Austere Diagnosis and Reduction of Anterior Shoulder Dislocations: 10-Year Review of a Ski Patrol-Based Program with Emergency Medical Technicians.

INTRODUCTION: Glenohumeral dislocations present a challenging management dilemma in austere settings where patient transport time may be prolonged. Expeditious reduction is preferable, but treatment is commonly expected to take place within a hospital or comparable facility. Through a novel shoulder injury program, professional ski patrollers trained as emergency medical technicians (EMTs) have diagnosed and reduced anterior shoulder dislocations using biomechanical techniques without sedation or analgesia for over 20 y. Summary records have been maintained to track the performance and safety of this program. METHODS: Five hundred forty-six records of winter sports-related shoulder injuries from 2009-10 to 2019-20 were retrospectively analyzed to determine the assessment performance and dislocation reduction efficacy of EMTs, with the intent of ascertaining whether EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations without premedication in a remote and resource-limited setting. RESULTS: EMTs identified anterior shoulder dislocations with 98% sensitivity and 96% diagnostic accuracy. The overall success rate of reduction attempts was 86%, or 88% when limited to confirmed anterior dislocations. Two fracture-dislocations and 4 misdiagnoses were manipulated. No instances of iatrogenic harm were identified, and no patients who underwent successful reductions required ambulance transportation. CONCLUSIONS: With appropriate education and within a structured program, EMT-trained practitioners can reliably and safely diagnose and reduce anterior shoulder dislocations using biomechanical techniques without premedication in remote and resource-limited environments. Implementation of similar programs in austere settings has the potential to improve patient care. Further, using biomechanical reduction techniques may reduce reliance on procedural sedation irrespective of care setting.

Preventable Disease, the Case of Colorado: School District Demographics and Childhood Immunizations.

The objective of this study was to evaluate the impact of selected sociodemographic factors on childhood vaccination hesitancy and to define their role according to specific exemptions. This population-based cohort study utilized vaccination rate and sociodemographic data from 1st to 12th grade from 2017 to 2021 for all school districts in Colorado. Data included immunization status and exemptions for each vaccine, race, ethnicity, and free and reduced meal status. Data were evaluated through dimensional analysis and Generalized Linear Mixed Models. School districts with a higher representation of White students had lower immunization rates and use more personal exemptions while school districts with larger Hispanic populations and higher proportions of free and reduced lunches had higher vaccination rates and used more religious exemptions. Black and Pacific Islander populations had higher rates of incomplete vaccination records while Asian American population displayed increased vaccination compliance. Colorado is a robust example of how socioeconomic and cultural differences are important factors with a direct influence on vaccination rates. Future childhood vaccination campaigns and legislation should consider complex socioeconomic and cultural factors.

A Demographic and Regional Comparison of Opioid-Related Hospital Visits within Community Type in the United States.

BACKGROUND: The opioid epidemic is a complex national crisis in the United States with a 400% increase in related deaths over the past two decades with no signs of slowing. The purpose of this study was to assess the incidence of opioid use, based on the geographic and population characteristics. METHODS: The opioid-related hospital inpatient stays and emergency department visits obtained from the 2010 to 2018 Healthcare Cost and Utilization Project and demographic confounders, including age, race, education, and income gathered from US Census data were analyzed through generalized linear mixed models and reported by community size and region. RESULTS: Opioid use varies among population center sizes and the region analyzed. In general, opioid visits in the southwest region were greatest across the majority of population center sizes. Rural usage was greatest in the northeast, southeast, and southwest. Unemployment and diverse ethnicities were commonly associated with opioid use in the metro areas studied but these associations were not seen in rural areas. CONCLUSION: Opioid use remains significant among diverse populations across the United States. Understanding the unique dynamics associated with opioid usage in populations within the regions studied is important in guiding future interventions to fight this crisis.

Comparison of a Novel Trainer to a Traditional Swine Model for Training Providers in Lateral Canthotomy and Cantholysis.

RESEARCH OBJECTIVE: Military personnel are at greater risks of head and facial traumas and permanent blindness from orbital compartment syndrome in modern warfare. Rapid treatment must be implemented with a low-risk surgical remedy: lateral canthotomy and cantholysis (LCC). Traditional training of LCC is primarily performed using an animal tissue trainer (ATT); however, limitations to these types of trainers exist. Therefore, our research objectives were focused on highlighting the effectiveness, benefits, and vision-saving potential of learning LCC on a synthetic trainer. METHODS: Participants included 22 second-year medical students and 6 healthcare professionals. A pre-quiz assessed baseline knowledge. Next, an experienced ophthalmologist provided an overview and instruction. Subjects were randomized to either the synthetic trainer or the ATT and then switched to the other model for comparison. After performing LCC procedures on both models, a post-quiz and survey were administered. RESULTS: Participants found the synthetic trainer easier to use than the ATT model (p < 0.01). There was no statistically significant preference (p = 0.23), or preference of practical eye anatomy (p = 0.26) between the trainers. Post-quiz results demonstrated an overall improvement from pre-quiz scores for participants (p < 0.001). CONCLUSIONS: The synthetic trainer is comparable to the traditional swine model for training LCC procedures, and should be considered as a future training platform.

Lights and Siren Transport and the Need for Hospital Intervention in Trauma Patients.

Emergent ambulance transportation is associated with increased risk of collision, injury, and death for EMS professionals, patients, and the general public. Time saved using lights and siren (L&S) is typically small, and often provides minimal clinical benefit. Our objective was to investigate the frequency of L&S transports, describe the precision of the decision to employ L&S to predict the need for a time critical hospital intervention (TCHI) within 15 minutes of hospital arrival, identify clinical predictors of a TCHI, and compare clinical outcomes in patients transported by Emergency Medical Services (EMS) with and without L&S in a trauma-specific population. EMS patient care reports and trauma registry data were retrospectively reviewed for trauma patients consecutively transported from the field by three EMS agencies to three trauma centers within urban and suburban settings over a two-year period. TCHIs were collaboratively developed by the study team. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were utilized to report the precision of the decision to employ L&S to predict the need of a TCHI. Univariate and multivariate analyses determined predictors of a TCHI and compared clinical outcomes. 2,091 patients were included in the study. Of the 19.8% of patients transported with L&S, 22.9% received a TCHI. The most common TCHI was airway or respiratory procedures (87.2% of all TCHI's). The sensitivity and specificity of L&S to predict the need for a TCHI was 87.2% (95% CI 79.4-92.8) and 84.0% (95% CI 82.2-85.5), respectively. PPV was 23.0% (95% CI 23.53-38.01); NPV was 99.2% (95% CI 98.6-99.6). L&S was predictive for the need for a TCHI (p < 0.001), as was abnormal Glasgow Coma Score (p < 0.001), abnormal systolic blood pressure and age (p < 0.05 for all). Among patients that received a TCHI, over a third that were transported with L&S (36.8%) expired, compared with two of 14 patients (14.3%) not transported L&S. EMS professionals in this study demonstrated a high ability to discern which trauma patients did not require L&S. Nevertheless, L&S transport resulted in a TCHI less than one quarter of the time, suggesting an opportunity for further reduction of L&S transports in trauma patients.

The rumen microbial metagenome associated with high methane production in cattle.

BACKGROUND: Methane represents 16 % of total anthropogenic greenhouse gas emissions. It has been estimated that ruminant livestock produce ca. 29 % of this methane. As individual animals produce consistently different quantities of methane, understanding the basis for these differences may lead to new opportunities for mitigating ruminal methane emissions. Metagenomics is a powerful new tool for understanding the composition and function of complex microbial communities. Here we have applied metagenomics to the rumen microbial community to identify differences in the microbiota and metagenome that lead to high- and low-methane-emitting cattle phenotypes. METHODS: Four pairs of beef cattle were selected for extreme high and low methane emissions from 72 animals, matched for breed (Aberdeen-Angus or Limousin cross) and diet (high or medium concentrate). Community analysis was carried out by qPCR of 16S and 18S rRNA genes and by alignment of Illumina HiSeq reads to the GREENGENES database. Total genomic reads were aligned to the KEGG genes databasefor functional analysis. RESULTS: Deep sequencing produced on average 11.3 Gb per sample. 16S rRNA gene abundances indicated that archaea, predominantly Methanobrevibacter, were 2.5× more numerous (P = 0.026) in high emitters, whereas among bacteria Proteobacteria, predominantly Succinivibrionaceae, were 4-fold less abundant (2.7 vs. 11.2 %; P = 0.002). KEGG analysis revealed that archaeal genes leading directly or indirectly to methane production were 2.7-fold more abundant in high emitters. Genes less abundant in high emitters included acetate kinase, electron transport complex proteins RnfC and RnfD and glucose-6-phosphate isomerase. Sequence data were assembled de novo and over 1.5 million proteins were annotated on the subsequent metagenome scaffolds. Less than half of the predicted genes matched matched a domain within Pfam. Amongst 2774 identified proteins of the 20 KEGG orthologues that correlated with methane emissions, only 16 showed 100 % identity with a publicly available protein sequence. CONCLUSIONS: The abundance of archaeal genes in ruminal digesta correlated strongly with differing methane emissions from individual animals, a finding useful for genetic screening purposes. Lower emissions were accompanied by higher Succinovibrionaceae abundance and changes in acetate and hydrogen production leading to less methanogenesis, as similarly postulated for Australian macropods. Large numbers of predicted protein sequences differed between high- and low-methane-emitting cattle. Ninety-nine percent were unknown, indicating a fertile area for future exploitation.

Archaeal abundance in post-mortem ruminal digesta may help predict methane emissions from beef cattle.

Methane produced from 35 Aberdeen-Angus and 33 Limousin cross steers was measured in respiration chambers. Each group was split to receive either a medium- or high-concentrate diet. Ruminal digesta samples were subsequently removed to investigate correlations between methane emissions and the rumen microbial community, as measured by qPCR of 16S or 18S rRNA genes. Diet had the greatest influence on methane emissions. The high-concentrate diet resulted in lower methane emissions (P < 0.001) than the medium-concentrate diet. Methane was correlated, irrespective of breed, with the abundance of archaea (R = 0.39), bacteria (-0.47), protozoa (0.45), Bacteroidetes (-0.37) and Clostridium Cluster XIVa (-0.35). The archaea:bacteria ratio provided a stronger correlation (0.49). A similar correlation was found with digesta samples taken 2-3 weeks later at slaughter. This finding could help enable greenhouse gas emissions of large animal cohorts to be predicted from samples taken conveniently in the abattoir.

Hydrogen and methane emissions from beef cattle and their rumen microbial community vary with diet, time after feeding and genotype.

The aims of the present study were to quantify hydrogen (H2) and methane (CH4) emissions from beef cattle under different dietary conditions and to assess how cattle genotype and rumen microbial community affected these emissions. A total of thirty-six Aberdeen Angus-sired (AAx) and thirty-six Limousin-sired (LIMx) steers were fed two diets with forage:concentrate ratios (DM basis) of either 8:92 (concentrate) or 52:48 (mixed). Each diet was fed to eighteen animals of each genotype. Methane (CH4) and H2 emissions were measured individually in indirect respiration chambers. H2 emissions (mmol/min) varied greatly throughout the day, being highest after feed consumption, and averaged about 0·10 mol H2/mol CH4. Higher H2 emissions (mol/kg DM intake) were recorded in steers fed the mixed diet. Higher CH4 emissions (mol/d and mol/kg DM intake) were recorded in steers fed the mixed diet (P< 0·001); the AAx steers produced more CH4 on a daily basis (mol/d, P< 0·05) but not on a DM intake basis (mol/kg DM intake). Archaea (P= 0·002) and protozoa (P< 0·001) were found to be more abundant and total bacteria (P< 0·001) less abundant (P< 0·001) on feeding the mixed diet. The relative abundance of Clostridium cluster IV was found to be greater (P< 0·001) and that of cluster XIVa (P= 0·025) lower on feeding the mixed diet. The relative abundance of Bacteroides plus Prevotella was greater (P= 0·018) and that of Clostridium cluster IV lower (P= 0·031) in the LIMx steers. There were no significant relationships between H2 emissions and microbial abundance. In conclusion, the rate of H2 production immediately after feeding may lead to transient overloading of methanogenic archaea capacity to use H2, resulting in peaks in H2 emissions from beef cattle.

Acute coronary ischemia identified by EMS providers in a standing middle-aged male with atypical symptoms.

Acute coronary syndrome and myocardial infarction have been described to present with atypical symptoms in certain subsets of patients. However, these subsets commonly do not include middle-aged males with a paucity of underlying medical conditions. We present a very unique case of acute coronary syndrome in a 53-year-old male, with no previously identified medical conditions other than chronic back pain. The patient was encountered by rural emergency medical service providers presenting with syncope followed by intermittent episodes of lightheadedness. Further, electrocardiographic changes consistent with acute ischemia could only be demonstrated with the patient in a standing position, prior to the development of an occurrence of ventricular tachycardia, which degenerated into ventricular fibrillation. To our knowledge, this is a very rare case of electrocardiographic changes consistent with occult, acute cardiac ischemia with a proven coronary artery lesion seen initially only with the patient in a standing position.

EMS triage and transport of intoxicated individuals to a detoxification facility instead of an emergency department.

STUDY OBJECTIVE: We evaluate the effectiveness and safety of emergency medical services (EMS) provider use of a checklist to triage alcohol-inebriated patients directly to a detoxification facility, rather than an emergency department (ED). METHODS: A retrospective cohort study was conducted of all patients evaluated during a 2-year period, from 2003 to 2005, by EMS providers who used a detoxification evaluation checklist to aid in triage decisionmaking. Patients who did not meet detoxification evaluation checklist criteria were transported to an ED. Twelve-hour follow-up was solicited for patients taken to the detoxification center. Hospital records of inebriated patients transported to an ED were reviewed to assess ultimate need for ED care. RESULTS: Seven hundred eighteen patient encounters were reviewed. One hundred thirty-eight of these patients (19.2%) were transported to the detoxification facility, whereas 580 (80.8%) were transported to an ED; 339 patients transported to an ED were ultimately deemed to have required ED care. The criteria that most commonly excluded transport to the detoxification center were an inability to ambulate with minimal assistance (N=334) and an unwillingness to cooperate with the physical examination (N=195). Low-acuity adverse events were observed in 4 subjects (0.6%) initially transported to the detoxification center who then required subsequent transport to an ED. No high-acuity clinical complications were identified at any time. The use of the detoxification evaluation checklist resulted in high sensitivity (99%; 95% confidence interval 97% to 100%) and low specificity (42%; 95% confidence interval 37% to 48%) in predicting need for ED care. CONCLUSION: Our analysis suggests that field triage criteria can be used effectively to safely divert inebriated patients to a detoxification facility rather than an ED, with minimal adverse events. Use of the detoxification evaluation checklist resulted in substantial ED overtriage, and further refinement of the detoxification evaluation checklist criteria is needed to reduce it.

Factors associated with the interfacility transfer of the pediatric trauma patient: implications for prehospital triage.

OBJECTIVE: The goal of this study was to identify prehospital factors associated with increased likelihood of interfacility transfer of pediatric trauma patients. Such factors might serve as a basis for improvements in future field pediatric trauma triage guidelines. METHODS: This was a retrospective cohort study of children aged 12 years or younger with blunt, penetrating, or thermal injuries who were transported by ground emergency medical services from the scene to the emergency department of a Level I, II, or III trauma center within the Denver metropolitan area from January 1, 2000, to December 31, 2008. Characteristics predicting subsequent interfacility transfer to a pediatric trauma center (PTC) were assessed. RESULTS: A total of 1673 patients were included in the analysis. Variables hypothesized to be most commonly associated with interfacility transfer were age, sex, mechanism of injury, body region of injury, and Glasgow Coma Scale score. The cohort included 1079 males and 593 females. Logistic regression analysis yielded the following as significant predictors of transfer: younger age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.15-1.25), lower Glasgow Coma Scale score (OR, 1.08; 95% CI, 1.01-1.16), the presence of burns (OR, 37.52; 95% CI, 7.3-191.7), non-accidental trauma (OR, 6.09; 95% CI, 2.44-15.25), falls (OR, 1.62; 95% CI, 1.06-2.48), other motor vehicle-related incidents (OR, 2.37; 95% CI, 1.08-5.19), abdominal injury (OR, 5.39; 95% CI, 2.31-12.55), head/neck injury (OR, 7.89; 95% CI, 4.21-14.77), limb injury (OR, 5.31; 95% CI, 2.78-10.16), and multiple injuries (OR, 13.01; 95% CI, 5.0-33.8). CONCLUSIONS: Factors highly associated with transfer of an injured child from a non-PTC to a PTC included younger age, burns, non-accidental trauma, head/neck injury, and multiple injuries in younger children. Further investigation is warranted to determine whether these factors may have applicability in future improvements in field pediatric trauma patient triage guidelines.

Car versus bicycle: conclusion.

A 58-year-old man was riding his bicycle and was struck by a car. He was ejected and landed on his back on the pavement of the roadway. He complained of severe pain in his lower back and sacral area. Ground emergency medical services (EMS) arrived to find a pale, diaphoretic man who was alert but in distress. His medical history was negative, and he was taking no medications. The initial heart rate was 130 beats/minute, and the blood pressure was 70 mmHg by palpation. A helicopter air ambulance was requested from the rural scene location to transport the patient to a trauma center. The physical examination by the flight crew demonstrated the patient had not changed from the original EMS assessment, despite the administration of 1 L normal saline intravenously. There were no apparent injuries to his head, neck, chest, or extremities.

Supraventricular tachycardia in a patient with a ruptured abdominal aortic aneurysm: conclusion.

A transport request was received from a free-standing emergency facility to transport a morbidly obese man with a ruptured abdominal aortic aneurysm (AAA). Weather conditions at the time prohibited rotor-wing transfer, so ground transport was arranged. The patient was a 58-year-old man being worked up for a possible back injury. During the evaluation, the patient had an episode of supraventricular tachycardia (SVT) with associated hemodynamic instability. Although the SVT corrected without intervention, the patient remained hemodynamically unstable. An abdominal computed tomographic (CT) scan with intravenous (IV) contrast demonstrated a 10-cm leaking abdominal aortic aneurysm. The patient complained of severe heartburn and abdominal pain. He had a significant medical history, including a previous three-vessel coronary artery bypass graft surgery, non-insulin-dependent diabetes, and chronic renal insufficiency. Physical examination was significant for limited mouth opening, limited neck mobility, a previous median sternotomy scar on the chest, and a markedly distended abdomen. Vital signs demonstrated a heart rate of 138 beats/min, respiratory rate 28 breaths/min, blood pressure 103/47 mmHg, and an oxygen saturation of 93% on 15 L/min by a nonrebreather (NRB) mask. Sinus tachycardia was identified on the monitor. Vascular access included an 18-gauge IV line in the right hand, a 16-gauge IV line in the left antecubital fossa, and a 7.5-French triple-lumen catheter in the right subclavian vein. Dopamine was running at 10 mug/kg/min. A unit of packed red blood cells (PRBCs) was also noted to be infusing at a rate of 999 mL/hour by infusion pump. Blood transfusion continued, and the dopamine was decreased to 5 mug/kg/min and eventually able to be discontinued. Despite this, approximately 15 minutes into the transport, the patient had another episode of SVT.