Anesthesia equipment malfunction: origins and clinical recognition.

Equipment malfunction is a problem of particular importance during anesthesia and resuscitation. A review of published reports shows that the most common clinical events involve endotracheal tubes, the inspired oxygen concentration, the volume of inspired anesthetic vapours and gases, and pressures in the breathing or ventilation system. It is concluded that protection of a patient from equipment malfunction depends on: (a) appropriate application of standards set by a national standards association; (b) careful evaluation of equipment prior to purchase; (c) comprehension of equipment function by the user; (d) conscientious routine servicing of all systems concerned with anesthesia and resuscitation, and checking after service and before clinical use; (e) preanesthesia testing of equipment, including the use of an oxygen analyser in the breathing circuit; (f) early inclusion of equipment malfunction in the differential diagnosis of events during anesthesia; and (g) rapid action that cannot present a new hazard to the patient to correct the results of apparatus malfunction.     

THE GROWING PROBLEM OF SUICIDE

Informed as to the epidemiologic aspects of suicide and as to warning signs, physicians could, by appropriate action, prevent self-destruction in many cases.Not only ought each physician''s office be a suicide prevention station, but all physicians ought to act in concert to gather data, to carry out a program of public instruction and to enlist the aid of the press in an effort to reduce the ever-increasing rate of suicide.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.     

The Effects of Direction of Exertion,Path, and Load Placement in Nursing Cart Pushing and Pulling Tasks: An Electromyographical Study

The purpose of this study was to explore the effects of direction of exertion (DOE) (pushing, pulling), path (walking in a straight line, turning left, walking uphill), and load placement (LP) (the 18 blocks were indicated by X, Y and Z axis; there were 3 levels on the X axis, 2 levels on the Y axis, and 3 levels on the Z axis) on muscle activity and ratings of perceived exertion in nursing cart pushing and pulling tasks. Ten participants who were female students and not experienced nurses were recruited to participate in the experiment. Each participant performed 108 experimental trials in the study, consisting of 2 directions of exertion (push and pull), 3 paths, and 18 load placements (indicated by X, Y and Z axes). A 23kg load was placed into one load placement. The dependent variables were electromyographic (EMG) data of four muscles collected bilaterally as follows: Left (L) and right (R) trapezius (TR), flexor digitorum superficialis (FDS), extensor digitorum (ED), and erector spinae (ES) and subjective ratings of perceived exertion (RPE). Split-split-plot ANOVA was conducted to analyze significant differences between DOE, path, and LP in the EMG and RPE data. Pulling cart tasks produced a significantly higher activation of the muscles (RTR:54.4%, LTR:50.3%, LFDS:57.0%, LED:63.4%, RES:40.7%, LES:36.7%) than pushing cart tasks (RTR:42.4%, LTR:35.1%, LFDS:32.3%, LED:55.1%, RES:33.3%, LES:32.1%). A significantly greater perceived exertion was found in pulling cart tasks than pushing cart tasks. Significantly higher activation of all muscles and perceived exertion were observed for walking uphill than walking in a straight line and turning left. Significantly lower muscle activity of all muscles and subject ratings were observed for the central position on the X axis, the bottom position on the Y axis, and the posterior position on the Z axis. These findings suggest that nursing staff should adopt forward pushing when moving a nursing cart, instead of backward pulling, and that uphill paths should be avoided in the design of work environments. In terms of distribution of the load in a nursing cart, heavier materials should be positioned at bottom of the cabinet, centered on the horizontal plane and close to the handle, to reduce the physical load of the nursing staff.     

Mobile platform for motion capture of locomotion over long distances

Motion capture is usually performed on only a few steps of over-ground locomotion, limited by the finite sensing volume of most capture systems. This makes it difficult to evaluate walking over longer distances, or in a natural environment outside the laboratory. Here we show that motion capture may be performed relative to a mobile platform, such as a wheeled cart that is moved with the walking subject. To determine the person’s absolute displacement in space, the cart’s own motion must be localized. We present three localization methods and evaluate their performance. The first detects cart motion solely from the relative motion of the subject’s feet during walking. The others use sensed motion of the cart’s wheels to perform odometry, with and without an additional gyroscope to enhance sensitivity to turning about the vertical axis. We show that such methods are practical to implement, and with present-day sensors can yield accuracy of better than 1% over arbitrary distances.     

Survey of 3765 cardiopulmonary resuscitations in British hospitals (the BRESUS Study): methods and overall results.

OBJECTIVE--To determine the circumstances, incidence, and outcome of cardiopulmonary resuscitation in British hospitals. DESIGN--Hospitals registered all cardiopulmonary resuscitation attempts for 12 months or longer and followed survival to one year. SETTING--12 metropolitan, provincial, teaching, and non-teaching hospitals across Britain. SUBJECTS--3765 patients in whom a resuscitation attempt was performed, including 927 in whom the onset of arrest was outside the hospital. MAIN OUTCOME MEASURE--Survival after initial resuscitation, at 24 hours, at discharge from hospital, and at one year, calculated by the life table method. RESULTS--There were 417 known survivors at one year, with 214 lost to follow up. By life table analysis for every eight attempted resuscitations there were three immediate survivors, two at 24 hours, 1.5 leaving hospital alive, and one alive at one year. Survival at one year was 12.5% including out of hospital cases and 15.0% not including these cases. Each hospital year averaged 30 survivors at one year: three who had an arrest outside hospital, seven who had one in the accident and emergency department, seven in the cardiac care unit, 10 in the general wards, and three in other, non-ward areas. Within the hospitals survival rates were best in those who had an arrest in the accident and emergency department, the cardiac care unit, or other specialised units. Outcome varied 12-fold in subgroups defined by age, type of arrest, and place of arrest. CONCLUSION--71% of the mortality at one year in patients undergoing attempted resuscitation occurred during the initial arrest. Hospital resuscitation is life saving and cost effective and warrants appropriate attention, training, coordination, and equipment.     

A community training scheme in cardiopulmonary resuscitation.

Community instruction in basic life support and resuscitation techniques has been offered in Brighton Health District since 1978. Classes are held frequently for the general public and businesses, schools, and other organisations. First aid care for unconscious patients, the treatment of respiratory obstruction or failure, and the recognition and management of cardiac arrest is taught in a single two hour session. Over 20 000 people have been taught, up to 40 at a time in multiple groups of six to eight, by lay instructors usually supervised by ambulancemen trained to "paramedic" standards. Fifty four incidents have been reported to us in which techniques learnt in the classes have been implemented. Five patients recovered after first aid support but subsequently did not seek medical treatment. Of the 34 patients reviewed in hospital, at least 20 survived to be discharged. We believe that intervention may have been life saving in 16 instances. The benefit of cardiopulmonary resuscitation for victims who may have been asystolic is, however, difficult to quantify because the outcome without intervention cannot be predicted accurately. Community training in basic life support should be considered in association with ambulances equipped for resuscitation and hospital intensive care and cardiac care units as an integrated service for the victims of sudden circulatory or respiratory emergencies. The results achieved so far in Brighton and in other more advanced schemes, particularly in the United States of America, may encourage other health authorities to adopt similar programmes.     

Contribution to knowledge of the morphogenesis of the nasal apparatus of the fallow deer (Dama dama L.)

As in the red deer, in the fallow deer embryo we found a number of ancestral structures reminiscent of relationships in other mammals, such as paraseptal cartilages, a septum nasi with trabecular widening, a lamina transversalis ant., a cart. ectochoanalis, a capsule wall with a roof and a lateral wall formed of a clearly distinguishable cart. parietotectalis and cart. paranasalis, an ethmoturbinale I projecting a long way rostrally and additionally, in the fallow deer, cart. paraseptales posteriores. I regard the relationship of the cart. alaris inf. to the parietotectal cartilage (or "marginoturbinale") as relatively "primitive"; this may mean that the term "atrioturbinale" is also justified in mammals and that the relevant structure is homologous with the one known by the same name in birds. The specializations found during study of the morphogenesis of the nasal apparatus in the red deer (Slaby 1990b) are accentuated in the fallow deer. The chief ones are the specific rostral processes of the anlage of the nasal septum, which are a significant part of reinforcement of the nostril, the marked widening of the nasal capsule in a lateral direction (so that even the paranasal cartilages have a largely horizontal course), the striking ventrolateral bulge in the nasal capsule at the beginning of the olfactory region and the final resultant decrease in the height (i. e. flattening) of the capsule. This leads to reduction of the frontoturbinalia and their corresponding recesses, which - where they are developed - are oriented more horizontally. The structure of ethmoturbinale I, together with its insertion, is also simplified. As in the corresponding red deer embryo, the paranasal cartilage zone in the anterior part of the olfactory region is strikingly thickened; the frontoturbinalia do not, however, originate (in our stage) by the formation of cavities in the cartilage, but develop as simple processes. A crista semicircularis and foramen epiphaniale and also, as distinct from the red deer embryo, cart. paraseptales posteriores, are clearly discernible. In conclusion, it can therefore be claimed that the morphogenesis of specialized cervid features is accentuated in Dama more than in Cervus and that relationships in the fallow deer represent a further step in specialization, or - if we are speaking of the development of radiations - specialization here has progressed further.     

Institutional and IACUC responsibilities for animal care and use education and training programs

Training and instruction of personnel are important components of animal care and use programs because they help to ensure the health and welfare of the animals and the integrity of the research or testing results. Training also helps to promote the consideration of alternatives, recognition of animal pain and distress, appropriate use of pain-relieving agents, aseptic technique, pre- and post-procedural care, and personnel health and safety. While individuals who provide the care for or conduct research or testing in laboratory animals should take personal responsibility for ensuring that they have the skills to perform their duties, the institution is ultimately responsible for ensuring their competency. The institution is also responsible for providing the training or instruction that is required by federal legislation, regulations, and policies. The institutional animal care and use committee (IACUC) is responsible for ensuring, as part of their review of research activities, that the personnel are capable of performing the procedures described. The IACUC must also assess the institution's training program as part of their semiannual animal care and use program review and make recommendations regarding training to the institutional official. This article provides a comprehensive overview of the US regulatory mandates for training and personnel qualification.     

Innovations in human genetics education. Alternative methods of instruction in medical genetics

A course in medical genetics for first-year medical students was developed with the use of alternative methods of instruction, including audiovisual materials and computer-assisted instruction. The use of this methodology enabled students to consider many significant areas of medical genetics, without a dependency on the traditional lecture-based instructional format. Seventy-eight percent of the students identified the alternative instructional methods as an enhancement to their education. These students performed a mean of 6% better on class examinations.     

Resuscitation and quantification of stressed Escherichia coli K12 NCTC8797 in water samples

The aim of this study was to investigate the impact on numbers of using different media for the enumeration of Escherichia coli subjected to stress, and to evaluate the use of different resuscitation methods on bacterial numbers. E. coli was subjected to heat stress by exposure to 55 degrees C for 1h or to light-induced oxidative stress by exposure to artificial light for up to 8h in the presence of methylene blue. In both cases, the bacterial counts on selective media were below the limits of detection whereas on non-selective media colonies were still produced. After resuscitation in non-selective media, using a multi-well MPN resuscitation method or resuscitation on membrane filters, the bacterial counts on selective media matched those on non-selective media. Heat and light stress can affect the ability of E. coli to grow on selective media essential for the enumeration as indicator bacteria. A resuscitation method is essential for the recovery of these stressed bacteria in order to avoid underestimation of indicator bacteria numbers in water. There was no difference in resuscitation efficiency using the membrane filter and multi-well MPN methods. This study emphasises the need to use a resuscitation method if the numbers of indicator bacteria in water samples are not to be underestimated. False-negative results in the analysis of drinking water or natural bathing waters could have profound health effects.     

Blast injury research models

Blast injuries are an increasing problem in both military and civilian practice. Primary blast injury to the lungs (blast lung) is found in a clinically significant proportion of casualties from explosions even in an open environment, and in a high proportion of severely injured casualties following explosions in confined spaces. Blast casualties also commonly suffer secondary and tertiary blast injuries resulting in significant blood loss. The presence of hypoxaemia owing to blast lung complicates the process of fluid resuscitation. Consequently, prolonged hypotensive resuscitation was found to be incompatible with survival after combined blast lung and haemorrhage. This article describes studies addressing new forward resuscitation strategies involving a hybrid blood pressure profile (initially hypotensive followed later by normotensive resuscitation) and the use of supplemental oxygen to increase survival and reduce physiological deterioration during prolonged resuscitation. Surprisingly, hypertonic saline dextran was found to be inferior to normal saline after combined blast injury and haemorrhage. New strategies have therefore been developed to address the needs of blast-injured casualties and are likely to be particularly useful under circumstances of enforced delayed evacuation to surgical care.     

Validation of a biodynamic model of pushing and pulling.

Pushing and pulling during manual material handling can increase the compressive forces on the lumbar disc region while creating high shear forces at the shoe-floor interface. A sagittal plane dynamic model derived from previous biomechanical models was developed to predict L5/S1 compressive force and required coefficients of friction during dynamic cart pushing and pulling. Before these predictions could be interpreted, however, it was necessary to validate model predictions against independently measured values of comparable quantities. This experiment used subjects of disparate stature and body mass, while task factors such as cart resistance and walking speed were varied. Predicted ground reaction forces were compared with those measured by a force platform, with correlations up to 0.67. Predicted erector spinae and rectus abdominus muscle forces were compared with muscle forces derived from RMS-EMGs of the respective muscle groups, using a static force build-up regression relationship to transform the dynamic RMS-EMGs to trunk muscle forces. Although correlations were low, this was attributed in part to the use of surface EMG on subjects of widely varied body mass. The biodynamic model holds promise as a tool for analysis of actual industrial pushing and pulling tasks, when carefully applied.     

Intra-abdominal infections

Intra-abdominal infections in the hospitalized patient differ from those arising in the community in their clinical presentation, sites of involvement, and characteristic microbiology. They are also associated with greater morbidity and mortality. New onset organ dysfunction, more than acute abdominal pain and tenderness, is the predominant clinical manifestation. Successful management depends on aggressive resuscitation and hemodynamic support, administration of adequate antimicrobial therapy, and the timely use of source control measures appropriate to the clinical situation.     

A cart cage for transferring macaques, capuchins, and small dogs

A novel mobile monkey transport cart cage allows ease of handling, safety, secure holding, good visual access to the monkeys, room for large macaques, and ease of assembly, all at a modest cost.     

Effect of a Neonatal Resuscitation Course on Healthcare Providers’ Performances Assessed by Video Recording in a Low-Resource Setting

Background

We assessed the effect of an adapted neonatal resuscitation program (NRP) course on healthcare providers’ performances in a low-resource setting through the use of video recording.

Methods

A video recorder, mounted to the radiant warmers in the delivery rooms at Beira Central Hospital, Mozambique, was used to record all resuscitations. One-hundred resuscitations (50 before and 50 after participation in an adapted NRP course) were collected and assessed based on a previously published score.

Results

All 100 neonates received initial steps; from these, 77 and 32 needed bag-mask ventilation (BMV) and chest compressions (CC), respectively. There was a significant improvement in resuscitation scores in all levels of resuscitation from before to after the course: for “initial steps”, the score increased from 33% (IQR 28–39) to 44% (IQR 39–56), p<0.0001; for BMV, from 20% (20–40) to 40% (40–60), p = 0.001; and for CC, from 0% (0–10) to 20% (0–50), p = 0.01. Times of resuscitative interventions after the course were improved in comparison to those obtained before the course, but remained non-compliant with the recommended algorithm.

Conclusions

Although resuscitations remained below the recommended standards in terms of quality and time of execution, clinical practice of healthcare providers improved after participation in an adapted NRP course. Video recording was well-accepted by the staff, useful for objective assessment of performance during resuscitation, and can be used as an educational tool in a low-resource setting.     

Heart-Alert: emergency resuscitation training in the community

One approach to reducing avoidable mortality from coronary artery disease is to provide resuscitation capability in the community. In Manitoba this is the function of the Heart-Alert program, sponsored by the Manitoba Heart Foundation. The program is based on public and professional education dealing with the recognition and immediate care of cardiac emergencies, including cardiopulmonary resuscitation (CPR). The three components to the program are (a) training in basic CPR for all health care and community rescue groups; (b) training in definitive CPR for physicians, critical care nurses and advanced emergency medical technicians; and (c) education of the public to recognize the signs of impending or actual cardiac emergencies and to take appropriate action to summon quickly an emergency rescue team.The initial emphasis of the program has been on developing an organizational structure and a training network for basic CPR. A corps of instructor-trainers and instructors has been certified to implement CPR training in the medical and community target groups. Developmental problems include problems of quality control, of providing for self-sustaining and continued expansion, and of evaluation of the overall results.It is suggested that widespread implementation of CPR training is facilitated by the incorporation of CPR into existing training activities, particularly those of the medical, nursing and other health care disciplines, those of community protection agencies such as police, fire and ambulance departments, and those of volunteer groups concerned with rescue work and first-aid. If the impetus, organizational structure and instructor training are provided by a strategic agency, wide dissemination of CPR training is then possible at relatively modest cost.