Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.

BACKGROUND: Many resuscitation scenarios include the use of emergency intubation to support injured patients. New video-guided airway management technology is available, which may minimize the risk to patients from this procedure. METHODS: This was a controlled clinical trial conducted in the trauma receiving unit in a university-affiliated urban hospital in which 623 consecutive adult patients requiring emergency airway management were prospectively randomized to intubation with either the direct laryngoscope (DL) or the GlideScope video laryngoscope (GVL) device. RESULTS: The primary outcome was survival to hospital discharge. There was no significant difference in mortality between the GVL group (28 [9%] of 303) and the DL group (24 [8%] of 320) (p = 0.43) for all patients. Within a smaller cohort identified retrospectively, there was a higher mortality rate seen in the subgroup of patients with severe head injuries (head Abbreviated Injury Scale [AIS] score > 3) who were randomized to intubation with GVL (22 [30%] of 73) versus DL (16 [14%] of 112) (p = 0.047). Among all patients, median intubation duration in seconds was significantly higher for the GVL group (median, 56; interquartile range, 40-81) than for the DL group (median, 40; interquartile range, 24-68) (p < 0.001). Among those with severe head injuries, median intubation duration in seconds was also significantly higher for the GVL group (median, 74) than for the DL group (median, 65) (p < 0.003). Correspondingly, this group also experienced a greater incidence of low oxygen saturations of 80% or less (27 [50%] of 54 for the GVL group and 15 [24%] of 63 for the DL group; p = 0.004). There were no significant differences between the two groups in first-pass success (80% for GVL and 81% for DL, p = 0.46). CONCLUSION: Use of the GlideScope did not influence survival to hospital discharge among all patients and was associated with longer intubation times than direct laryngoscopy. Among the video laryngoscope cohort, a smaller subgroup of severe head injury trauma patients identified retrospectively seemed to be associated with a greater incidence of hypoxia of 80% or less and mortality.

Training dedicated emergency physicians in surgical critical care: knowledge acquisition and workforce collaboration for the care of critically ill trauma/surgical patients.

BACKGROUND: The Leapfrog Group initiative has led to an increasing public demand for dedicated intensivists providing critical care services. The Acute Care Surgery training initiative promotes an expansion of trauma/surgical care and operative domain, redirecting some of our focus from critical care. Will we be able to train and enforce enough intensivists to care for critically ill surgical patients? METHODS: We have been training emergency physicians (EPs) alongside surgeons in our country's largest Trauma/Surgical Critical Care Fellowship Program annually for more than a decade. We reviewed our Society of Critical Care Medicine Multidisciplinary Critical Care Knowledge Assessment Program (MCCKAP, critical care in-training examination) scores from 2006 to 2009 (4 years). The MCCKAP, administered during the ninth month of a Critical Care Fellowship, is the only known standardized objective examination available in this country to compare critical care knowledge acquisition across different specialties. Subsequent workforce outcome for these Emergency Medicine Critical Care Fellowship graduates was analyzed. RESULTS: Over the 4-year period, we trained 42 Fellows in our Program who qualified for this study (30 surgeons and 12 EPs). Surgeons and EP performance scores on the MCCKAP examination were not different. The mean National Board Equivalent score was 419 ± 61 (mean ± standard deviation) for surgeons and 489 ± 87 for EPs. The highest score was achieved by an EP. The lowest score was not achieved by an EP. Ten of 12 (83%) EP Critical Care Fellowship graduates are practicing inpatient critical care in intensive care units with attending physician level responsibilities. CONCLUSIONS: EPs training in a Surgical Critical Care Fellowship can acquire critical care knowledge equivalent to that of surgeons. EPs trained in a Surgical Critical Care paradigm can potentially expand the intensive care unit workforce for Surgical Critical Care patients.

Challenge of hospital emergency preparedness: analysis and recommendations.

In the United States, recent large-scale emergencies and disasters display some element of organized medical emergency response, and hospitals have played prominent roles in many of these incidents. These and other well-publicized incidents have captured the attention of government authorities, regulators, and the public. Health care has assumed a more prominent role as an integral component of any community emergency response. This has resulted in increased funding for hospital preparedness, along with a plethora of new preparedness guidance.Methods to objectively measure the results of these initiatives are only now being developed. It is clear that hospital readiness remains uneven across the United States. Without significant disaster experience, many hospitals remain unprepared for natural disasters. They may be even less ready to accept and care for patient surge from chemical or biological attacks, conventional or nuclear explosive detonations, unusual natural disasters, or novel infectious disease outbreaks.This article explores potential reasons for inconsistent emergency preparedness across the hospital industry. It identifies and discusses potential motivational factors that encourage effective emergency management and the obstacles that may impede it. Strategies are proposed to promote consistent, reproducible, and objectively measured preparedness across the US health care industry. The article also identifies issues requiring research.