Psychological distress and line-of-duty head injuries in firefighters.

BACKGROUND: Head injuries are common injury in the fire service; however, very little data exist on the risks this may pose to the development of post-traumatic stress disorder (PTSD) and depression in this high-risk population. AIMS: Our study aimed to compare levels of PTSD and depression symptoms in firefighters with a line-of-duty head injury, non-line-of-duty head injury and no head injury. METHODS: In this cross-sectional study, we assessed current PTSD and depression symptoms as well as retrospective head injuries. RESULTS: Seventy-six per cent of the total sample reported at least one head injury in their lifetime. Depression symptoms were significantly more severe among firefighters with a line-of-duty head injury compared to those with no head injury, but not compared to those who sustained a non-line-of-duty head injury. Depression symptoms did not differ between firefighters with a non-line-of-duty head injury and those with no head injury. PTSD symptoms were significantly more severe among firefighters with a line-of-duty head injury compared to both firefighters with no head injury and those with a non-line-of-duty head injury. CONCLUSIONS: We found that firefighters who reported at least one line-of-duty head injury had significantly higher levels of PTSD and depression symptoms than firefighters who reported no head injuries. Our findings also suggest head injuries sustained outside of fire service could have less of an impact on the firefighter's PTSD symptom severity than head injuries that occur as a direct result of their job.

[Intraoperative vascular air embolism : Evidence for risks, diagnostics and treatment]. / Intraoperative vaskuläre Luftembolie : Evidenz bei Risiko, Diagnostik und Therapie.

The entry of gases into the vascular system is called vascular air embolism (VAE). The blocking of the pulmonary circulation by VAE can lead to fulminant right-sided heart failure and cardiocirculatory arrest. A VAE can occur at any time if there is an open connection between the environment and a venous vessel with subatmospheric pressure. This situation occurs during ear nose throat surgery, hip surgery, surgery of the lesser pelvis or breast surgery, if the surgical field is above the level of the heart; however, a VAE can also occur during routine tasks, such as insertion or removal of a central venous catheter or during endoscopic procedures with the insufflation of gas.Because during these procedures VAE is not the main focus of the anesthesia or surgery personnel, in such situations its sudden unexpected occurrence can have severe consequences. In contrast, in cardiac surgery or neurosurgery the risk of intraoperative VAE is much better known. In procedures with a higher risk of a clinically relevant VAE, a patent foramen ovale should be ruled out by preoperative transesophageal echocardiography (TEE). Intraoperatively TEE is the most sensitive procedure not only to detect a VAE but also to visualize the clinical expression, e.g. acute right heart overload.The avoidance of an initial and repeated air embolism is the primary measure to minimize the incidence and severity of VAE.Intraoperatively the following measures should be undertaken: excellent communication between anesthesia and surgery personnel with predetermined actions, maintenance of normal volume, patient positioning with minimal difference in height between heart and head, state of the art surgical technique with closure of potential air entry sites, sufficient detection of air by TEE, repeated jugular vein compression during neurosurgery, intraoperative Trendelenburg positioning of the patient during persisting or clinically evident VAE, differentiated adjustment of ventilatory settings and catecholamine treatment, aspiration of the blood-air mixture (air lock) at the junction of the superior vena cava and right atrium through a large bore central venous line and keeping check of the coagulation status.

Alcohol use and mental health symptoms in female firefighter recruits.

BACKGROUND: Limited research suggests that female firefighters report problem drinking at higher rates than the general population. AIMS: To identify longitudinal drinking patterns in female firefighters, make comparisons to male firefighters and examine problem drinking in relation to post-traumatic stress disorder (PTSD) and depression. METHODS: Study participants included 33 female and 289 male firefighter recruits, who were assessed over their first 3 years of fire service. RESULTS: Female firefighters consumed increasing numbers of drinks per week, with a median of 0.90 drinks per week at baseline, and 1.27 drinks in year 3. Female firefighters reported binge drinking at high rates, with nearly half binging at least once per year across all time points (44-74%). The percentage that reported binge drinking three or more times per month doubled over the course of the study (from 9% to 18%). Overall, males reported higher rates of binge drinking and a greater number of drinks per week; however, binge drinking rates among females increased over time and became comparable to rates of binge drinking among males. A greater percentage of female than male firefighters met the criteria for problem drinking by year 1. Problem drinking was associated with screening positive for PTSD at year 1 and depression at year 2, but not with occupational injury. CONCLUSIONS: Over time, female firefighters reported increasing amounts of drinking, more frequent binge drinking and more negative consequences from drinking. These findings along with existing literature indicate female firefighters change their drinking in the direction of their male counterparts.

Four wishes for Aubrey.

In the critical care environment, what begins as cure-oriented and life-extending treatment may become unsuccessful in overcoming the patient's increasingly complex pathophysiology. A case from the neonatal intensive care unit is presented and used to elaborate upon care transitions toward palliative and supportive care that can be rendered in the hospital, at home or in a hospice facility. Successful transitions may rest upon anticipatory guidance by the primary physician and team, or a consultant, to facilitate and enable parents and team members alike in addressing the hard realities that cure, or even successful ICU discharge, is unlikely. A simple mechanism of addressing and accommodating a family's wishes is provided.

An interdisciplinary, family-focused approach to relational learning in neonatal intensive care.

OBJECTIVE: The aim of this study is to show the efficacy of the Program to Enhance Relational and Communication Skills-Neonatal Intensive Care Unit (PERCS-NICU). STUDY DESIGN: In this study, 74 practitioners attended workshops and completed baseline, post-training and follow-up questionnaires. RESULT: On yes/no questions, 93 to 100% reported improved preparation, communication skills and confidence post-training and follow-up. A total of 94 and 83% improved their ability to establish relationships, and 76 and 83% reported reduced anxiety post-training and follow-up, respectively. On Likert items, 59 and 64% improved preparation, 45 and 60% improved communication skills and confidence, 25 and 53% decreased anxiety and 16 and 32% improved relationships post-training and follow-up, respectively. Qualitative themes included integrating new communication and relational abilities, honoring the family perspective, appreciating interdisciplinary collaboration, personal/human connection and valuing the learning. In total, 93% applied skills learned, three-quarters transformed practice and 100% recommended PERCS-NICU. CONCLUSION: After PERCS-NICU, clinicians improved preparation, communication and relational abilities, confidence and reduced anxiety when holding difficult neonatal conversations.

Analysis of enacted difficult conversations in neonatal intensive care.

OBJECTIVE: To analyze the communicative contributions of interdisciplinary professionals and family members in enacted difficult conversations in neonatal intensive care. STUDY DESIGN: Physicians, nurses, social workers, and chaplains (n=50) who attended the Program to Enhance Relational and Communication Skills, participated in a scenario of a preterm infant with severe complications enacted by actors portraying family members. Twenty-four family meetings were videotaped and analyzed with the Roter Interaction Analysis System (RIAS). RESULT: Practitioners talked more than actor-family members (70 vs 30%). Physicians provided more biomedical information than psychosocial professionals (P<0.001), and less psychosocial information than nurses, and social workers and chaplains (P<0.05; P<0.001). Social workers and chaplains asked more psychosocial questions than physicians and nurses (MD=P<0.005; RN=P<0.05), focused more on family's opinion and understanding (MD=P<0.01; RN=P<0.001), and more frequently expressed agreement and approval than physicians (P<0.05). No differences were found across disciplines in providing emotional support. CONCLUSION: Findings suggest the importance of an interdisciplinary approach and highlight areas for improvement such as using silence, asking psychosocial questions and eliciting family perspectives that are associated with family satisfaction.

Different low constant flows can equally determine the lower inflection point in acute respiratory distress syndrome patients.

Among the possible techniques to obtain the pressure-volume (P x V) curve at the bedside the low constant flow (CF) is the easiest and quickest one. However, the best value for CF to perform a good semi-static P x V curve is still to be determined. The purpose of this study was to evaluate the influence of 4 different CFs (1, 2, 5, and 10 L/min) on determination of lower inflection point of the P x V curve (L-Pflex) and upper inflection point of the P x V curve (U-Pflex) on the maximum slope and on the inspiratory work of breathing (up to volume of 1.35 L; inspiratory work L/cm H2O), comparing the volume estimated from the CF with the measured volume obtained by the respiratory inductive plethysmograph. The design was a prospective study, and the setting was an adult medical intensive care unit of a university hospital. There were 7 acute respiratory distress syndrome (ARDS) patients, less than 5 days of installation, after the standardization of lung volume history received sequentially from 4 different low inspiratory CFs in 2 trials. The P x V curve lasted from 73 +/- 1.6 s (1 L/min) to 8.8 +/- 0.69 s (10 L/min). The L-Pflex differed in the 2 performed trials (p = 0.04). There was no difference of L-Pflex among the 4 CFs comparing the 3 methods (p = 0.072) used for its calculation as well as comparing the estimated and the measured volume (p = 0.456). The maximum slope decreased significantly while increasing the flow from 1 to 10 L/min just in the estimated volume (p = 0.03). The inspiratory work did not increase with the increment of the flow either in the estimated volume (p = 0.217) or in the measured volume (p = 0.149). The U-Pflex differed among the trials (p = 0.003) and the methods used for its calculation (p < 0.01). Constant flows from 1 to 10 L/min can equally determine L-Pflex in ARDS patients and is an easy and quick way to obtain the L-Pflex in order to optimize positive end expiratory pressure (PEEP) in ARDS patients.

Ventilação não-invasiva no cardiopata grave / Noninvasive ventilation in the severe congestive heart failure patient

A insuficiência cardíaca congestiva leva a aumento na água extravascular pulmonar, redução do volume e da complacência pulmonar e aumento da resistência de vias aéreas, resultando em aumento do trabalho respiratório, aumento do consumo de oxigênio e aumento da sobrecarga ventricular esquerda. A utilização de pressão positiva contínua nesses pacientes melhora a oxigenação, diminui o trabalho respiratório, melhora a mecânica pulmonar, reduz a pressão transmural sobre o ventrículo esquerdo e diminui o retorno venoso, contribuindo para maior desempenho cardíaco. O uso de pressão positiva contínua diminui a necessidade de ventilação mecânica no edema agudo de pulmão e reduz o tempo de internação na unidade de terapia intensiva. A utilização de pressão positiva contínua noturna em cardiopatas crônicos demonstrou melhora significativa da fração de ejeção durante o dia, em associação com melhora da classe funcional, após o tratamento por um mês em pacientes com cardiomiopatia dilatada e apnéia obstrutiva do sono concomitante. O uso de pressão positiva contínua deve ser entendido não só como o primeiro suporte ventilatório no edema agudo dos pulmöes, como também um tratamento não-farmacológico que tem o potencial de melhorar a função cardíaca nos pacientes clinicamente estáveis, porém com insuficiência cardíaca grave.

Pediatric intensive care: the parents' experience.

A child's emergent admission to the pediatric intensive care unit (PICU) can strike fear and feelings of helplessness into the hearts of parents who only hours earlier had been in control of their lives. Acute critical illness seriously threatens the parents' ability to fulfill their familiar and important roles of protecting and providing for their child. The PICU setting can rapidly undermine the sense of competence, control, and stability of even the most dedicated parents. Parental stress is primarily caused by their displacement from familiar roles, the child's appearance and behavior, and difficulties in communicating with staff members. In planning interventions, these issues should be considered as well as the specific needs that parents have emphasized: accurate information, ready access to their children, and meaningful participation in their children's care. Advanced practice nurses are in an excellent position to improve delivery of psychosocial services to parents of critically ill children through direct care, acting as models of care practices and mentoring staff, staff education, policy development, and clinical research.

Brothers and sisters of young children with communication disorders.

Family-centered approaches have revolutionized the way that clinicians provide services to young children with communication disorders and their families. With greater recognition of the significant impact that siblings have on each other's development and the potential stress and role confusion that siblings may experience when there is childhood disability in the family, it becomes more critical that the needs of siblings are considered and addressed. In this article, a variety of issues are considered relative to siblings' experiences. First, the roles of siblings and their effects on each other's development is reviewed, followed by a historical perspective of the impact of childhood disability on brothers and sisters. Next, sibling roles relative to a brother or sister with a communication disability are considered. Finally, clinical implications are discussed, with specific reference to active inclusion of siblings in family-centered assessment and intervention efforts.