Marianne Gausche - Academia.edu (original) (raw)

Papers by Marianne Gausche

The Journal of Pediatrics, 2011

Years of violence have resulted in a lack of trained health care providers in Iraq. To address th... more Years of violence have resulted in a lack of trained health care providers in Iraq. To address this need, International Medical Corps has implemented a national emergency care program for the country. As part of this program, we implemented via tele-education the country's first civilian course in Pediatric Advanced Life Support.

Journal of Paramedic Practice, 2011

Prehospital and disaster medicine, 2014

Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly ad... more Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly administered drug by prehospital personnel. There is increasing evidence of harm with too much supplemental oxygen in certain conditions, including stroke, chronic obstructive pulmonary disease (COPD), neonatal resuscitations, and in postresuscitation care. Recent guidelines published by the British Thoracic Society (BTS) advocate titrated oxygen therapy, but these guidelines have not been widely adapted in the out-of-hospital setting where high-flow oxygen is the standard. This report is a description of the implementation of a titrated oxygen protocol in a large urban-suburban Emergency Medical Services (EMS) system and a discussion of the practical application of this out-of-hospital protocol.

Annals of Emergency Medicine, 1994

To determine the efficacy and feasibility of adenosine for the treatment of paroxysmal supraventr... more To determine the efficacy and feasibility of adenosine for the treatment of paroxysmal supraventricular tachycardia (PSVT) in the prehospital setting. Prospective case series. Large, urban, advanced life support emergency medical services system. One hundred twenty-nine adult patients with PSVT, as identified by paramedic personnel. Pregnant patients and those taking carbamazepine or dipyridamole were excluded. Dose of 12 mg adenosine by rapid i.v. push followed by a 5-mL saline flush and a repeat dose of 12 mg adenosine i.v. push if the patient's rhythm remained unchanged. Six-second lead II rhythm strips and vital signs were documented before and 2 minutes after the administration of adenosine. Demographic information, past medical history, medications, number of adenosine doses given, and complications were recorded by the paramedic on a case-report form. One hundred six of 129 (82%) of the case-report forms included the rhythm strips from before and after adenosine administration. Actual initial rhythms were determined by a consensus panel. The initial rhythms were PSVT in 79% (84 of 106) of patients, atrial fibrillation in 12% (13 of 106), sinus tachycardia in 5% (five of 106), atrial flutter in 2% (two of 106), and ventricular tachycardia in 2% (two of 106). Eighty-five percent (71 of 84) of patients in PSVT were successfully converted to sinus rhythms; four (5.6%) of these patients required a second 12-mg dose. One patient in atrial fibrillation spontaneously converted to normal sinus rhythm and one patient in ventricular tachycardia converted after adenosine. All other patients not initially in PSVT remained in their initial rhythm. Complications occurred in 12 of 129 patients and included chest pain (five), flushing (three), shortness of breath (two), nausea (one), anxiety (one), dizziness (one), headache (one), and seizure (one). All complications were transient and required no treatment. Prior history of PSVT was the only variable associated with a higher rate of conversion (P = .029). Paramedics are able to accurately identify PSVT using a single lead. Adenosine is safe and effective treatment for PSVT in the prehospital setting. This series is the largest prehospital study of adenosine use to date.

Annals of Emergency Medicine, 1995

To describe emergency department quality assurance (QA)/improvement (QI) practices for pediatric ... more To describe emergency department quality assurance (QA)/improvement (QI) practices for pediatric patients. Mail survey of a cohort of emergency physicians. Pediatric Section members of the American College of Emergency Physicians and a computer-generated random sample of general ACEP members. Pediatric Section and general ACEP physicians were mailed a 13-question QA survey. Of the 500 surveys distributed, 207 (41.4%) were returned. Three emergency care settings for pediatric patients seen in the ED were identified: (1) children's hospital ED (14%), (2) general ED with a separate area designated for the evaluation of pediatric patients (12%), and (3) general ED where pediatric and adult patients are evaluated in the same area (74%). Separate QA indicators were used to monitor care of the pediatric patients seen in the ED by 61% of the respondents; 39% used "adult" indicators only. High pediatric census was associated with pediatric representation on the ED QA/QI Committee, the use of separate pediatric indicators to monitor care of pediatric patients in the ED, the separation of pediatric and adult patient care areas and satisfaction with the respondent's ED QA/QI plan. The bulk of pediatric emergency patients are cared for in a general ED. Most ACEP members surveyed reported the use of separate QA indicators to monitor the care of pediatric patients seen in the ED. This survey provides the first description of QA/QI practices for pediatric patients by EDs nationwide.

Academic Emergency Medicine, 1998

Objective: To evaluate the concordance with criteria developed by the study investigators and sup... more Objective: To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of IV lines and saline locks by paramedics in the out-of-hospital setting. Methods: This was a retrospective consecutive case series a t an urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995. Base hospital written records and taped patient calls were reviewed to determine actual IV access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of IV access was determined for each patient based on predetermined criteria developed by the investigators. IV access methods were ranked by cost of supplies as follows: IV line (IV) > saline lock (SL) > no I V line (NOW). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual > indicated, and discordant-undertreatment when actual < indicated. Results: 452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received an W. 28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253

Academic Emergency Medicine, 2006

OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the tr... more OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart.

Pediatric Emergency Care, 1989

Violent death (homicide and suicide) in the pediatric age group is a major public health problem.... more Violent death (homicide and suicide) in the pediatric age group is a major public health problem. A descriptive study was undertaken to review retrospectively the 1077 pediatric coroner&#39;s cases in 11 California counties for differences between urban and rural violent death rates. Pediatric violent death was more prevalent in the urban region than in the rural region (P less than 0.0007). High urban homicide rates accounted for most of this difference. Suicide rates were not significantly different (P = 0.18). Seventy-four percent of the violent deaths were in the 15- to 18-year age group, and most of these deaths were caused by firearms (81%). Blacks had the highest homicide and suicide rates. Child abuse was an important cause of death for young children in the urban area only. Socioeconomic factors, cultural differences, high population density, and the availability of firearms were proposed as factors affecting violent death in the pediatric age group.

Pediatric Emergency Care, 2014

This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-h... more This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-hospital seizure. This is a retrospective study of pediatric patients with seizure transported by paramedics to the pediatric emergency department (PED) of a tertiary center from July 2008 to June 2009. Patients with traumatic injury and those with another diagnosis after PED evaluation were excluded. We evaluated the effect of field diazepam and other potential risk factors on the occurrence of apnea, defined as the need for airway management, that is, bag-mask ventilation by paramedics or bag-mask ventilation or intubation by PED staff within 30 minutes of arrival. There were 336 pediatric patients meeting inclusion criteria. The median age was 1.9 years (interquartile range,1.3-3.0 years); 193 patients (57%) were male. Fifty-four patients (16%) were treated with diazepam before PED arrival. There were 28 apneic events (8.3%). The adjusted relative risk for apnea given diazepam in the field by any route was 10.2 (95% confidence interval, 3.9-21.8; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), adjusted for age and seizure on arrival. Persistent seizure on PED arrival was also highly associated with apnea, with an adjusted relative risk of 15.8 (95% confidence interval, 6.5-28.9; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). Field treatment with diazepam and seizing at the time of PED arrival are associated with the occurrence of apnea in children 0 to 5 years of age with out-of-hospital seizure. Larger studies are needed to determine what other factors may contribute to this risk.

Prehospital Emergency Care, 2013

Some emergency medical services (EMS) systems transport infants with an apparent life-threatening... more Some emergency medical services (EMS) systems transport infants with an apparent life-threatening event (ALTE) directly to hospitals capable of pediatric critical care (PCC) monitoring. To describe factors identifiable by EMS providers that distinguish ALTE patients who may require PCC monitoring and management. This was an observational analysis of ALTE patients who were transported by EMS and presented to four emergency departments (EDs). ED data were prospectively collected. Hospital records or reports from contacted parents were reviewed for interventions that mandated PCC management. We defined a priori the criteria by which PCC monitoring and management were required: if the subject needed 1) airway intervention with bag-valve-mask ventilation or advanced airway (e.g., endotracheal intubation) in the field, ED, or pediatric intensive care unit (PICU); 2) administration of vasopressors; 3) invasive monitoring; 4) surgery during the hospitalization; or 5) subspecialty consultation. Univariate analysis was performed to describe factors associated with requiring PCC management, and a multivariable model, accounting for within-hospital correlations, was developed. A total of 513 patients were enrolled. Of these, 51 (9.9%) had an intervention warranting PCC management. Univariate predictors for requiring PCC management included prematurity, past medical history, resuscitation attempt, upper respiratory infection, apnea, previous ALTE, more than one ALTE in 24 hours, and cyanosis. The multivariable model yielded the following independent predictors for requiring PCC management: resuscitation attempt before EMS arrival, cyanosis, and more than one ALTE in 24 hours. This model demonstrated a sensitivity of 96.3%, a specificity of 25.8%, a negative predictive value of 98.3%, and a positive predictive value of 13.5%. Only 9.9% of infants presenting in the field with ALTE had an intervention warranting PCC management, suggesting that many ALTE patients may be safely transported to hospitals without PCC capability. This would allow for better resource utilization of specialty care hospitals and still provide an option for secondary transports for those few patients not correctly identified in the field as requiring PCC. History of resuscitation attempt, cyanosis, and more than one ALTE in 24 hours are independent risk factors for requiring PCC management.

Pediatric Emergency Care, 1989

A total of 1078 pediatric coroners&#39; cases in 11 rural and urban California counties were ... more A total of 1078 pediatric coroners&#39; cases in 11 rural and urban California counties were reviewed as they relate to emergency medical services (EMS). Pediatric coroners&#39; death rates per 100,000 population varied from an average of 2.17 in the rural region to 30.4 in the urban region. Vehicular accidents caused the majority (66%) of the accidental deaths, and firearms caused 61% of the violent deaths. Violent deaths (homicide and suicide) were significantly more common in the urban region (P less than 0.001), and vehicular deaths (excluding auto versus pedestrian) were more common in the rural region (P less than 0.001). EMS provider usage was greater in the urban areas (84 vs 66%, P less than 0.001), as was the number of cases receiving advanced life support (97 vs 66%, P less than 0.001). Urban and rural differences in place of death were significant for two places of death; street and highway, and inhospital deaths. A significantly greater number of children died on the street/highway in rural areas (P less than 0.05). Hospital deaths were more likely to occur on the ward in the rural region, versus the intensive care unit in the urban region (P less than 0.001). Proposed factors which may explain these findings include differences in medical resources and in local transfer policies. The study demonstrates that EMS providers are involved in the care of children who have had a fatal emergency. Further evaluation of rural and urban differences in prehospital care of the pediatric patient is indicated.

Pediatric Clinics of North America, 1999

The Journal of Emergency Medicine, 2013

Paget-Schroetter syndrome (PSS) is a rare presentation of primary axillary subclavian vein thromb... more Paget-Schroetter syndrome (PSS) is a rare presentation of primary axillary subclavian vein thrombosis that classically occurs in young men with a degree of underlying thoracic outlet syndrome after a period of upper extremity exertion. The primary complication of PSS is post-thrombotic syndrome, a result of chronic venous hypertension. To educate Emergency Physicians on this condition to potentiate timely diagnosis and appropriate disposition. A 29-year-old right-handed restaurant waiter presented with 3 days of non-painful, gradual-onset right upper extremity swelling with normal vital signs. The patient&amp;amp;amp;amp;#39;s history was otherwise notable for subjective fevers and a right forearm abrasion. Upon examination, the right upper extremity was neurovascularly intact and remarkable for uniform edema and erythema extending distally from the level of the mid-humerus. The primary differential diagnoses were deep venous thrombosis (DVT) vs. soft tissue infection. Venous phase contrast computed tomography did not reveal evidence of underlying soft tissue infection and was inconclusive regarding a DVT. Ultrasound demonstrated a right subclavian vein DVT. The patient was admitted and underwent thrombolysis, venolysis, and first rib resection and initiation of warfarin. PSS is a rare presentation of upper-extremity DVT occurring classically in patients without commonly recognized pro-thrombotic risk factors. PSS carries the potential of significant morbidity in the form of post-thrombotic syndrome and pulmonary embolism. Current literature suggests that optimal outcomes are achieved when treatment is initiated within 6 weeks of onset. The treatment paradigm calls for thrombolysis and, frequently, a first rib resection.

Journal of Emergencies, Trauma, and Shock, 2014

We compared the survival of trauma patients in urban versus rural settings after the implementati... more We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP). We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters. A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center. This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care.

JAMA, 2000

Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hosp... more Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome. To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI. Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997. Two large, urban, rapid-transport emergency medical services (EMS) systems. A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up. Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420). Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group. There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22). These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.

International Journal of Trauma Nursing, 1998

Annals of Emergency Medicine, 2013

We identify factors in emergency department (ED) patients presenting with apparent life-threateni... more We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). We found 3 variables (obvious need for admission, significant medical history, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation.

Annals of Emergency Medicine, 1996

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injur... more Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children.

Annals of Emergency Medicine, 1990

Vital signs are an integral part of the field assessment of patients. A twopart study was underta... more Vital signs are an integral part of the field assessment of patients. A twopart study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patient's severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P < .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P < .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patient's chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient. The number of runs a provider made during a 24-hour shift was the only demographic factor related to the level of provider confidence. Future emergency medical services research must link field vital sign assessment to outcome to determine the value of this type of field assessment in the pediatric age group.

The Journal of Pediatrics, 2011

Years of violence have resulted in a lack of trained health care providers in Iraq. To address th... more Years of violence have resulted in a lack of trained health care providers in Iraq. To address this need, International Medical Corps has implemented a national emergency care program for the country. As part of this program, we implemented via tele-education the country&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s first civilian course in Pediatric Advanced Life Support.

Journal of Paramedic Practice, 2011

Prehospital and disaster medicine, 2014

Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly ad... more Oxygen is one of the most frequently-used therapeutic agents in medicine and the most commonly administered drug by prehospital personnel. There is increasing evidence of harm with too much supplemental oxygen in certain conditions, including stroke, chronic obstructive pulmonary disease (COPD), neonatal resuscitations, and in postresuscitation care. Recent guidelines published by the British Thoracic Society (BTS) advocate titrated oxygen therapy, but these guidelines have not been widely adapted in the out-of-hospital setting where high-flow oxygen is the standard. This report is a description of the implementation of a titrated oxygen protocol in a large urban-suburban Emergency Medical Services (EMS) system and a discussion of the practical application of this out-of-hospital protocol.

Annals of Emergency Medicine, 1994

To determine the efficacy and feasibility of adenosine for the treatment of paroxysmal supraventr... more To determine the efficacy and feasibility of adenosine for the treatment of paroxysmal supraventricular tachycardia (PSVT) in the prehospital setting. Prospective case series. Large, urban, advanced life support emergency medical services system. One hundred twenty-nine adult patients with PSVT, as identified by paramedic personnel. Pregnant patients and those taking carbamazepine or dipyridamole were excluded. Dose of 12 mg adenosine by rapid i.v. push followed by a 5-mL saline flush and a repeat dose of 12 mg adenosine i.v. push if the patient&amp;amp;#39;s rhythm remained unchanged. Six-second lead II rhythm strips and vital signs were documented before and 2 minutes after the administration of adenosine. Demographic information, past medical history, medications, number of adenosine doses given, and complications were recorded by the paramedic on a case-report form. One hundred six of 129 (82%) of the case-report forms included the rhythm strips from before and after adenosine administration. Actual initial rhythms were determined by a consensus panel. The initial rhythms were PSVT in 79% (84 of 106) of patients, atrial fibrillation in 12% (13 of 106), sinus tachycardia in 5% (five of 106), atrial flutter in 2% (two of 106), and ventricular tachycardia in 2% (two of 106). Eighty-five percent (71 of 84) of patients in PSVT were successfully converted to sinus rhythms; four (5.6%) of these patients required a second 12-mg dose. One patient in atrial fibrillation spontaneously converted to normal sinus rhythm and one patient in ventricular tachycardia converted after adenosine. All other patients not initially in PSVT remained in their initial rhythm. Complications occurred in 12 of 129 patients and included chest pain (five), flushing (three), shortness of breath (two), nausea (one), anxiety (one), dizziness (one), headache (one), and seizure (one). All complications were transient and required no treatment. Prior history of PSVT was the only variable associated with a higher rate of conversion (P = .029). Paramedics are able to accurately identify PSVT using a single lead. Adenosine is safe and effective treatment for PSVT in the prehospital setting. This series is the largest prehospital study of adenosine use to date.

Annals of Emergency Medicine, 1995

To describe emergency department quality assurance (QA)/improvement (QI) practices for pediatric ... more To describe emergency department quality assurance (QA)/improvement (QI) practices for pediatric patients. Mail survey of a cohort of emergency physicians. Pediatric Section members of the American College of Emergency Physicians and a computer-generated random sample of general ACEP members. Pediatric Section and general ACEP physicians were mailed a 13-question QA survey. Of the 500 surveys distributed, 207 (41.4%) were returned. Three emergency care settings for pediatric patients seen in the ED were identified: (1) children&#39;s hospital ED (14%), (2) general ED with a separate area designated for the evaluation of pediatric patients (12%), and (3) general ED where pediatric and adult patients are evaluated in the same area (74%). Separate QA indicators were used to monitor care of the pediatric patients seen in the ED by 61% of the respondents; 39% used &quot;adult&quot; indicators only. High pediatric census was associated with pediatric representation on the ED QA/QI Committee, the use of separate pediatric indicators to monitor care of pediatric patients in the ED, the separation of pediatric and adult patient care areas and satisfaction with the respondent&#39;s ED QA/QI plan. The bulk of pediatric emergency patients are cared for in a general ED. Most ACEP members surveyed reported the use of separate QA indicators to monitor the care of pediatric patients seen in the ED. This survey provides the first description of QA/QI practices for pediatric patients by EDs nationwide.

Academic Emergency Medicine, 1998

Objective: To evaluate the concordance with criteria developed by the study investigators and sup... more Objective: To evaluate the concordance with criteria developed by the study investigators and supply costs associated with placement of IV lines and saline locks by paramedics in the out-of-hospital setting. Methods: This was a retrospective consecutive case series a t an urban base hospital. Patients were treated by paramedics using one base hospital for medical control during December 1995. Base hospital written records and taped patient calls were reviewed to determine actual IV access method used by paramedics, chief complaint, and whether fluid administration was ordered. Indicated method of IV access was determined for each patient based on predetermined criteria developed by the investigators. IV access methods were ranked by cost of supplies as follows: IV line (IV) > saline lock (SL) > no I V line (NOW). An assignment of concordant treatment was made when actual = indicated method, discordant-overtreatment when actual > indicated, and discordant-undertreatment when actual < indicated. Results: 452 patients were treated via radio by the base hospital during the study period. 380 of 452 (84%) received an W. 28 of 380 (7%) received fluid resuscitation in the field. 166 of 452 (37%) received concordant treatment; 253

Academic Emergency Medicine, 2006

OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the tr... more OBJECTIVE. The goal was to describe the change in the rate of epinephrine dosing errors in the treatment of pediatric patients in prehospital cardiopulmonary arrest after the Los Angeles County Emergency Medical Services Agency instituted a program in which paramedics were required to use the Broselow tape and to report color zone categories to the base station and base stations were given and instructed formally in the use of the color-coded drug dosing chart.

Pediatric Emergency Care, 1989

Violent death (homicide and suicide) in the pediatric age group is a major public health problem.... more Violent death (homicide and suicide) in the pediatric age group is a major public health problem. A descriptive study was undertaken to review retrospectively the 1077 pediatric coroner&#39;s cases in 11 California counties for differences between urban and rural violent death rates. Pediatric violent death was more prevalent in the urban region than in the rural region (P less than 0.0007). High urban homicide rates accounted for most of this difference. Suicide rates were not significantly different (P = 0.18). Seventy-four percent of the violent deaths were in the 15- to 18-year age group, and most of these deaths were caused by firearms (81%). Blacks had the highest homicide and suicide rates. Child abuse was an important cause of death for young children in the urban area only. Socioeconomic factors, cultural differences, high population density, and the availability of firearms were proposed as factors affecting violent death in the pediatric age group.

Pediatric Emergency Care, 2014

This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-h... more This study aimed to quantify risk factors for apnea in children 0 to 5 years of age with out-of-hospital seizure. This is a retrospective study of pediatric patients with seizure transported by paramedics to the pediatric emergency department (PED) of a tertiary center from July 2008 to June 2009. Patients with traumatic injury and those with another diagnosis after PED evaluation were excluded. We evaluated the effect of field diazepam and other potential risk factors on the occurrence of apnea, defined as the need for airway management, that is, bag-mask ventilation by paramedics or bag-mask ventilation or intubation by PED staff within 30 minutes of arrival. There were 336 pediatric patients meeting inclusion criteria. The median age was 1.9 years (interquartile range,1.3-3.0 years); 193 patients (57%) were male. Fifty-four patients (16%) were treated with diazepam before PED arrival. There were 28 apneic events (8.3%). The adjusted relative risk for apnea given diazepam in the field by any route was 10.2 (95% confidence interval, 3.9-21.8; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001), adjusted for age and seizure on arrival. Persistent seizure on PED arrival was also highly associated with apnea, with an adjusted relative risk of 15.8 (95% confidence interval, 6.5-28.9; P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001). Field treatment with diazepam and seizing at the time of PED arrival are associated with the occurrence of apnea in children 0 to 5 years of age with out-of-hospital seizure. Larger studies are needed to determine what other factors may contribute to this risk.

Prehospital Emergency Care, 2013

Some emergency medical services (EMS) systems transport infants with an apparent life-threatening... more Some emergency medical services (EMS) systems transport infants with an apparent life-threatening event (ALTE) directly to hospitals capable of pediatric critical care (PCC) monitoring. To describe factors identifiable by EMS providers that distinguish ALTE patients who may require PCC monitoring and management. This was an observational analysis of ALTE patients who were transported by EMS and presented to four emergency departments (EDs). ED data were prospectively collected. Hospital records or reports from contacted parents were reviewed for interventions that mandated PCC management. We defined a priori the criteria by which PCC monitoring and management were required: if the subject needed 1) airway intervention with bag-valve-mask ventilation or advanced airway (e.g., endotracheal intubation) in the field, ED, or pediatric intensive care unit (PICU); 2) administration of vasopressors; 3) invasive monitoring; 4) surgery during the hospitalization; or 5) subspecialty consultation. Univariate analysis was performed to describe factors associated with requiring PCC management, and a multivariable model, accounting for within-hospital correlations, was developed. A total of 513 patients were enrolled. Of these, 51 (9.9%) had an intervention warranting PCC management. Univariate predictors for requiring PCC management included prematurity, past medical history, resuscitation attempt, upper respiratory infection, apnea, previous ALTE, more than one ALTE in 24 hours, and cyanosis. The multivariable model yielded the following independent predictors for requiring PCC management: resuscitation attempt before EMS arrival, cyanosis, and more than one ALTE in 24 hours. This model demonstrated a sensitivity of 96.3%, a specificity of 25.8%, a negative predictive value of 98.3%, and a positive predictive value of 13.5%. Only 9.9% of infants presenting in the field with ALTE had an intervention warranting PCC management, suggesting that many ALTE patients may be safely transported to hospitals without PCC capability. This would allow for better resource utilization of specialty care hospitals and still provide an option for secondary transports for those few patients not correctly identified in the field as requiring PCC. History of resuscitation attempt, cyanosis, and more than one ALTE in 24 hours are independent risk factors for requiring PCC management.

Pediatric Emergency Care, 1989

A total of 1078 pediatric coroners&#39; cases in 11 rural and urban California counties were ... more A total of 1078 pediatric coroners&#39; cases in 11 rural and urban California counties were reviewed as they relate to emergency medical services (EMS). Pediatric coroners&#39; death rates per 100,000 population varied from an average of 2.17 in the rural region to 30.4 in the urban region. Vehicular accidents caused the majority (66%) of the accidental deaths, and firearms caused 61% of the violent deaths. Violent deaths (homicide and suicide) were significantly more common in the urban region (P less than 0.001), and vehicular deaths (excluding auto versus pedestrian) were more common in the rural region (P less than 0.001). EMS provider usage was greater in the urban areas (84 vs 66%, P less than 0.001), as was the number of cases receiving advanced life support (97 vs 66%, P less than 0.001). Urban and rural differences in place of death were significant for two places of death; street and highway, and inhospital deaths. A significantly greater number of children died on the street/highway in rural areas (P less than 0.05). Hospital deaths were more likely to occur on the ward in the rural region, versus the intensive care unit in the urban region (P less than 0.001). Proposed factors which may explain these findings include differences in medical resources and in local transfer policies. The study demonstrates that EMS providers are involved in the care of children who have had a fatal emergency. Further evaluation of rural and urban differences in prehospital care of the pediatric patient is indicated.

Pediatric Clinics of North America, 1999

The Journal of Emergency Medicine, 2013

Paget-Schroetter syndrome (PSS) is a rare presentation of primary axillary subclavian vein thromb... more Paget-Schroetter syndrome (PSS) is a rare presentation of primary axillary subclavian vein thrombosis that classically occurs in young men with a degree of underlying thoracic outlet syndrome after a period of upper extremity exertion. The primary complication of PSS is post-thrombotic syndrome, a result of chronic venous hypertension. To educate Emergency Physicians on this condition to potentiate timely diagnosis and appropriate disposition. A 29-year-old right-handed restaurant waiter presented with 3 days of non-painful, gradual-onset right upper extremity swelling with normal vital signs. The patient&amp;amp;amp;amp;#39;s history was otherwise notable for subjective fevers and a right forearm abrasion. Upon examination, the right upper extremity was neurovascularly intact and remarkable for uniform edema and erythema extending distally from the level of the mid-humerus. The primary differential diagnoses were deep venous thrombosis (DVT) vs. soft tissue infection. Venous phase contrast computed tomography did not reveal evidence of underlying soft tissue infection and was inconclusive regarding a DVT. Ultrasound demonstrated a right subclavian vein DVT. The patient was admitted and underwent thrombolysis, venolysis, and first rib resection and initiation of warfarin. PSS is a rare presentation of upper-extremity DVT occurring classically in patients without commonly recognized pro-thrombotic risk factors. PSS carries the potential of significant morbidity in the form of post-thrombotic syndrome and pulmonary embolism. Current literature suggests that optimal outcomes are achieved when treatment is initiated within 6 weeks of onset. The treatment paradigm calls for thrombolysis and, frequently, a first rib resection.

Journal of Emergencies, Trauma, and Shock, 2014

We compared the survival of trauma patients in urban versus rural settings after the implementati... more We compared the survival of trauma patients in urban versus rural settings after the implementation of a novel rural non-trauma center alternative care model called the Model Rural Trauma Project (MRTP). We conducted an observational cohort study of all trauma patients brought to eight rural northern California hospitals and two southern California urban trauma centers over a one-year period (1995-1996). Trauma patients with an injury severity score (ISS) of &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;10 were included in the study. We used logistic regression to assess disparities in odds of survival while controlling for Trauma and Injury Severity Score (TRISS) parameters. A total of 1,122 trauma patients met criteria for this study, with 336 (30%) from the rural setting. The urban population was more seriously injured with a higher median ISS (17 urban and 14 rural) and a lower Glasgow Coma Scale (GCS) (GCS 14 urban and 15 rural). Patients in urban trauma centers were more likely to suffer penetrating trauma (25% urban versus 9% rural). After correcting for differences in patient population, the mortality associated with being treated in a rural hospital (OR 0.73; 95% CI 0.39 to 1.39) was not significantly different than an urban trauma center. This study demonstrates that rural and urban trauma patients are inherently different. The rural system utilized in this study, with low volume and high blunt trauma rates, can effectively care for its population of trauma patients with an enhanced, committed trauma system, which allows for expeditious movement of patients toward definitive care.

JAMA, 2000

Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hosp... more Endotracheal intubation (ETI) is widely used for airway management of children in the out-of-hospital setting, despite a lack of controlled trials demonstrating a positive effect on survival or neurological outcome. To compare the survival and neurological outcomes of pediatric patients treated with bag-valve-mask ventilation (BVM) with those of patients treated with BVM followed by ETI. Controlled clinical trial, in which patients were assigned to interventions by calendar day from March 15, 1994, through January 1, 1997. Two large, urban, rapid-transport emergency medical services (EMS) systems. A total of 830 consecutive patients aged 12 years or younger or estimated to weigh less than 40 kg who required airway management; 820 were available for follow-up. Patients were assigned to receive either BVM (odd days; n = 410) or BVM followed by ETI (even days; n = 420). Survival to hospital discharge and neurological status at discharge from an acute care hospital compared by treatment group. There was no significant difference in survival between the BVM group (123/404 [30%]) and the ETI group (110/416 [26%]) (odds ratio [OR], 0.82; 95% confidence interval [CI], 0.61-1.11) or in the rate of achieving a good neurological outcome (BVM, 92/404 [23%] vs ETI, 85/416 [20%]) (OR, 0.87; 95% CI, 0.62-1.22). These results indicate that the addition of out-of-hospital ETI to a paramedic scope of practice that already includes BVM did not improve survival or neurological outcome of pediatric patients treated in an urban EMS system.

International Journal of Trauma Nursing, 1998

Annals of Emergency Medicine, 2013

We identify factors in emergency department (ED) patients presenting with apparent life-threateni... more We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). We found 3 variables (obvious need for admission, significant medical history, &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation.

Annals of Emergency Medicine, 1996

Airway compromise is the most common cause of death and severe morbidity in acutely ill and injur... more Airway compromise is the most common cause of death and severe morbidity in acutely ill and injured children. Rapid-sequence intubation (RSI) is a technique for emergency airway control designed to maximize successful endotracheal intubation while minimizing the adverse physiologic effects of this procedure. RSI requires familiarity with patient evaluation, airway-management techniques, sedation agents, neuromuscular blocking agents, additional adjunctive agents, and postintubation management techniques. Emergency physicians should use RSI techniques in the endotracheal intubation of critically ill children.

Annals of Emergency Medicine, 1990

Vital signs are an integral part of the field assessment of patients. A twopart study was underta... more Vital signs are an integral part of the field assessment of patients. A twopart study was undertaken to determine which vital signs are taken in the field assessment of pediatric patients and to determine whether the frequency of vital signs taken is influenced by base station contact, patient's severity of illness or injury, or paramedic demographic factors such as parenting and field experience. An initial pilot study of prehospital care records (run sheets) from two base hospitals in Los Angeles County revealed that there were significant differences between field vital sign assessment in pediatric and adult patients (P < .0001). A retrospective review of 6,756 pediatric run sheets from Los Angeles County showed that the frequency of vital sign assessment varied with the age of the pediatric patient (P < .05) (ie, the frequency of vital sign assessment increased correspondingly with the age of the patient). Base hospital contact occurred in 26% of the runs; when contact was made, vital signs were more likely to be taken in all age groups studied. Vital signs often were not assessed in children less than 2 years old, even if the patient's chief complaint suggested the possibility of a major illness or trauma. The second part of the study was a field assessment survey that was distributed to 1,253 active paramedics in Los Angeles County; the results showed that paramedics were less confident in their ability to assess vital signs in children less than 2 years old. Confidence increased with age of the patient. The number of runs a provider made during a 24-hour shift was the only demographic factor related to the level of provider confidence. Future emergency medical services research must link field vital sign assessment to outcome to determine the value of this type of field assessment in the pediatric age group.