Responses of Tuatara (Sphenodon punctatus) to removal of introduced Pacific rats from islands.

Invasive mammalian predators such as rats are now widespread on islands, but hypotheses about their effects have rarely been tested. Circumstantial evidence from New Zealand indicates that, when introduced to islands, Pacific rats (Rattus exulans) have negative effects on endemic plants, invertebrates, birds, and reptiles, including the tuatara (Sphenodon punctatus). We tested the effects of Pacific rats on tuatara by comparing the demographic structure and body condition of tuatara populations on three islands before and after removal of rats and on a fourth island where rats remained. In the presence of rats, juvenile tuatara constituted on average 0-5% of the sample tuatara populations. When Pacific rats were removed after at least 200 years' occupancy, the proportion of juvenile tuatara increased 3.5- to 17-fold and body condition of adult males and females also improved (sometimes dramatically). We predict that, unless Pacific rats are removed from Taranga Island, the tuatara population will collapse because of low population density and the lack of juvenile recruitment. Our results demonstrate that when invasive species exert subtle effects on recruitment and body condition, the effects on populations of long-lived endemic species may only become apparent long after the invasion.

Ingested endotracheal tube in an adult following intubation attempt for head injury.

General surgeons are often consulted for assistance in the management of ingested foreign bodies. Deglutition of an endotracheal tube is an unusual complication of airway management. In these cases, the artificial airway is "lost" when it becomes lodged deep into the esophagus. Endoscopic extraction has been described as therapeutic. We report a case in which prehospital endotracheal intubation attempt for the management of closed head injury resulted in a swallowed endotracheal tube. The tube remained undetected until radiographs were performed for a second unrelated traumatic event 2 years later. Endoscopic extraction was unsuccessful, due to rigidity of the tube. Surgical extraction via gastrotomy was uneventful. Surgeons involved in trauma and other emergency settings should be aware of this complication and options in management.

Interpreting the fetal heart rate tracing. Effect of knowledge of neonatal outcome.

OBJECTIVE: To determine if knowledge of neonatal outcome influences obstetricians' retrospective interpretation of fetal heart rate monitor tracings and opinion on the appropriateness of obstetric care. STUDY DESIGN: Ten obstetric case histories that involved a critical judgment by the managing obstetrician were selected for this study. Each case contained a point in the patient's labor at which the physician made a judgment regarding route and timing of delivery. We assembled prenatal history, labor course, delivery, fetal heart rate tracing and neonatal outcome into a concise format. For each case, we created a sham case with identical information and monitor tracing, differing only in having an opposite neonatal outcome. Reviewers were recruited to participate and were unaware of the true intent of the study. Reviewers evaluated tracings for: variability, late decelerations and evidence of hypoxia, and judged whether the decision regarding delivery versus continued labor had been appropriate. Reviewers evaluated the case pairs with one month's time between the true and sham outcome cases. RESULTS: Thirty-six obstetricians reviewed 2 case pairs each for a total of 72 case pairs. When the alleged neonatal outcome was poor, there was a significant tendency to respond that evidence of hypoxia was present (P = .007) or that the obstetrician had made an incorrect decision (P < .001). CONCLUSION: Obstetricians are biased by knowledge of poor neonatal outcome when retrospectively interpreting fetal heart rate tracings and judging appropriateness of obstetric care.

Medical examiner data in injury surveillance: a comparison with death certificates.

Increasingly, researchers use medical examiner reports to study the epidemiology of fatal injuries, often assuming that reports of all fatal injuries are included in medical examiner databases. This study evaluated that assumption by comparing the medical examiner database with the death certificates of persons who died of fatal injuries in Iowa during 1990-1991. The authors also examined the association between demographic variables and the presence of a medical examiner report. Overall, medical examiners reported 68.7% of fatal injuries. Among broad categories of injury deaths, the percentages of medical examiner reports varied: 36.9% of fatalities from unintentional falls, 79.2% of transportation fatalities, 82.6% of intentional fatalities, and 57.3% of other external causes of death. Age and sex were also associated with the presence of a medical examiner report. Women's deaths were half as likely as men's to be reported by the medical examiner. Deaths among the elderly were underreported as well. Among the elderly, fatalities from unintentional falls and, to a lesser extent, transportation fatalities were less likely to be investigated by a medical examiner, but intentional fatalities were more likely to be. Although medical examiner reports may contain detailed information, they underreport the actual number of injury deaths. This underreporting is of special concern for injury research, since certain demographic groups were found to be underrepresented in medical examiner reports.

Acute urinary retention: an unusual presentation of appendiceal abscess.

Emergency physicians frequently encounter patients with acute urinary retention. Although most common among the elderly, pediatric and young adult patients occasionally may present with this complaint. The differential diagnosis and emergency department work-up must be age specific. We discuss the case of a young man who presented with acute urinary retention, subsequently found to be caused by undiagnosed appendicitis with appendiceal abscess formation. Only nine such cases have been reported in the literature thus far, with only one occurring in the nonpediatric population. This case represents the second such case to be reported. The importance of a thorough history, physical examination, and diagnostic work-up of patients who present with acute urinary retention, particularly those in the younger age group, is emphasized.

Arteriovenous malformation of the vein of Galen: a rare cerebral arteriovenous malformation.

A 32-year-old male presented to the emergency department for evaluation of a 12-day history of altered mental status. Workup revealed the presence of an arteriovenous malformation (AVM) of the great vein of Galen, an exceedingly rare and often fatal type of cerebral vascular malformation. Concurrent aneurysmic dilatation of the vein, a frequent finding associated with this type of AVM, resulted in compression of the aqueduct of Sylvius and acute hydrocephalus. A brief review of cerebral AVMs is presented, with specific attention to the pathophysiology, clinical presentation, and emergent treatment of those that involve the vein of Galen.

Physical fitness is inversely related to heart disease risk: a factor analytic study.

We measured cardiorespiratory endurance, muscular strength and endurance, anaerobic run time, coronary risk factors, and dietary habits in male fire fighters (n = 779, ages 18 to 64 years) and performed factor analysis to determine the interrelationships and underlying factor structure of the data set. Principal component analysis produced nine factors (eigenvalues greater than 1.0) accounting for 61% of the total variance. However, the variable loadings were inconsistent, preventing a meaningful interpretation of the factor solution. These problems were solved through the principal axis method of common factor analysis, which revealed three factors (eigenvalues greater than 1.0) accounting for 29% of the total variance. Orthogonal rotation (varimax method), showed Factors 1, 2, and 3 accounting for 52%, 29%, and 19%, respectively, of the common variance. Factor 1, labeled physical fitness capacity (PFC), included age, situps, treadmill performance time, pushups, maximum exercise heart rate, and anaerobic run time. Factor 2, designated coronary risk status (CRS), included body mass index, resting systolic and diastolic blood pressure, triglycerides, and the total cholesterol-high density lipoprotein cholesterol ratio. Factor 3, termed food frequency intake (FFI), included the weekly intake of fried foods, beef, pork, eggs, caffeine, and cheese. Percentage body fat loaded on both PFC and CRS. Measures such as blood pressure, grip strength, resting heart rate, maximum exercise systolic blood pressure, cigarettes smoked per day, and weekly frequency of milk, fish, fowl, and alcohol intake contributed little to the factor solution. Correlation coefficients after oblique rotation showed PFC to be inversely related to CRS (r = -0.48). However, FFI was independent of PFC (r = 0.07) and CRS (r = -0.10).(ABSTRACT TRUNCATED AT 250 WORDS)

Emergency department experience with sudden death: a survey of survivors.

Sudden death in the emergency department occurs frequently. Intervention by ED support staff may have a significant impact on the survivor's grief response. This study was undertaken to assess sudden death survivors' perceptions and satisfaction with their ED experience, as well as to identify potential weaknesses in their management. Family members of 66 patients who died in the ED from January 1980 to March 1985 were surveyed by telephone interview regarding the care they, as survivors, received while in the ED. Forty-seven of 66 (71%) were satisfied, 19 of 66 (29%) believed that their family received average or worse than average care. Thirty-seven of 66 (56%) survivors viewed the deceased in the ED; five regretted this. Twenty-nine survivors did not view; seven (24%) had regrets. Participants were questioned about attitudes expressed by the ED staff. Most responses were favorable, but a significant number thought the staff cold, unsympathetic, and not reassuring. Areas of apparent survivor dissatisfaction are discussed.

Rural interhospital helicopter transport of motor vehicle trauma victims: causes for delays and recommendations.

One hundred twenty-six consecutive ACS Category I motor vehicle trauma patients transported by helicopter from 25 hospitals to a regional trauma center in rural Pennsylvania during a 14-month period were reviewed retrospectively. The overall mortality was 13%. Average round-trip distance was 79 miles. Interventions by the medical flight team (emergency physician/nurse) included endotracheal intubation, tube thoracostomy, and/or central venous access in 42 patients (33%) prior to lift-off. Ground time at the referring facility, from landing to lift-off, when no interventions were required of the flight team, averaged 31.2 minutes (baseline). Ground time when major therapeutic interventions were required (principally airway management), however, averaged 57.4 minutes, an 84% increase over baseline (P less than .01). A major cause of the excessive ground times was the lack of standardized diagnostic workup and stabilization of patients prior to arrival of the flight team. Recommendations for standardized emergency department preparation of trauma victims requiring aeromedical evacuation are made.

Intraosseous infusions in the emergency department.

For most emergency physicians and pediatricians, the frustrations encountered when obtaining intravenous access in infants involved in traumatic or medical emergencies are well known. Although it is rare that parenteral access is absolutely unobtainable in a pediatric patient, minutes and sometimes hours are often lost as futile attempts are made to cannulate a collapsed vein of such a patient. Many alternatives to such a crisis situation, including the intratracheal, intracardiac, and sublingual routes of administration, have been proposed and efficaciously used. Disadvantages to these alternatives, however, include the inability to administer volume-expanding colloids or crystalloids, and a relatively narrow spectrum of useful medications. One relatively safe, well-proven, and technically easy method for giving replacement fluids, blood products, and numerous resuscitative drugs is infusion by the intraosseous route. Although not recommended as a replacement for current modes of intravascular access, we feel it has definite utility in selected situations and warrants the awareness of emergency physicians. The value, historical aspects, technique, and complications of this procedure are discussed.

Bilateral posterior fracture-dislocations of the shoulder after convulsive status epilepticus.

Presented is the case of a 30-year-old man who sustained bilateral posterior fracture-dislocations of the shoulder as an unusual complication of status epilepticus. Initial evaluation failed to reveal this unsuspected diagnosis. After improvement in the patient's mental status, his subjective complaints made the diagnosis evident. He subsequently underwent hemiarthroplasty for one shoulder and active assisted range of motion exercises for the other, with partial return of function in both arms.