The pediatric critical care experience at Naval Hospital Guam: suggestions for critical care training during residency.

OBJECTIVES: To determine the critical care experience encountered by three recently graduated military pediatricians at an overseas military hospital and present one model of maximizing allowable critical care training time during residency. METHOD: Retrospective reviews of all admissions to the special care nursery and intensive care unit at U.S. Naval Hospital Guam were performed for a 3-year and a 2-year period, respectively. Age, diagnosis, birth weight (if applicable), level of nursery care, invasive procedures performed in the nursery (endotracheal tube, umbilical artery, and umbilical venous catheter placement), patient outcome, and the need for medical transport were recorded. RESULTS: During a 3-year period, there were 122 admissions to the special care nursery (7.1% of all deliveries). In addition, pediatricians performed a total of 53 invasive procedures on these patients, and 29 infants required medical transport to an off-island neonatal intensive care unit for additional care. During a 2-year period, 70 pediatric patients were admitted to the adult intensive care unit, representing 10.2% of all intensive care unit admissions during this period. Fourteen of these patients required medical transport to an off-island referral hospital. CONCLUSION: Graduating military pediatric residents may be faced with caring for a wide range of critically ill neonatal and pediatric patients depending on their assignment. Residency training programs, with the recent increased emphasis on primary pediatric care, will need to streamline instruction in pediatric critical care to provide maximal benefit to the resident while maintaining compliance with Residency Review Committee guidelines.

Use of gabapentin in the treatment of childhood reflex sympathetic dystrophy.

Reflex sympathetic dystrophy, a painful syndrome involving an extremity after trauma or injury, is increasingly reported in the pediatric population. Although no clear pathophysiologic mechanism for this disorder has been identified, the role of central serotonin activity seems important. Gabapentin, a new antiepileptic medication, has been demonstrated to be effective in adults with reflex sympathetic dystrophy. The first reported case of a child with a diagnosis of reflex sympathetic dystrophy who was treated successfully with gabapentin is presented.

A protocol of early spiral computed tomography for the detection of stones in patients with renal colic has reduced the time to diagnosis and overall management costs.

BACKGROUND: The recent use of spiral computed tomography (CT) without contrast for the diagnosis of acute flank pain has been shown to be highly sensitive and specific for the detection of urolithiasis. This method has not, however, been evaluated for its contribution to savings in management costs. The present study aims to evaluate the cost savings gained by instituting a protocol of early spiral CT to investigate these patients. METHODS: The records of 200 patients presenting to the Accident and Emergency Department (A&E) with acute flank pain during two periods were retrospectively reviewed. The first period was before the spiral CT protocol was instituted and the second was after. Cost analyses between the two periods were performed. RESULTS: After the spiral CT protocol, 72 versus 31 patients had a definitive diagnosis prior to discharge from hospital. The time taken to diagnosis was also significantly shorter after the protocol implementation (6.3 vs. 16.8 h). This resulted in a shorter time spent in the A&E, and hence bed cost savings. Radiological costs were reduced by 22%, but the major cost saving was made by a reduction in time spent in A&E (44%). CONCLUSIONS: The implementation of a protocol of early spiral CT for patients with suspected renal colic has led to earlier definitive diagnosis and shorter hospital stays. This is associated with a significant reduction in costs associated with managing this condition.

Development of a pediatric critical care transport team: experience at a military medical center.

INTRODUCTION: A pediatric critical care transport program was initiated and organized at Naval Medical Center San Diego in January 1994. The primary goal of the program was to formally train military pediatric residents in the early stabilization and transport of the critically ill neonatal and pediatric patient. It was also felt that such a program would generate significant cost savings to the Department of Defense. We present the statistics, training protocol, and the cost savings. In addition, we surveyed previous residents who had been involved with this program to determine its perceived benefit. METHODS: In the first phase of this project, the pediatric critical care transport program database from January 1994 to December 1997 was reviewed. The number and types of transports were recorded. Next, we determined cost savings for the transport program for fiscal year 1996-1998 (the period for which fiscal data were available). In the second phase of this project, we sent surveys to the 23 graduating residents who had participated in the pediatric critical care transport program. The survey sought to determine the perceived value of the transport training experience and the degree to which that training is now being used. All investigators were blinded to the responses. Statistical analysis consisted of determining the percentage of each response. RESULTS: During the 4-year period reviewed, 404 transports were performed (198 neonatal and 206 pediatric). During fiscal year 1996-1998, there was a cost avoidance of $1,962 per transport. In the second phase, 91% of the surveys were returned and analyzed. The majority of residents were practicing in overseas or isolated communities. All respondents rated their experience in the pediatric critical care transport program as worthwhile and educational, and they complemented their training in the neonatal and pediatric intensive care units. Seventy-one percent of the respondents had transported a critically ill neonate or child to another facility within the last year. CONCLUSIONS: In summary, we report our experience with the development of a pediatric critical care transport program. The program was developed to provide military pediatric residents instruction and experience in the stabilization and transport of critically ill children. In addition, we were able to demonstrate a significant cost avoidance.

Streptococcal pyomyositis: case report and review.

Pyomyositis is most often associated with Staphylococcus aureus infections after trauma. We describe an unusual presentation of pyomyositis of the chest wall secondary to group A betahemolytic streptococcus infection in a 15-month-old child with acute abdominal symptoms. In addition, the patient had no history or evidence of trauma to the affected area. Pyomyositis presenting in this manner secondary to group A beta-hemolytic streptococcus infection in the absence of a primary varicella infection has not been previously reported.

The travail and triumph of Sidney Greenspan.

The question of whether a feeding-tube could be withdrawn from Sidney Greenspan, a man who had survived in a Chicago nursing home for six years in a vegetative state, has focused ethical and legal deliberation on the issue of whether Illinois will follow the tradition of cases of court-sanctioned withdrawal (Quinlan, Fox, Conroy, Jobes, et al) or the more ambiguous precedents of Longeway and Cruzan, which disallowed withdrawal.

Preventive control of AIDS by the dental profession: a survey of practices in a large urban area.

The purpose of this study was threefold: (1) to report the proportion of dental practitioners adhering to the 1987 Centers for Disease Control (CDC) procedures for using infection control techniques (ICTs); (2) to identify attitudes toward infection control and disease; and (3) to establish whether certain practitioner characteristics or use of certain ICTs were related to willingness to treat HIV-positive patients, willingness to volunteer for an HIV specialty clinic outside of regular practice, vaccination against hepatitis B, and a felt need for a specialty clinic within the practice to treat HIV patients effectively. A survey of approximately 3,800 members of a major metropolitan dental society found that 89 percent of respondents regularly used at least one CDC ICT beyond routine medical histories. Ninety-one percent indicated a moderate to extreme change in attitude toward the risks of infectious diseases and the regular use of ICTs (80.2% identified AIDS as the major factor in this change). Twenty-seven percent indicated that they would knowingly treat HIV-positive patients. No differences were found among practitioners willing to treat HIV-infected patients and those unwilling to treat these patients in terms of adherence to the CDC ICT recommendations for dentists. Statistical association between ICT use and other practitioner response variables are discussed.

Initiating and maintaining an ethics committee.

Ethics committees are an evolving approach to conflict resolution. They provide education and set Institutional policy. They are an exciting and sometimes frightening reflection of changing health care, as issues involving allocation of scarce resources, withholding or withdrawing treatment, autonomy and the patient's right to refuse treatment, and access to care arise in clinical care. This article has described how to initiate and maintain an ethics committee, as well as the nurse's pivotal role in identifying conflict and assisting in conflict resolution. Cranford and Roberts offer a few timeless tips for the beginning committee. They advise forming the committee with three or four people who have expressed interest, rather than recruiting those who may lose interest. More than three or four people may be needed to conduct committee business, so if recruiting is necessary, select compassionate people who are not likely to monopolize the meetings. Likewise, the chair should be affable yet assertive. Recognize that ethics committees will function differently from institution to institution, so comparisons may not be helpful. Proceed toward goals, but pay attention to the process of committee function and modify the process as needed. Finally, proceed at a pace most comfortable to members of the committee and to the institution. The pace may seem slow, but attitudes toward the committee, which may be negative at first, are slow to change. The end result is a viable body of caring people to address the needs of its institution, its staff, and most importantly, its patients and families. That is the goal we all seek.

Debbie's dying: mercy killing and the good death.

KIE: Vaux, a consultant in medical ethics, reflects on the issue of physician-administered euthanasia raised in JAMA's controversial article, "It's over, Debbie" (1988 Jan 8; 259(2): 272). He asks if the death of the young terminal cancer patient was really a case of morally acceptable double-effect euthanasia, resulting from the anonymous resident's use of morphine primarily to relieve her pain with death as an unfortunate side effect. Vaux argues that, while the cardinal purpose of medicine is "to save and sustain life and never intentionally to harm or kill," and while euthanasia must be proscribed in principle, "in exceptional cases it may be abided in deed."^ieng

Ethical issues in caring for tiny infants.

In the early years of perinatal medicine and heroic programs of saving premature infants, we have witnessed "halfway" technology practiced in an environment of morally simplistic ethics, law, and policy. These practices have led to troubling outcomes. The lessons learned during this difficult phase of perinatal health care now yield to a period characterized by more advanced research, more appropriately applied technology, more sensitive and sensible public policy, and more responsible ethics.