Communication for Medical Advices between Prehospital Providers and Physician Medical Directors

PURPOSE: On-line medical control, in addition to indirect control like protocols, is known to exert a positive effect on the quality of prehospital care. Because the decision-making process of directing physicians depends on the information provided by prehospital providers via telecommunication, brief and organized reporting of significant points is of paramount importance. METHODS: Telecommunications regarding direct medical control provided by emergency physicians in a university hospital were recorded from May 1 to June 30, 2012. All communications were between cellular phones. Analysis of the recorded dialogues was performed by an independent researcher. RESULTS: A total of 115 cases were included for analyses. Affiliated fire offices were reported in 107 (93.0%) cases, while certification of responding officers was reported in only 62 (53.9%) cases. All five vital signs were reported in only 9 cases (7.8%), including blood pressure, heart rate, respiration rate, temperature, and oxygen saturation. Procedures delivered before telephone contact were reported in 30.4% of cases, and reporting rate of patient response to treatment was 16.5%. Estimated times of arrival to the destined hospital were reported in only 8.7%. CONCLUSION: Reporting procedures regarding prehospital direct medical control should be concise and comprehensive, including essential elements like certification of the provider, consciousness and vital signs of the patient, and estimated time of hospital arrival.

Efficacy and Necessity of the Certification Program for Emergency Medical System Directors on the Actual On-Line Medical Direction

PURPOSE: The purpose of this study is to evaluate the usefulness and necessity of an emergency medical service director program for board certified emergency physicians. METHODS: A retrospective analysis of records of direct medical advice provided by board certified emergency physicians in the Busan area from April 1, 2011 to July 11, 2011 was conducted. The medical and legal validity of the medical direction was evaluated by two independent emergency physicians with experience and certification in the field of medical control. RESULTS: Fifteen emergency physicians provided direct medical control during the study period. Five of them were certified as an emergency medical service (EMS) director by the Korean council of EMS physicians (KCEMSP), and the other 10 were not. An analysis of 992 cases of direct medical direction was performed. No differences in the diagnostic appropriateness and medical validity of medical advice were observed between the two groups. A significant difference was observed in legal validity (p=0.048). However, in multivariate analysis, experience as a certified emergency physician was a significant factor determining legal validity (p=0.02), while certification by the KCEMSP was not significant. CONCLUSION: The current EMS director certification program did not have a significant influence on the appropriateness of direct medical direction. EMS director courses and emergency medicine residency programs are in need of improvement in the legal aspect of prehospital emergency service.

Change in Acceptance Rate of Emergency Transfer According to Personnel who Receive the Emergency Transfer Request

PURPOSE: To allocate emergency patients to appropriate hospitals, the 1339 emergency medical information center should contact personnel in individual hospitals for information about the availability of medical resources, with the contacted individuals deciding to accept or to reject the transfer request. The acceptance ratio would influence the time spent finding appropriate hospitals, and would affect the quality of emergency care. The acceptance or rejection ratio of emergency transfer request was analyzed with regard to the personnel receiving the transfer requests. METHODS: The study involved intern doctors in their emergency medicine (EM) rotation or nurses in 2007, EM doctors in 2008~2010, and doctors from the specialty departments in 2010 in one study hospital who made decisions whether to accept patients asked to be received by emergency information center. The data registered in computerized database in the emergency information center were analyzed. RESULTS: The total number of phone calls asking for emergency transfers to the study hospital from March 1 to August 31 in 2007, 2009, and 2010 was 798, 1,100, and 1,334, respectively. Accepted cases were 375(47%) in 2007, 708(64.4%) in 2009 and 801(60.0%) in 2010. CONCLUSION: The hospital staffs or members of department (e.g. Emergency department) who can take charge of the data related to pre-hospital patients should decide whether to accept the patients asked to be received into hospital or not.

Case of Adult-onset Still's Disease with Anaphylatic Shock and Acute Kidney Failure

Adult-onset Still's disease is an uncommon systemic inflammatory disease of unknown etiology and pathogenesis. It is characterized by an evanescent rash, spiking fever (>39degrees), arthralgia, sore throat, abnormal liver function tests and leukocytosis (>10,000/mm3). We report a case involving a 41-year-old male with initial symptoms suggestive of anaphylactic and septic shock. Steroid therapy led to recovery. Adult-onset Still's disease was ultimately confirmed.

Case of Adult-onset Still's Disease with Anaphylatic Shock and Acute Kidney Failure

Adult-onset Still's disease is an uncommon systemic inflammatory disease of unknown etiology and pathogenesis. It is characterized by an evanescent rash, spiking fever (>39degrees), arthralgia, sore throat, abnormal liver function tests and leukocytosis (>10,000/mm3). We report a case involving a 41-year-old male with initial symptoms suggestive of anaphylactic and septic shock. Steroid therapy led to recovery. Adult-onset Still's disease was ultimately confirmed.

Giant Thoracic Spinal Arteriovenous Fistula with Cord Compression: A Case Report / 대한정형외과학회잡지

A spinal arteriovenous fistula is a rare vascular disease that is characterized by abnormal connections between the vertebral artery or its branches and the neighboring veins. Bruit and back pain are common symptoms related to the fistula. Spinal cord dysfunction can also occur as a result of blood flow steal, venous hypertension, or mechanical compression of the nerve roots and spinal cord. We report a huge arteriovenous fistula in the spinal canal at the thoracic vertebra, which was characterized by a large azygous vein connected to the epidural vein causing osteolysis on the vertebral body and spinal cord compression symptoms. Staged embolization was performed using 80 coils.

Comparison of Quality in Chest Compressions at Scene, in a Moving Ambulance by Student Nurses, the 119 Member Group, and an Automatic CPR Machine

PURPOSE: In an emergency, the quality of CPR prior to hospital arrival is a very important component for the survival of victims. We want to know differences in chest compression quality performed by groups that have variant experiences of CPR, and automatic CPR machine on the floor, or in an ambulance moving at 40 km/hr, or at 80 km/hr. METHODS: We analysed the chest compression quality of each group, and that performed on the floor, in an ambulance moving as 40 km/hr, and at 80 km/hr. We measured the following factors: mean compression depth; mean compression rate; exact performance percentile; and the compression error through too deep, too weak, wrong compression location, and no full recoil. RESULTS: In the student-nurse group, the quality of chest compression performed on the floor was better than that performed in a moving ambulance. In 119 member group, chest compression performed in an ambulance moving as 40 km/hr was better than that performed in an ambulance moving at 80 km/hr. The use of an automatic CPR machine, there were no differences in chest compression quality in all circumstances. In comparing each group, compression quality of the 119 member group and the automatic CPR machine group was better than that of the student nurses. CONCLUSION: In the group with real CPR experience, there were no differences between chest compression performed on the floor and that performed moving at 40 km/hr. Chest compression performed moving as 40 km/hr is better than that performed moving at 80km/hr. In the group without CPR experience, chest compression performed on the floor is better than that performed in a moving ambulance.

Effects of Additional Instructor's Intervention on CPR Performance Immediately after DVD-based or Instructor-led Instruction

PURPOSE: Effective training in CPR is important for medical personnel and the public and a variety of educational methods have been used. We compared the results of the two most common CPR teaching methods, video-based and Instructorled teaching, with particular emphasis on the effects of supervised practice by an instructor. METHODS: Sixty college students who had never been taught CPR were divided into 2 groups of 30. One group was given a 30-minute lecture using slides and the other watched the 30-minute CPR Anytime DVD. Afterwards, all participants were tested on the Mini Anne manikin. All students were re-tested after 30 minutes of practice under the supervision of an instructor. RESULTS: The only statistically significant difference between the two groups was an increased accuracy in breath delivery in the DVD group before the instructor supervised practice. There were no statistically significant differences between the 2 groups after the instructor supervised practice. CONCLUSION: Self practice via DVD was relatively more effective than the theory lecture. However, the effect of the education significantly increased with instructor's participation and the difference between teaching methods was insignificant.

Immunohistochemical Study for Expression of cFos, pERK1/2 and pAkt Proteins in a Macrosphere Animal Model for Permanent Focal Brain Ischemic Injury

PURPOSE: Recently, a new animal model for permanent focal brain ischemia using macrospheres was developed wherein the hypothalamic area was free from ischemic injury. The purpose of this study was to evaluate spatiotemporal changes in the expressions of cFos, pERK, and pAkt proteins in the macrosphere model. METHOD: Three or four macrospheres were injected into the internal carotid artery after ligation of the external carotid artery to induce permanent focal brain ischemic injury. RESULT: Twenty-four hours after macrosphere injection, 2,3,5-Triphenyltetrazlium (TTC) staining showed a marked ischemic injury in the blood supply territory of the middle cerebral artery, for example, the cerebral cortex and striatum. Furthermore, TUNEL staining revealed apoptotic cell death in the ischemic injury region of the cerebral cortex and striatum. Expression of the cFos protein was significant in the penumbral zone, but not in the ischemic core of the cortex and striatum, two and six hours after ischemic insult. A transient prominent expression of the pERK1/2 protein was noted in the penumbral zone of the cortex and striatum two hours after injection of macrospheres. In contrast, there was a strong immunoreactivity for the pAkt protein in the ischemic core, but not in the penumbral zone of the cortex and striatum, six hours after ischemic injury. CONCLUSION: The above results suggest that early expressions of cFos, pERK1/2, and pAkt proteins take part in different signaling cascades for cell survival or death in macrosphere animal model of permanent focal brain ischemic injury.

Plasma Homocysteine Level and Blood Coagulation Factors in Acute Ischemic Cerebral Stroke

PURPOSE: We studied the plasma homocysteine level and coagulation factors such as fibrinogen and antithrombin III (ATIII) in acute cerebral infarction (ACI). METHODS: We enrolled 222 patients who visited our emergency department from March 1, 2003, to August 31, 2003. The ACI patient group included those who visited the emergency department within 24 hours due to cerebral infarction symptoms and included 115 patients the control group included those visited the emergency department due to minor trauma (CRAMS score>9) and include 56 patients in the homocysteine control group and 51 in the fibrinogen and ATIII group. ACI patient group was subclassified according to great artery, small artery, or cardioembolic cerebral infarction. RESULTS: The plasma homocysteine level, the fibrinogen, and ATIII were 16.3+/-7.9 micrommol, 283.2+/-60.1 mg/dl, 87.3+/-25.8%, respectively, in the ACI patient group and 9.6+/-4.0 micrommol, 245.3+/-62.2 mg/dl, 109.8+/-14.7% in the control group. The values of plasma homocysteine and fibrinogen in the was higher than it was in the control group. The value of ATIII in the ACI patient group was lower than it was in the control group. In according to cerebral infarction type, no differences were observed in the plasma homocyteine, fibrinogen, and ATIII. CONCLUSION: In cases of acute cerebral infarction, fibrinogen and ATIII have no statistical usefulness in classifying the type of cerebral infarction. However, the value of plasma homocysteine, fibrinogen, and ATIII have statistical usefulness in deciding on the existence or nonexistence of an acute cerebral infarction.

Expressions of the pERK1/2 and the cFos Proteins at an Early Stage of Transient Global Ischemia-reperfusion Injury in the Hippocampus of Rats

PURPOSE: This study was to evaluate temporal changes in the expressions of the phosphorylated extracellular-regulated kinase1/2 (pERK1/2), the phosphorylated MAPK/ERK kinase1/2 (pMEK1/2) and the cFos proteins in the hippocampus of rats following transient global ischemia. METHODS: Transient global ischemia was induced in the forebrains of Sprague-Dawley rats by using a 4-vessel occlusion for 20 min under anesthetic condition. Hematoxyline-eosin staining showed typical microscopic findings that represented neuronal cell death in hippocampal CA1 regions 5 days after transient global ischemia. Four-vessel occlusion-reperfusion produced ischemic injury in major forebrain structures, such as the striatum, the cortex and the hippocampus, in the finding of triphenyltetrazolium chloride (TTC) staining. RESULTS: A high density of pERK1/2 immunoreactivity existed in the pyramidal-cell layers of the CA2-3 regions and in the granular-cell layers of the dentate gyrus 5 min after ischemia. Following ischemia, expression of the pMEK1/2 protein showed temporal changes similar to that of the pERK1/2 protein. A significant expression of the cFos protein was noted in the pyramidal-cell layers of the CA2-3 regions and in the granular-cell layers of the dentate gyrus 2 hours after global ischemia. CONCLUSION: Intracellular signaling cascades of the ERK or the cFos protein take part in early cellular events in the hippocampus of rats in response to ischemic insult.

Boutonniere Deformity of the knee Following Patellectomy: A Case Report / 대한정형외과학회잡지

A 60-year-old man visited our hospital complaining of an inability to actively extend his left knee beyond 45 degrees for seven months after a slip down injury. Twenty years earlier he had sustained a falling down injury to the left knee and had undergone a patellectomy due to comminuted patellar fracture. In the operating room, a defect in the patellar tendon was demonstrated. As the knee was flexed, the medial and lateral portions of the defect in the patellar tendon separated and moved posterioly over the femoral condyles, producing a boutonniere effect. The scarred lateral retinacula and vastus lateralis were released, allowing the medial and lateral portions of the patellar tendon to be brought together. These were then reefed and sutured together, forming a cord that rode in the intercondylar notch. Twelve months postoperatively the knee had an active range of motion from 0 degrees through 120 degrees.

Results of PCL Substituting Total Knee Replacement Arthroplasty / 대한정형외과학회잡지

PURPOSE: To report the clinical and roentgenographic results of patients who had received PCL substituting total knee replacement arthroplasty. MATERIALS AND METHODS: Forty-eight knees in thirty-two patients who received the PCL sustituting total knee system insertion from October 1994 to May 1997 were evaluated. There were ten men (31.3%) and twenty-two women (68.7%), and the average duration of follow upwas 73 months (range, 60 months to 91 months). Clinical evaluation was performed according to Hospital for Special Surgery (HSS) scaleand the radiologic evaluation was performed according to The Knee Society Roentgenographic Evaluation and Scoring System. RESULTS: The average HSS score improved from 46.4 preoperatively to 92.4 postoperatively, and the average range of motion improved from 93.1degree preoperatively to 110.4degree postoperatively. The tibio-femoral angle improved from 4.1degree varus preoperatively to 6.5degree valgus at final follow-up. Forty four knees (91.7%) showed excellent or good clinical results. Radiolucent lines around the prosthesis were found in 20cases (41.7%), but none showed any clinical symptom. One case had a revision operation due to aseptic loosening. CONCLUSION: PCL substituting total knee replacement arthroplasty is a good treatment method for osteoarthritis of the knee joint.

MR Imaging of Gestational Trophoblastic Tumor: Role of Gadolinium Enhancement

PURPOSE: To investigate the role of gadolinium enhanced MR imaging in the evaluation of gestational trophoblastic tumors (invasive mole and choriocarcinoma). MATERIALS AND METHODS: Pre-enhanced T1-and T2-weighted images and gadolinium enhanced T1-weighted images of 34 gestational trophoblastic tumors (15 choriocarcinomas, 19 invasive moles) were evaluated retrospectively. Enhanced patterns of gestational trophoblastic tumors were analyzed. Morphologic differences and structural characterstics were analyzed by the evaluation of tumor margin, patterns of hemorrhagic necroses, development of intratumoral vascularity, and molar villi. Graded scores of MR findings between pre- and gadolinium enhanced images were given in the following criteria ; 1) visualization of tumor margin 2) distinction between tumor necrosis and zone of trophoblastic proliferation, and 3) molar villi. Statistical differences between graded scores of pre-and post-enhanced images were analyzed. RESULTS: Choriocarcinoma was a well-defined mass with peripheral rim enhancement and central hemorrhagic necrosis. Invasive mole was a ill-defined mass with partial necrosis, tiny cystic areas and increased intratumoral vascularity with dense reticular enhancement. Interface between tumor necrosis and zone of trophoblastic proliferation was better visualized on the gadolinium enhanced images than on the pre-enhanced images. Tumor margin and intratumoral molar villi were clearly discrimated on the gadolinium enhanced images only in invasive mole. There was no statistical difference in the visualization of tumor margin of choriocarcinoma between the pre-and post-enhanced images. CONCLUSION: Gadolinium enhanced MR image was helpful in the visualization of tumor characterstics in gestational trophoblastic tumors, and in the differential diagnosis between invasive mole and choriocarcinoma.