Faculty Bibliography

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants

ACADEMIC EMERGENCY MEDICINE 2011; 18:313-316 (c) 2011 by the Society for Academic Emergency Medicine ABSTRACT: Objectives: In preparation for development of a clinical decision rule (CDR) to promote more efficient use of computed tomography (CT) for diagnosing orbital fractures, the authors sought to estimate the annual incidence of orbital fractures in emergency departments (EDs) and the usage of CT to make these diagnoses. The authors also sought to evaluate a mandatory electronic data collection instrument (EDCI) administered to providers to facilitate CDR data collection. Methods: National estimates were made by analyzing the 2007 National Hospital Ambulatory Medical Care Survey (NHAMCS) database, while hospital billing system and coding data were used to make local estimates. An EDCI was integrated into the CT ordering system such that providers had to complete the form to perform a CT. Because the EDCI had to be filled out for every CT ordered, data collection efficiency was measured by compliance (counting the number of unrealistic data collection instrument answers) and by timing a convenience sample of providers completing the EDCI. Results: Out of 116.8 million ED visits in the United States in 2007, 4.1 million patients were treated for injuries of the eye and face. Of those, 820,252 patients underwent CT imaging, with 102,999 patients (12.5%) diagnosed with an orbital fracture. In our local hospital system with 122,500 annual ED visits, 752 CTs of orbits were performed, with 172 (23%) orbital fractures. The EDCI compliance rate was 94.9% and took less than 5 minutes to complete. Conclusions: National and local data demonstrate a low yield for CT imaging in identifying orbital fractures. Data collection using a mandatory EDCI linked to computerized provider order entry can provide prospective, consecutive patient data that are needed to develop a CDR for the selective use of CT imaging in orbital trauma. Such a decision rule could increase the efficiency in diagnosing orbital fractures, thereby improving patient care, reducing radiation exposure, and decreasing costs. ACADEMIC EMERGENCY MEDICINE 2011; 18:1-4 (c) 2011 by the Society for Academic Emergency Medicine

Background: Emergency medical servies (EMS) systems improve outcomes for a subset of patients in need of emergent care. Unfortunately, much of the world's population does not have access to EMS. Unique challenges hinder developing nations' ability to provide this service. In October 2002, the West African nation of Gabon introduced its EMS system in Libreville, yet few access it. Objectives: To identify barriers to EMS access among Libreville residents. Methods: In this qualitative study, we interviewed a convenience sample of patients and family members who presented to the emergency department (ED) at Jeanne Ebori Hospital, a public teaching facility in Libreville, Gabon, in October 2009. Eligible subjects were ill enough to require hospital admission, but arrived by means other than EMS. Subjects were excluded if under 21, unable to speak French, or medically unstable without family present. Questions explored subjects' knowledge of and attitudes toward EMS, including perceptions about access and need. Audio- recorded interviews were conducted in French and transcribed in English by a bilingual team member. Two trained investigators organized the relevant text into themes and theoretical constructs using an iterative coding strategy. Data were collected until achieving theoretical saturation. Results: We achieved theoretical saturation at 27 subjects (22 patients and 5 family members). Two additional subjects were approached, but did not participate in the study; one refused participation, one did not speak French. Subjects recognize EMS may save lives. However, subjects rarely call EMS, because they are unaware of how to access it (e.g., lack the phone number), habitually use other transport modes, and have no means to pay. Subjects are frustrated by difficulty in contacting EMS and prolonged response times. Subjects also indicate that people often have no phone to call EMS and that poor neighborhoods are hard to access due to lack of roads and safety concerns. Conclusion: Barriers to EMS access among Libreville residents have been identified. Future policy may be directed to establish means for payment, station vehicles throughout the city to decrease response times, and improve infrastructure to allow better vehicle access. Public outreach should be considered to improve community awareness of the EMS system. Future work will be undertaken to design and evaluate reform based on these results to improve access to EMS in Libreville

Background: Significant variation and inefficiency exist in ordering computed tomography (CT) imaging for detecting orbital fractures in patients presenting with acute orbital trauma. Clinical decision rules (CDRs) can help improve diagnostic accuracy, decrease resource utilization, and limit exposure of radiosensitive organs (such as the globe) to ionizing radiation. Objectives: To derive a CDR that is highly predictive of acute orbital fracture in ED patients presenting with acute orbital trauma. (Figure Presented). Methods: Prospective cohort study conducted from July 2007- October 2009 at two urban hospitals. Consecutive patients with acute orbital trauma undergoing CT were enrolled using a mandatory electronic data collection instrument (EDCI) integrated into the computerized order system. Physicians evaluated patients on 15 clinical findings prior to CT. The main outcome was any acute orbital bone fracture identified in the final CT report. The CDR was derived using multivariate logistic regression with multiple imputation to determine which findings were most predictive for acute orbital fracture. Results: of 3,123 EDCIs completed, 2,549 (81.6%) were for patients suffering traumatic injury. Compliance with the EDCI was high (95.0%) resulting in 2,422 complete forms. For EDCIs with missing data, we used multiple imputation so that all surveys could be used for CDR derivation. Median age was 39 with male predominance (68.8%). CT results were available for all patients, with 408 (16.0%) having acute orbital fractures. Majority of injuries were caused by fist to orbit (36.7%) or fall (32.9%). The CDR with the highest predictive value was selected; cross-validation and regression diagnostics were performed to ensure calibration and confirm model fit. Patients lacking any of the equally-weighted six exam findings (Table 1) had a 6.4% (95% CI 4.7-8.4) prevalence of acute orbital fracture. Patients with four or more exam findings had a fracture prevalence of 44.7% (Figure 1). Conclusion: The CDR derived in this study identifies six exam findings highly predictive for acute orbital fracture; however, with a prevalence of 6.4% in the 0 score group, the CDR is not sufficiently sensitive to rule out'' fracture. Subsequent study using fractures of clinical importance as the outcome may yield a more sensitive CDR. Table 1: Orbital Fracture Risk Score (Table Pesented)

BACKGROUND: Osteopathic physicians believe that the birthing process causes cranial dysfunction that may be manifested in somatic symptoms, one of which is excessive crying of infancy. Cranial dysfunction can be determined by assessing the cranial rhythmic impulse (CRI). OBJECTIVE: The objective of this study is to examine whether an abnormal CRI is associated with excessive crying of infancy. DESIGN: Full-term infants in the well-baby nursery of an urban public hospital in the Bronx, New York were enrolled. Two (2) osteopathic physicians independently measured the CRI in infants before discharge. One (1) osteopath repeated the CRI measurement at 2 weeks. At 6 weeks, an investigator blinded to the CRI and birth data assessed infant crying using the modified Ames Cry Score via telephone interview with the primary caretaker. The caretaker was also asked about maternal stress, use of home or cultural remedies, and the infant's diet. The main outcome measure was the presence of excessive crying. RESULTS: One hundred and thirty-nine (139) patients were included in the final sample. The overall incidence of excessive crying was 41.7%. Excessive crying was associated with an abnormal CRI at 2 weeks (p < 0.001) but not with the CRI at birth (p = 0.23). Infants with an abnormal CRI at 2 weeks were 6.8 times (95% confidence intervals 2.2, 20.6) more likely to develop excessive crying than infants with a normal CRI. Infant diet was independently associated with excessive crying. Inter-rater agreement for CRI measurement was 0.70 using the kappa statistic. CONCLUSIONS: These data suggest that an abnormal CRI at 2 weeks of age may be associated with excessive crying.

There is mounting evidence that exercise tolerance is an important predictor of heart disease. Our objective was to determine if decreased exercise tolerance, as estimated by physicians, may be useful in stratifying risk in Emergency Department (ED) patients with potential acute coronary syndromes. We conducted a prospective cohort study on a convenience sample of ED patients at an urban teaching hospital. Patients with chest pain, dyspnea, syncope, or epigastric pain who were evaluated for acute coronary syndromes were included. Clinical and laboratory data were recorded. In addition, the Emergency Physicians were asked to estimate the exercise tolerance of the patient as excellent, good, bad, or very poor. The primary outcome of the study was myocardial infarction (MI) or death in patients stratified by physician-perceived exercise tolerance (excellent or good vs. bad or very poor). There were 166 patients enrolled in the study. Nine patients (5%) had an MI; there were no deaths. Physicians reported exercise tolerance as excellent in 33 patients, good in 63, bad in 50, and very poor in 20. The unadjusted risk of MI was significantly elevated in patients with physician-perceived decreased exercise tolerance (relative risk = 4.8, 95% confidence interval 1.03-22). After adjustment for age, sex, and major cardiovascular risk factors, decreased exercise tolerance remained a significant predictor of MI (adjusted odds ratio = 7.3, 95% confidence interval 1.2-46). Exercise tolerance, as estimated by clinical impression, may be an important predictor of complications in ED patients presenting with potential acute coronary syndromes.

It is well documented that transplants save lives and improve quality of life for patients suffering from kidney, liver, and heart failure. Uncontrolled donation after cardiac death (UDCD) is an effective and ethical alternative to existing efforts towards increasing the available pool of organs. However, people who die from an out-of-hospital cardiac arrest are currently being denied the opportunity to be organ donors except in those few locations where out-of-hospital UDCD programs are active, such as in Paris, Madrid, and Barcelona. Societies have the medical and moral obligation to develop UDCD programs