Development and characterization of polymorphic microsatellite markers in northern fulmar, Fulmarus glacialis (Procellariiformes), and cross-species amplification in eight other seabirds.

BACKGROUND: In the North Pacific, northern fulmar (Fulmarus glacialis) forms extensive colonies in few locales, which may lead to limited gene flow and locale-specific population threats. In the Atlantic, there are thousands of colonies of varying sizes and in Europe the species is considered threatened. Prior screens and classical microsatellite development in fulmar failed to provide a suite of markers adequate for population genetics studies. OBJECTIVES: The objective of this study was to isolate a suite of polymorphic microsatellite loci with sufficient variability to quantify levels of gene flow, population affinity, and identify familial relationships in fulmar. We also performed a cross-species screening of these markers in eight other species. METHODS: We used shotgun sequencing to isolate 26 novel microsatellite markers in fulmar to screen for variability using individuals from two distinct regions: the Pacific (Chagulak Island, Alaska) and the Atlantic (Hafnarey Island, Iceland). RESULTS: Polymorphism was present in 24 loci in Chagulak and 23 in Hafnarey, while one locus failed to amplify in either colony. Polymorphic loci exhibited moderate levels of genetic diversity and this suite of loci uncovered genetic structuring between the regions. Among the other species screened, polymorphism was present in one to seven loci. CONCLUSION: The loci yielded sufficient variability for use in population studies and estimation of familial relationships; as few as five loci provide resolution to determine individual identity. These markers will allow further insight into the global population dynamics and phylogeography of fulmars. We also demonstrated some markers are transferable to other species.

Documentation of pediatric vital signs by EMS providers over time.

BACKGROUND: Pediatric patients make up approximately 10% of EMS transports nationwide. Previous studies demonstrated that pediatric patients do not consistently have a full set of vitals signs obtained in the prehospital setting [1]. In certain conditions, such as traumatic head injury and shock, unrecognized hypotension and/or hypoxia are associated with increased morbidity and mortality [2,3]. PRIMARY OBJECTIVE: To measure how often EMS providers obtain blood pressure (BP), heart rate (HR), pulse oximetry (Po), and respiratory rate (RR) on pediatric transport patients in the state of Utah from 2007 to 2014. SECONDARY OBJECTIVE: To assess whether educational interventions improved the percentage of pediatric transport patients with a full set of vital signs documented. RESULTS: The trend of documenting the four critical vital signs improved over time for all four categories. Measurement of Po increased most consistently across all age groups. Blood pressure remained the most inconsistently obtained vital sign, especially in younger pediatric patients. The educational interventions introduced in late 2010 correlated with an increase in vital sign attainment. CONCLUSIONS: Assessment of pediatric vitals signs is a critical part of the evaluation and care of pediatric patients in the prehospital setting. Utah EMS providers improved their practice of documenting four pediatric vital signs over time after educational interventions. Obtaining a BP, especially in younger children, continues to be a challenge. More work remains to achieve the state goal of documenting all vital signs in >90% of pediatric transports.

Dead men tell no tales: analysis of the use of autopsy reports in trauma system performance improvement activities.

PURPOSE: To analyze the influence and use of autopsy report review on preventability judgments as part of trauma system performance improvement activities. METHODS: All cases trauma fatalities occurring across one state within 1 year were reviewed. Preventability judgments were first analyzed by multidisciplinary panel consensus without benefit of autopsy report. Deaths were then reanalyzed after the panel was provided with autopsy findings. Changes in panel determinations of preventability and cause of death were noted. RESULTS: A total of 434 cases were reviewed, autopsies were performed in 240 (55%) patients. Autopsy rate was 83% for prehospital deaths (PHDs) and 37% for hospital deaths (HDs). A complete examination (CA) was performed in 166 (69%) cases, and 74 (31%) cases were limited internal or external examinations only (NCA). Of autopsies performed on HD, 60% were CA versus 75% in PHD. Autopsy review changed preventability determination in four cases (1%). All changes were from nonpreventable to possibly preventable. For all patients with autopsy, the panel felt that the autopsy should have been of sufficient quality to analyze the cause of death in 83%. The autopsy was felt to actually establish a specific cause of death in 70% of all patients with autopsy, 71% in patients with NCA, and 74% in patients with CA. The autopsy changed the panel's preautopsy review-determination cause of death in 31% of all patients with autopsy (37% in the CA group; 13% in the NCA group). For PHD, autopsy changed the panel-determination cause of death in 44% and in 13% for HD. CONCLUSION: Review of autopsy reports adds little to the trauma performance improvement process. It does not significantly change death review panel determinations. It may, perhaps, be most useful in PHD. Ardent initiatives to expend resources on autopsy performance and acquisition of autopsy reports in all patients with trauma is unwarranted.

Analysis of preventable trauma deaths and opportunities for trauma care improvement in utah.

BACKGROUND: The objective is to determine the rate of preventable mortality and the volume and nature of opportunities for improvement (OFI) in care for cases of traumatic death occurring in the state of Utah. METHODS: A retrospective case review of deaths attributed to mechanical trauma throughout the state occurring between January 1, 2005, and December 31, 2005, was conducted. Cases were reviewed by a multidisciplinary panel of physicians and nonphysicians representing the prehospital and hospital phases of care. Deaths were judged frankly preventable, possibly preventable, or nonpreventable. The care rendered in both preventable and nonpreventable cases was evaluated for OFI according to nationally accepted guidelines. RESULTS: The overall preventable death rate (frankly and possibly preventable) was 7%. Among those patients surviving to be treated at a hospital, the preventable death rate was 11%. OFIs in care were identified in 76% of all cases; this cumulative proportion includes 51% of prehospital contacts, 67% of those treated in the emergency department (ED), and 40% of those treated post-ED (operating room, intensive care unit, and floor). Issues with care were predominantly related to management of the airway, fluid resuscitation, and chest injury diagnosis and management. CONCLUSIONS: The preventable death rate from trauma demonstrated in Utah is similar to that found in other settings where the trauma system is under development but has not reached full maturity. OFIs predominantly exist in the ED and relate to airway management, fluid resuscitation, and chest injury management. Resource organization and education of ED primary care providers in basic principles of stabilization and initial treatment may be the most cost-effective method of reducing preventable deaths in this mixed urban and rural setting. Similar opportunities exist in the prehospital and post-ED phases of care.

Rural trauma and emergency medical service challenges in a sample of Western States.

State trauma system managers from the western region meet annually to identify and address health care issues, particularly those related to trauma care access and delivery. In each of these states, policy makers face a host of convergent problems: declining populations, rapid growth, low incomes, and high poverty rates. Challenges of providing emergency medical services to largely rural states include geographic barriers of vast expanses of unpopulated landmass, provision of services across mountain ranges, volcanoes, and extreme weather conditions, communication challenges due to lack of cell or radio coverage in some areas, and difficulty recruiting and retaining trained personnel.

Development of a state medical surge plan, Part II: Components of a medical surge plan.

In 2003, the Utah State Department of Health received funding from the Health Resources and Services Administration to develop a medical surge plan to increase the number of available hospital beds in the state by 1250 beds, including 125 beds for burn or critical trauma patients. A prior article discussed the planning procedures and process. This article describes the major components of the plan, including analysis of threats, direction and control, activation and system response; communications; and critical issues.

Development of a state medical surge plan, part I: the procedures, process, and lessons learned or confirmed.

In 2003, the Utah Department of Health received funding from the Health Resources and Services Administration to develop a medical surge plan. The plan was designed to increase the number of available hospital beds in the state by 1250 beds, including 125 beds for patients with burns or trauma patients. Interested parties were contacted and a coordinating group composed of Utah Department of Health and University of Utah Health Sciences Center representatives was formed, who were responsible for developing the plan. This article is Part I of a 2-part series that discusses the planning process and identification of a group of stakeholders who served as a planning task force, and concludes with a summary of lessons learned or confirmed during the planning process. Part II will discuss the content of the medical surge plan.