Hepatitis C core antigen testing for diagnosis of hepatitis C virus infection: A systematic review and meta-analysis

Annals of Internal Medicine

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Case Western Reserve-led international team identifies fungus in humans for first time as key factor in Crohn's disease

Case Western Reserve University School of Medicine News

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Proton pump inhibitors increase risk for hepatic encephalopathy in patients with cirrhosis in population study

Gastroenterology

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Recent trends in the prevalence of overweight and obesity among Canadian children

Canadian Medical Association Journal

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Assessment of pharmacokinetic interaction between capecitabine and cetuximab in metastatic colorectal cancer patients

Anticancer Research

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Energy restriction at young age, genetic variants in the insulin-like growth factor pathway and colorectal cancer risk in the Netherlands Cohort Study

International Journal of Cancer

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Human cathelicidin compensates for the role of apolipoproteins in hepatitis C virus infectious particle formation

Journal of Virology

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Simple tests for the diagnosis of childhood obesity: A systematic review and meta-analysis

Obesity Reviews

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Assessment of the rate of decrease in serum IgG4 level of autoimmune pancreatitis patients in response to initial steroid therapy as a predictor of subsequent relapse

Pancreas

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Systematic review and meta-analysis of occupational outcomes after bariatric surgery

Obesity Surgery

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Low preoperative prognostic nutritional index predicts poor survival post-gastrectomy in elderly patients with gastric cancer

Annals of Surgical Oncology

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Standard dose versus low dose of azathioprine in the treatment of Crohn's Disease: A prospective randomized study

Journal of Digestive Diseases

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Influence of preoperative sodium concentration on outcome of patients with hepatitis B virus cirrhosis after liver transplantation

European Journal of Gastroenterology & Hepatology

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Community-Based Colorectal Cancer Screening in a Rural Population: Who Returns Fecal Immunochemical Test (FIT) Kits?

The Journal of Rural Health

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Association between source control and mortality in 258 patients with intra-abdominal candidiasis: A retrospective multi-centric analysis comparing intensive care versus surgical wards in Spain

European Journal of Clinical Microbiology & Infectious Diseases

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Enhanced recovery pathway for right and left colectomy: Comparison of functional recovery

World Journal of Surgery

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Anterior neurectomy in children with a recalcitrant anterior cutaneous nerve entrapment syndrome is safe and successful

Journal of Pediatric Surgery

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A pilot study of the effects of niacin administration on free fatty acid and growth hormone concentrations in children with obesity

Pediatric Obesity

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Is nonoperative management warranted in ventral hernia patients with comorbidities?: A case-matched, prospective, patient-centered study

Annals of Surgery

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Per diem or full time EMT, AEMT, Paramedic - Bennington Rescue Squad

The primary focus of the EMT is to provide basic emergency medical care for critical and emergent patients who access the emergency medical system. This individual possesses the basic knowledge and skills necessary to provide patient care and transportation. EMTs function as part of a comprehensive EMS response, under medical oversight. EMTs perform interventions with the basic equipment typically ...

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Per diem or full time EMT, AEMT, Paramedic - Bennington Rescue Squad

The primary focus of the EMT is to provide basic emergency medical care for critical and emergent patients who access the emergency medical system. This individual possesses the basic knowledge and skills necessary to provide patient care and transportation. EMTs function as part of a comprehensive EMS response, under medical oversight. EMTs perform interventions with the basic equipment typically ...

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Reply to Dr Lessire et al.

No abstract available

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Delayed Neuraxial Hematoma in Parturient With Fontan Circulation Following Neuraxial Anesthesia for Cesarean Section.

Objective: Neuraxial hematoma is a rare complication of spinal or epidural anesthesia. However, variable coagulation factor defects are relatively common in patients with Fontan circulation, and may predispose such patients to either increased risk of thrombosis or coagulopathy. These defects may indirectly increase their risk of neuraxial hematoma. Case Report: We report a case of delayed neuraxial hematoma after the start of full-dose anticoagulation for pulmonary embolus on a postpartum patient with Fontan physiology who had continuous spinal anesthesia for cesarean delivery 4 days earlier. Conclusions: Parturients with single ventricle physiology present numerous challenges to balance, including pregnancy-related physiologic alterations in blood volume, cardiac output, systemic vascular resistance, oxygen consumption, and coagulation. Although neuraxial anesthesia is common in this population, it is not without risks. We report the circumstances surrounding a parturient with single ventricle physiology who experienced neuraxial hematoma 4 days after continuous spinal anesthesia despite adherence to accepted guidelines. Eighteen months after undergoing a cesarean section, she had a full recovery and returned to her baseline medical status. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Periprocedural Management of Direct Oral Anticoagulants Should Be Guided by Accurate Laboratory Tests.

No abstract available

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Necrotizing Fasciitis as a Complication of a Continuous Sciatic Nerve Catheter Using the Lateral Popliteal Approach.

Objective: Necrotizing fasciitis is an infection of the soft tissue that is characterized by rapidly spreading inflammation and subsequent necrosis. It is a rare complication of peripheral nerve blocks. We report a rare case of necrotizing fasciitis after placement of a peripheral nerve catheter. Case Report: A 58-year-old woman presented for an elective right second metatarsal resection and received a sciatic nerve catheter for postoperative pain control. On postoperative day 7, clinical examination and imaging supported the diagnosis of necrotizing fasciitis. Conclusions: Multiple reports have been published of necrotizing fasciitis after single-shot peripheral nerve block injections, neuraxial anesthesia, and intramuscular injections. This case highlights the potential for the rare complication of necrotizing fasciitis after peripheral nerve catheter placement. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Local Anesthetic-Induced Myotoxicity After Continuous Adductor Canal Block.

Objective: Local anesthetic-induced myotoxicity occurs consistently in animal models, yet is reported rarely in humans. Herein, we describe 3 sentinel cases of local anesthetic myotoxicity after continuous adductor canal block (ACB). Case Report: Three patients underwent total knee arthroplasty that was managed with subarachnoid block plus ACB induced with 1.5% lidocaine or 1.5% mepivacaine bolus followed by 2% ropivacaine at 8 mL/h. Although initial postoperative recovery was normal, each patient on either postoperative day 1 or 2 developed progressive, profound weakness of the quadriceps muscles. Clinical course, imaging, and neurophysiologic studies were consistent with myositis. The patients experienced partial to full functional recovery over the ensuing weeks to months. Conclusions: Clinically apparent local anesthetic-induced myotoxicity has been documented rarely in humans undergoing non-ophthalmic surgery. We report 3 sentinel cases associated with continuous ACB. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Local Infiltration of Analgesics at Surgical Wound to Reduce Postoperative Pain After Laparotomy in Rats.

Background and Objectives: There is an increasing use of local infiltration analgesia (LIA) to reduce postoperative pain. Despite widespread use of LIA, wide variations in drug combinations and concomitant use of systemic analgesics have made it difficult to determine the optimal drug combinations for LIA. Using a previously validated rat laparotomy model, the optimal LIA combination of medications to reduce postoperative pain was determined. Methods: Laparotomy was performed in an adult rat model under isoflurane anesthesia. During surgery, combinations of bupivacaine, ketorolac, and dexamethasone were injected over the sutured muscle wound before skin closing, and compared to saline (placebo). The same medications were injected systemically as controls. Postoperative pain was assessed by measuring spontaneous rearing activity. Results: A high-dose 3-drug LIA combination (50 [mu]L of bupivacaine 0.75%, ketorolac 6.0 mg/mL, and dexamethasone 2.0 mg/mL) increased rearing (decreased pain) at 2 hours (P = 0.0032) postsurgery compared to saline. However, the same 3 drugs injected systemically had a similar analgesic effect (P = 0.0002). Bupivacaine 0.75% alone was not effective for LIA. When low-dose (9-fold reduction) 3-drug LIA combination was used, LIA increased rearing (P = 0.0034) whereas the same 3 drugs injected systemically had no effect. Low-dose LIA ketorolac/dexamethasone (2-drug combination) also increased rearing (P = 0.0393). Conclusions: Our animal study suggests that clinical trials with low-dose LIA combinations of local anesthetic, nonsteroidal anti-inflammatory drug, and corticosteroid may be useful for reducing postoperative pain after laparotomy. Copyright (C) 2016 by American Society of Regional Anesthesia and Pain Medicine.

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Pharmacogenetic study focused on fluoxetine pharmacodynamics in children and adolescent patients: impact of the serotonin pathway.

Objective: Pharmacogenetic studies of fluoxetine in children and adolescents are scarce. After reporting the effect of genetic variants in genes related to the fluoxetine pharmacokinetics on clinical response in a pediatric population, we now evaluate the impact of genetic markers involved in its pharmacodynamics. Patients and methods: The assessment was performed in 83 patients after 12 weeks of fluoxetine treatment. The genetic association analysis included a total of 316 validated single nucleotide polymorphisms in 45 candidate genes involved in six different pathways. Results: Clinical improvement after treatment with fluoxetine in our pediatric population was associated significantly with two polymorphisms located in genes related to the serotonergic system: the 5-hydroxytryptamine receptor 1B (HTR1B) and the tryptophan 5-hydroxylase 2 (TPH2). Conclusion: Although a wide range of candidate genes related to different pathways were assessed, the results show that genetic markers directly related to serotonin have an important effect on fluoxetine response. Copyright (C) 2016 Wolters Kluwer Health, Inc. All rights reserved.

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Chronic cholestasis in a patient with sickle-cell anemia: Histological findings

A 22-year-old Senegalese man with sickle-cell anaemia (SCA; HbS/HbS) was referred to Hepatology department because of cholestasis [AST 82U/l, ALT 41U/l, ALP 241U/l, gGT 135U/l, bilirubin 8.1 (3.7) mg/dl]; liver function tests were preserved. He was asymptomatic, denied any alcohol or drug intake. Common causes of chronic liver disease were excluded: he was negative for anti-HCV, HBsAg and autoimmune hepatitis markers; copper and iron overload were also excluded. A hard liver was appreciable at the umbilical line, without splenomegaly or decompensation signs.

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Step-Count Accuracy of Three Motion Sensors for Older and Frail Medical Inpatients

Publication date: Available online 22 September 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Ruth McCullagh, Christina Dillon, Ann Marie O'Connell, N.Frances Horgan, Suzanne Timmons
ObjectivesTo measure the step-count accuracy of an ankle-worn accelerometer, a thigh-worn accelerometer and one pedometer in older and frail inpatients.DesignCross-sectional design study.SettingResearch room within a hospital.ParticipantsConvenience sample of inpatients aged ≥65 years, able to walk 20 metres unassisted, with or without a walking-aid.Intervention: Patients completed a 40-minute programme of predetermined tasks while wearing the three motion sensors simultaneously. Video-recording of the procedure provided the criterion measurement of step-count.Main Outcome MeasuresMean percentage (%) errors were calculated for all tasks, slow versus fast walkers, independent versus walking-aid-users, and over shorter versus longer distances. The Intra-class Correlation was calculated and accuracy was visually displayed by Bland-Altman plots.ResultsThirty-two patients (78.1 ±7.8 years) completed the study. Fifteen were female and 17 used walking-aids. Their median speed was 0.46 m/sec (interquartile range, IQR 0.36-0.66). The ankle-worn accelerometer overestimated steps (median 1% error, IQR -3 to 13). The other motion sensors underestimated steps (40% error (IQR -51 to -35) and 38% (IQR -93 to -27), respectively). The ankle-worn accelerometer proved more accurate over longer distances (3% error, IQR 0 to 9), than shorter distances (10%, IQR -23 to 9).ConclusionsThe ankle-worn accelerometer gave the most accurate step-count measurement and was most accurate over longer distances. Neither of the other motion sensors had acceptable margins of error.



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A nested cohort study to identify characteristics that predict near-term disablement from lung cancer brain metastases

Publication date: Available online 22 September 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Andrea L. Cheville, Jeffrey R. Basford, Ian Parney, Ping Yang, Felix E. Diehn
ObjectivesTo test whether the presence of patient- and imaging-level characteristics: 1) are associated with clinically meaningful changes in mobility among late stage cancer patients with metastatic brain involvement; and 2) can predict their risk of near-term functional decline.DesignProspective nested cohort studySettingQuaternary academic medical centerParticipantsThe study population consisted of a nested cohort of the 66 patients with imaging confirmed brain metastases among a larger cohort of 311 patients with late stage lung cancer.InterventionsNot applicableMain OutcomesFunctional evaluations with the Activity Measure for Post-Acute Care Computer Adaptive Test (AM-PAC-CAT) and symptom intensity ratings were collected at monthly intervals for up to 2 years.ResultsIn exploratory univariate models, whole brain radiation therapy (WBRT) and imaging findings of cerebellar or brain stem involvement were associated with large AM-PAC-CAT declines in mobility (-4.55, SE 1.12; -2.87, SE 1.0; and -3.14, SE 1.47, respectively). Also in univariate models, participants with new neurological signs or symptoms at imaging (-2.48, SE 0.99), new brain metastases (-2.14, SE 0.99), or new and expanding metastases (-2.64, SE 1.14) declined significantly. Multivariate exploratory mixed logistic models including WBRT, cerebellar/brainstem location, presence of new and expanding metastases, and worst pain intensity had excellent predictive capabilities for AM-PAC-CAT score declines of 7.5 and 10 points, C statistics >0.8.ConclusionsAmong patients with lung cancer and brain metastases, a cerebellar/brainstem location, new and expanding metastases, and treatment with WBRT may predict severe, near-term mobility losses and indicate a need to consider rehabilitation services.



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Comparison between Steroid and Two Different Sites of Botulinum Toxin Injection in the Treatment of Lateral Epicondylalgia: A Randomized, Double-blind, Active Drug-controlled Pilot Study

Publication date: Available online 22 September 2016
Source:Archives of Physical Medicine and Rehabilitation
Author(s): Yao-Hong Guo, Ta-Shen Kuan, Kuan-Lin Chen, Wei-Chih Lien, Pei-Chun Hsieh, I-Chieh Hsieh, Szu-Hao Chiu, Yu-Ching Lin
ObjectivesTo compare the effects of two different injection sites of low doses of botulinum toxin type A with steroid in treating lateral epicondylalgia.DesignDouble-blind, randomized, active drug-controlled trial.SettingTertiary medical center.ParticipantsTwenty-six patients with lateral epicondylalgia for more than six months were recruited from hospital-based outpatient population. A total of 66 patients were approached, and 40 were excluded. No participant withdrew due to adverse effects.InterventionsPatients were randomly assigned into three groups: 1. The Botox-Epic group (n=8) received 20 units of Botox injection into the lateral epicondyle; 2. The Botox-Tend group (n=7) had 20 units of Botox injected into tender points of muscles; 3. The Steroid group (n=11) had 40 mg of triamcinolone acetonide injected into the lateral epicondyle.Main Outcome MeasuresA visual analogue scale, dynamometer, and Patient-Rated Tennis Elbow Evaluation were used to evaluate the perception of pain, maximal grip strength, and functional status, respectively. Outcome measures were assessed before intervention and at 4, 8, 12 and 16 weeks after the treatment. The primary outcome measure was a visual analogue scale.ResultsAt 4 weeks after injection, the Steroid group was superior to the Botox-Tend group in improvement on the visual analogue scale (p=0.006), grip strength (p=0.03) and Patient-Rated Tennis Elbow Evaluation (p=0.02). However, these differences were not observed at the 8-, 12-, and 16-week follow-ups. There was no significant difference between the Steroid and Botox-Epic groups.ConclusionsInjections with the Botox and with steroid effectively reduced pain and improved upper limb function in patients with lateral epicondylalgia for at least 16 weeks. The onset of effect was earlier in the Steroid and Botox-Epic groups than in the Botox-Tend group.



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Foundation NorwegianAirAmbulance -Filming in Jotunheimen:

Want to relax? -Enjoy the the view ..: ( But: Kill sound in the Vid. -Start this song, in separate window/under new "flag" (-It is way better, IMO).From the Norwegian band Big Bang... Wild Bird: https://youtube/XpF2qP6epOI ("Girl in Oslo": https://youtu.be/xHh6ns3HD5w ) :-) ExEMTNor

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Chronic cholestasis in a patient with sickle-cell anemia: Histological findings

A 22-year-old Senegalese man with sickle-cell anaemia (SCA; HbS/HbS) was referred to Hepatology department because of cholestasis [AST 82U/l, ALT 41U/l, ALP 241U/l, gGT 135U/l, bilirubin 8.1 (3.7) mg/dl]; liver function tests were preserved. He was asymptomatic, denied any alcohol or drug intake. Common causes of chronic liver disease were excluded: he was negative for anti-HCV, HBsAg and autoimmune hepatitis markers; copper and iron overload were also excluded. A hard liver was appreciable at the umbilical line, without splenomegaly or decompensation signs.

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Foundation NorwegianAirAmbulance -Filming in Jotunheimen:

Want to relax? -Enjoy the the view ..: ( But: Kill sound in the Vid. -Start this song, in separate window/under new "flag" (-It is way better, IMO).From the Norwegian band Big Bang... Wild Bird: https://youtube/XpF2qP6epOI ("Girl in Oslo": https://youtu.be/xHh6ns3HD5w ) :-) ExEMTNor

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Foundation NorwegianAirAmbulance -Filming in Jotunheimen:

Want to relax? -Enjoy the the view ..: ( But: Kill sound in the Vid. -Start this song, in separate window/under new "flag" (-It is way better, IMO).From the Norwegian band Big Bang... Wild Bird: https://youtube/XpF2qP6epOI ("Girl in Oslo": https://youtu.be/xHh6ns3HD5w ) :-) ExEMTNor

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Foundation NorwegianAirAmbulance -Filming in Jotunheimen:

Want to relax? -Enjoy the the view ..: ( But: Kill sound in the Vid. -Start this song, in separate window/under new "flag" (-It is way better, IMO).From the Norwegian band Big Bang... Wild Bird: https://youtube/XpF2qP6epOI ("Girl in Oslo": https://youtu.be/xHh6ns3HD5w ) :-) ExEMTNor

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Creating Opportunities for Optimal Nutritional Experiences for Infants With Complex Congenital Heart Disease

To our knowledge, successful breastfeeding in the population with single ventricle congenital heart disease has not been reported in the literature, particularly during the interstage period.

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Opioid Addiction in Adolescents: A Background and Policy Brief

In 2014, nearly half a million adolescents 12 to 17 years of age in the United States reported using nonmedical opioid pain relievers, and 168,000 adolescents reported having a documented opioid addiction (American Society of Addiction Medicine [ASAM], 2016). As the number of opioid exposures increases, the need for abuse and addiction treatment also rises. Unfortunately, there are a number of barriers to the treatment and management of opioid addiction in the adolescent population. These barriers range from provider knowledge deficits to limitations in state and federal regulations and legislation governing opioids.

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The Affordable Care Act Prompts City of Lincoln (IL) to Switch to Aladtec Online Employee Scheduling and Workforce Management Software

September, 2016 - Although cities and municipalities work in conjunction in many ways, when it comes to software, individual departments often choose their own software system without considering the advantages of one software solution for multiple departments. In addition, keeping track of workforce management tasks on paper makes regulation compliance more difficult. "Here at the City of Lincoln ...

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Twelve Novel Mutations in the SLC26A3 Gene in 17 Sporadic Cases of Congenital Chloride Diarrhea.

Objectives: we aimed to improve the knowledge of pathogenic mutations in sporadic cases of congenital chloride diarrhea (CCD) and to emphasize the importance of functional studies to define the effect of novel mutations. Methods: all SLC26A3 coding regions were sequenced in 17 sporadic CCD patients. Moreover, the minigene system was used to analyse the effect of two novel splicing mutations. Results: we defined the SLC26A3 genotype of all 17 CDD patients and we identified twelve novel mutations. Using the minigene system we confirmed the in silico prediction of a complete disruption of splicing pattern caused by two of these novel mutations: the c.971+3_971+4delAA and c.735+4_c.735+7delAGTA. Moreover, several prediction tools and a structure-function prediction defined the pathogenic role of six novel missense mutations. Conclusion: we confirm the molecular heterogeneity of sporadic CDD adding twelve novel mutations to the list of known pathogenic mutations. Moreover, we underline the importance, for laboratories that offer molecular diagnosis and genetic counseling, to perform fast functional analysis of novel mutations. (C) 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,

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Lack of Knowledge and Low Readiness for Healthcare Transition in Eosinophilic Esophagitis and Eosinophilic Gastroenteritis.

Objectives: A growing population of adolescents/young adults with eosinophilic esophagitis (EoE) and eosinophilic gastroenteritis (EGE) will need to transition from pediatric to adult health providers. Measuring healthcare transition (HCT) readiness is critical, but no studies have evaluated this process in EoE/EGE. We determined the scope and predictors of HCT knowledge in patients and parents with EoE/EGE and measured HCT readiness in adolescents/young adults. Methods: We conducted an online survey of patients >=13 years and parents of patients with EoE/EGE who were diagnosed when

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Objective Assessment of Fellows: Doable and Worth Doing.

No abstract available

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Disease Status and Pubertal Stage Predict Improved Growth in Anti-TNF Therapy for Pediatric Inflammatory Bowel Disease.

Background: Growth failure is well-recognised in pediatric Inflammatory Bowel Disease (PIBD; =2 years and duration of IFX >=12 months were associated with improved linear growth for IFX; for ADA only improvement was seen in Tanner 1-3. For IFX, Tanner 1-3 median [DELTA] ht SDS -0.3 (-0.7,0.2) at T0 changed to 0.04 (-0.5, 0.7) at T+12 (p 0.05). For IFX disease duration >=2 year, median [DELTA] ht SDS was -0.13 (-0.6, 0.3) at T0 then 0.07 (-0.3, 0.6) at T+12 (p

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Paramedic - Ambitrans

Job Description Job Title: Paramedic FLSA Status: Non-Exempt Division: Ambitrans Medical Transport Reports To: Date: August 1, 2015 Purpose: To provide Advance Life Support patient care and ambulance transportation. Also performs other duties as assigned. Essential Job Functions Provides emergency and non-emergency ambulance operations in conjunction with a partner, demonstrating excellent driving ...

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Stiftelsen Norsk Luftambulanse -Filming in Jotunheimen:

Want to relax? -Enjoy the the view ..: ( But: Start this song, in separate window / under new "flag" ( -It is way better, IMO ). From the Norwegian band Big Bang... Wild Bird: https://youtu.be/XpF2qP6epOI ExEMTNor

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Global and Cerebral Metabolism and Systemic and Cerebral Oxygenation During and After Intraoperative Seizures in a Patient Undergoing Brain Tumor Surgery.

No abstract available

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Cerebral Oximetry During CEA: Is It an Ideal Monitor?.

No abstract available

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Stiftelsen Norsk Luftambulanse -Filming in Jotunheimen:

Want to relax? -Enjoy the the view ..: ( But: Start this song, in separate window / under new "flag" ( -It is way better, IMO ). From the Norwegian band Big Bang... Wild Bird: https://youtu.be/XpF2qP6epOI ExEMTNor

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Va. ambulance agency celebrates 25th anniversary

By EMS1 Staff

RICHMOND, Va. — The Richmond Ambulance Authority celebrated its 25th anniversary on Wednesday, Sept. 21. After a quarter century in operation, RAA has transformed from the nascent EMS service created by the city under dire circumstances in 1991, to become a preeminent world-leader in pre-hospital healthcare.

"When RAA was created 25 years ago, EMS service in the city was in complete disarray with multiple ambulance companies competing for the best, highest-paying transports, leaving some sectors of the City without coverage," Chip Decker, Richmond Ambulance Authority CEO said.  "There was no accountability at all, which is why the Richmond Ambulance Authority was created and given responsibility for providing EMS services in the City of Richmond.  Over the course of these 25 years, particularly since we severed ties with our operations contractor in 2007 and became self-operated, the city of Richmond truly has a world-class EMS system."

RAA uses data and information systems to conduct demand analysis to ensure ambulances are in the right place at the right time to meet or exceed emergency response time requirements. Annual call volume has gone from 43,000 in 1991, to 66,000 calls in 2016 — a 50 percent increase. 

In 2015, RAA was named the Career EMS Agency of the Year by the National Association of Emergency Medical Technicians and EMS World magazine. RAA's other distinctions include being accredited by the Commission on Accreditation of Ambulance Services and named an Accredited Center of Excellence by the International Academies of Emergency Dispatch.

For years, RAA has had a significant impact on EMS internationally, most recently with its partnership with the Panamerican Trauma Society. Trauma surgeons from Central and South America come to Richmond to participate in this international observer program. They spend weeks at a time embedded with RAA to fully understand the role an EMS organization plays in the overall trauma system. These clinicians then take the lessons learned in the Richmond system and apply them in their own countries.  

Since becoming a self-operated system in 2007, RAA has hosted numerous visitors who want to learn more about Richmond's EMS successes including government officials, doctors and EMS personnel from England, Scotland, Ireland, Sweden, Finland, Holland, Norway, Columbia, Chile, Brazil, Ecuador, Mexico, Australia, Turkmenistan and Taiwan.

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