift, standing star exercise, walking up and down a ramp while holding a weight, ascending/descending stairs while holding a weight in the preferred hand, and walking indoors while passing a weighted ball from hand to hand. Subjects performed the exercises for one minute with (when indicated) a one pound weight. Progressions included either an increase in weight or time to perform the activity. Subjects in the TE program performed four-way straight leg raises (4 way SLR), seated knee extension, wall slides, step ups, and ambulation on the treadmill. Two sets of ten repetitions were performed for each exercise. Weight repetition progression based on subject's tolerance. Subjects ambulated on the treadmill at their own pace for a period that did not exceed 15 minutes. Both the groups were given exercises supervised by physiotherapist on regular basis for 12 weeks. Data for measurements of pain on VAS scale, Physical Function on WOMAC, Balance & mobility on Time Up & Go Test (TUG), Functional performance on Stair Climbing test (SCT) was collected on day 1 (pre treatment session), at 6 week, and at week 12. Results: Results indicate that both groups improved in all measures of pain, Balance and functional outcomes. However upon Intergroup analysis the mean changes in the score of VAS, WOMAC & TUG was highly significant across the two testing periods (at 6 week & 12 week) for the functional task training group (FTT). The mean change in the score of SCT was also highly significant at week 12 in FTT group. Conclusion: Functional task training on regular basis is an effective rehabilitation program for improving functional mobility, balance and decreasing pain in OA Knee. Key words: Functional Task Training, Traditional exercises, OA Knee, visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
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Richard Beebe: A trusted friend, expert teacher and passionate EMS advocate
I can't remember when I first met Rich Beebe, nor can he.
Oddly, he posed this question to me several weeks ago.
We concluded that our meeting happened at a rural EMS conference in the Hudson Valley area of New York State some 15 or 16 years ago. We were both presenting at the conference and very quickly became the closest of friends.
While we had much in common as speakers, authors, EMS educators and fellow nurse/paramedics, our personalities were miles apart. Those differences, in retrospect, helped the both of us grow and change, forge new projects together and gave us the fodder for hours upon hours of conversation. It didn't hurt that we both enjoyed Starbucks and fine cigar.
I will miss Rich terribly, not unlike the thousands of students and health care providers he has trained and entertained over the years. His enthusiasm and passion for EMS are literally unbridled. Rich lived, breathed, ate, slept and drank EMS.
He inspired others to reach for excellence. When a student faltered, he took it personally and did whatever it took to make them successful.
I could tell you countless stories from successful professionals that fondly remember Rich finding them a work-study job when they ran out of money to pay their paramedic tuition or folks that he personally tutored for hours on end. There was no student he would turn away and no colleague he would not lend a helping hand.
Rich was also brilliant. His many textbooks are a testament to the breadth and depth of his knowledge. He worked tirelessly to improve EMS education, helping to revise the EMS Educational Standards and serving on the board of NAEMSE. His lively and dynamic presentation style was widely sought after at local, state and national EMS conferences.
The future of many of the projects Rich and I did together seems cloudy. Conferences we coordinate, such as the annual New York State Volunteer Ambulance and Rescue Association Pulse Check conference, and the many critical care transport courses we put on around the country were products of neither McEvoy nor Beebe but rather our team of two.
Richard Beebe, left, and Mike McEvoy at the closing of the Pulse Check 2015
Rich's humor balanced my sarcasm; his eternal patience balanced my rigidity; his social grandiosity balanced my shyness; his never ending imagination balanced my conservatism.
In my grief … and in the grief of the entire EMS community, the first thing that Rich would want us to do is to learn from his experience. That may take some time.
The second thing he would want us to do is continue to push his EMS agendas. Those I can put in print right here and now. Rich had a lot to say about our EMS system and EMS education, but his bottom line focused on a few very powerful beliefs.
Firstly, Rich believed in a solid EMS education and lifelong learning. That means college educated faculty with a passion for EMS education, a talent for teaching and continued active practice in the field.
Secondly, Rich believed that EMS providers need to act as professionals if they expect to be treated as such: no excuses.
Lastly, Rich believed in dreams. Anything can be achieved if you set your mind to it. If you fail, then you need to get up and try again.
On the way, every one of us needs help, support, and counsel. Rich was there for so many. It's our turn to pick up that ball: mentor and support the newbies, draw the right people into our profession and allow those who need to leave to do so.
Godspeed to you, my brother; your EMS family will take it from here. Thank you for your lifetime of service.
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Project 6 Summit: SAGES telementoring initiative
Abstract
Background
Advances in telecommunications technology have facilitated telementoring initiatives that virtually link a mentor and mentee in the operating room and have shown significant promise in conferring high rates of safe procedure adoption. Recognizing that telementoring has the potential to be one solution to the global demand for what is sure to be a constant need for surgical retraining and safe incorporation of new technologies, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) convened the Project 6 Summit.
Methods
Content experts in minimally invasive surgery, surgical mentoring and telementoring, surgical education, business development, healthcare innovation, and regulation were invited to attend a two-day summit to outline the current state of surgical telementoring and chart the challenges and opportunities going forward.
Results
Five opportunity buckets consisting of: Legal and Regulatory, Business Development and Proving Value, Effective Communication and Education Requirements, Technology Requirements and Logistics were the subject of focused working groups and subsequent review and consensus by summit attendees. The current state-of-the-art and guiding principles are presented herein.
Conclusion
Telementoring activities are poised for exponential growth but will require a coordinated effort by stakeholders working through and around a healthcare system not yet suited for this paradigm shift.
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Brenham Police Move to True Mobility with Motion Rugged Tablet Platforms
Brenham Police are saving money and improving productivity with their implementation of Motion rugged tablets mounted in-vehicle. GO MOBILE with Motion's complete ecosystem of tablets, accessories, software partnerships and hardware peripherals today.
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Characterization of the 3rd International Standard for hepatitis B virus surface antigen (HBsAg)
Journal of Clinical Virology
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The Power of Raw Data.
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Oncologic outcomes of extended robotic resection for rectal cancer
Annals of Surgical Oncology
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Cerebral Oxygenation Under General Anesthesia Can Be Safely Preserved in Patients in Prone Position: A Prospective Observational Study.
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Remember 2 Things: Medication Administration
A large percentage of errors are due to medication administration errors. In this episode of Remember 2 Things Steve Whitehead reminds paramedics of the importance of drawing up a medication dose into a syringe and what to do with the medication remaining in a vial. After watching share your medication administration tips in the comments and read this excerpt from "Med Math Simplified."
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Anorectal biofeedback for neurogenic bowel dysfunction in incomplete spinal cord injury
Spinal Cord
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Anesthetic Challenges in the Management of Distal Posterior Cerebral Artery Aneurysm for Surgical Clipping: A Report of 2 Cases.
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EMS use of red lights and sirens is a dangerous sacred cow
By Douglas M. Wolfberg, Esq.
Few cows are more sacred in EMS than the ones that flash, wail and yelp. The use of red lights and sirens is an inseparable part of everyday EMS life. It's as if RLS use is encoded in the DNA of EMS responders. It's seemingly part of who we are.
When we're dispatched for an emergency, RLS gets switched on as a standard part of response operations. But in this era of evidence-based medicine, everything we do must be viewed through the critical lens of "does it work""
Like every practice, procedure, policy and protocol in EMS, RLS use must be safe and have a proven benefit to patient care. And the practice should be curtailed if it doesn't.
The EMS graveyard is full of the corpses of other sacred cows that have not withstood the test of time. MAST trousers are long gone. The use of long spine boards is being curtailed in many systems. Protocols for airway management are always in a state of flux based on the latest science.
Yet, these aspects of EMS are viewed as clinical, where the use of RLS is looked at as operational. Why should we view RLS use differently than any other aspect of EMS"
Shouldn't virtually everything we do be subject to the same test" That is, if it doesn't help us help patients, why should we continue to do it"
Does it work"
It is imperative to first properly frame the question. When we ask "does it work," we must define what it means "to work." Something works in health care (and I hope by now we have satisfied ourselves that EMS is health care and not merely public safety) if it is safe and reduces morbidity and mortality.
More specifically, in this post-reform era of health care, something works if it satisfies one or more of the "Triple Aims" of improving the patient experience of care, improving the health of populations and reducing the cost of health care.
Having spent many years working in the provision of EMS, I know from personal experience that RLS "works" to clear traffic and warn drivers, pedestrians and others that an ambulance is approaching in emergency mode.
And RLS "works" by showing the public that we are treating their emergency calls seriously. RLS "works" when we show our public officials that we are meeting their response time expectations and being accountable.
But even though RLS "works" for those purposes, the real question is whether those purposes ultimately serve the larger purposes of benefitting patients.
Where is the evidence"
The hard evidence about whether RLS use helps patients is severely lacking. No studies of which I am aware have ever directly linked the use of RLS to improved patient outcomes.
In fact, the National Association of State EMS Officials concluded that "no evidence-based model exists for what mode of operation (lights and sirens) should be used by ambulances … when dispatched … or when transporting patients [1]."
Most studies only link RLS use to time. While some studies have found that time saved with RLS use is operationally significant, there is no evidence that RLS use is clinically significant.
In other words, if RLS use reduces response time or transport time by six minutes, the extra six minutes typically wouldn't make a difference in the care or outcome of the patient. Although the response time debate is beyond the scope of this article, most studies and publications I've seen suggest that EMS response times generally make much less of a difference than the public believes.
Response times are driven more by public perception of quality service and by local officials believing that response time performance is the primary mechanism for holding their EMS systems accountable.
Why do we respond RLS"
So, if RLS hasn't been shown to benefit patient care, why is their use so prevalent in EMS" The answers are a mix of cultural, operational and political realities.
RLS use is certainly engrained in the EMS culture, given its long association with police, fire and other public safety services. Although interestingly NASEMSO said, "EMS providers are at a greater risk of death on the job than their police and firefighter counterparts, with 74 percent of EMS fatalities being transportation related [1].")
Operationally, there is a logic to using warning devices to alert traffic that an ambulance on an important mission would like to clear an intersection or overtake other vehicles. In some cases, RLS is used because that's what dispatchers tell us to do when calls are dispatched hot.
RLS use can have political roots as well, often being necessitated by response time performance standards that are part of local EMS system design. Local officials tend to look at response times as a strong indicator of EMS system performance. And the public wants us to treat their emergencies as, well, emergencies.
Therefore, there are strong public expectations of RLS use as part of regular EMS system operations.
As with any patient-care practices in EMS, however, we must always look at the safety of what we do as an integral part of the analysis in whether our customs and practices "work." Ambulances are being designed to be more crashworthy. The use of active and passive restraints to protect EMS crewmembers is becoming more prevalent.
Awareness of responder safety after tragic events like 9/11 is at an all-time high. Yet, the simple fact is that twice as many ambulance crashes involve RLS use. So why does our profession seem to turn a blind eye when it comes to the safety issues associated with RLS" [2].
In one study, RLS was found to be in use in 80 percent of all crashes involving ambulances [3]. This same study went on to conclude that an "essential issue verified in the analysis of these data is the fact that the use of lights or sirens often places the responding ambulance and the civilian population at risk."
The authors went on to note that EMS personnel may assume that using RLS "give[s] them license to disregard certain rules of the road," a particular risk when civilians are "clearly under-informed on how to respond to visual and/or audible signals from emergency vehicles."
Another study found that most crashes (60 percent) and most fatalities (58 percent) involving ambulances occurred during emergency use when RLS was activated [4].
Reevaluate the use of RLS
As an attorney, I must mention that where there are more ambulance crashes, there will be more lawsuits, settlements and payouts by EMS agencies and local governments. In that sense, reducing RLS use can have a direct impact on reducing legal liability for EMS providers and EMS agencies.
A few facts are uncontestable. No evidence links RLS use to better patient care or improved patient outcomes. RLS use is associated with markedly higher rates of ambulance crashes and higher rates of EMS provider fatalities than non-RLS operations.
With no proven clinical benefit and well-established risks to providers and the public, RLS practices need to be reevaluated as a daily part of EMS operations. This leads me to making these six recommendations.
1. Start with dispatch
All EMS systems should be using validated dispatch protocols and trained dispatchers. The number of local PSAPs and EMS systems not employing emergency medical dispatch protocols and trained EMDs still amazes me.
If your dispatch agency tells you to run everything hot, you and your dispatch agency are walking on a liability minefield. It's only a matter of time until your organization experiences a catastrophic loss.
2. Set policies
Whether or not your dispatch agency is up to par with its dispatch protocols, your EMS agency can — and should — have its own policies and training when it comes to RLS use and other aspects of ambulance safety.
In the absence of any evidence that RLS use improves patient care or protects providers (in fact, the evidence establishes the contrary — that RLS use endangers EMS personnel), your agency's polices should make non-RLS use the rule and RLS use the infrequent exception.
3. Train personnel
Because RLS use is an engrained part of EMS culture, changing our RLS mindset will take time, training and a cultural change. But effective training of emergency vehicle operators is a key to reducing RLS use and improving operational safety for EMS workers.
4. Make RLS part of clinical QA programs
Just as 100 percent of certain clinical cases — cardiac arrest or STEMI activation — undergo review in many EMS quality improvement programs, the use of RLS needs to be integrated into EMS clinical QA programs.
Personnel should document when RLS is used either in the response phase or during patient transport. The appropriateness of RLS use should be subject to retrospective review as with any other aspects of our care.
5. Educate decision makers
Work with your local officials to educate them why quality prehospital emergency health care doesn't necessarily go hand in hand with RLS. When local officials are properly educated on the risk that RLS adds to their liability, and that the benefits of RLS use have not been shown to outweigh those risks, public demand for hot responses can start to cool.
6. Embrace new technology
Just as vehicle-to-infrastructure (V2I) technology has allowed emergency vehicles to communicate with traffic signals, newer vehicle-to-vehicle (V2V) technologies will allow emergency vehicles to communicate directly with other vehicles to request lane access, pass safely, and alert traffic to the presence of emergencies.
EMS systems should stay abreast of this technology so that RLS use can hopefully become a thing of the past as newer, safer technologies emerge.
RLS use involves proven risks and unproven benefits in EMS. It is a major factor in causing injuries and deaths of EMS workers. RLS use creates liability risks for EMS agencies and local governments. Recognizing the risks and changing EMS culture to reduce those risks is an imperative for all EMS systems in the United States.
Running lights and sirens is not an inevitable part of every EMS response. It is time to put that sacred cow out to pasture.
About the author
Doug Wolfberg is a longtime former EMS provider who also worked as a county EMS director and as a state and federal-level EMS administrator prior to attending law school. Doug is an EMS attorney and founding partner of Page, Wolfberg & Wirth, the nation's leading EMS industry law firm.
References
1. National Association of State Emergency Medical Services Officials (NASEMSO), Emergency Medical Services: Considerations for Toward Zero Deaths: A National Strategy on Highway Safety. August 19, 2010.
2. NHTSA Fatal Analysis Reporting System (FARS), 1992-2010, NHTSA Office of Emergency Medical Services, April 2014 presentation.
3. Sanddal, et al., Ambulance Crash Characteristics in the US Defined by the Popular Press: A Retrospective Analysis. Emergency Medicine International, Vol 2010, Article ID 525979 (2010).
4. Kahn, et al., Characteristics of Fatal Ambulance Crashes in the United States: An 11-Year Retrospective Analysis. Prehospital Emergency Care, Vol. 5, No. 3 (July/September 2001).
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