Faculty Bibliography

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: 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.

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

STUDY OBJECTIVE: This study determined whether Spanish and English educational videos are superior to routine discussion for informing emergency department (ED) patients about risks, benefits, and alternatives to receiving intravenous contrast for computed tomography (CT). METHODS: A prospective randomized controlled trial was performed on a convenience sample of adult ED patients scheduled to receive intravenous contrast for CT. Patients randomized to the intervention group watched a video in Spanish or English explaining the procedure and its risks, benefits, and alternatives. The control group underwent routine discussion, receiving intravenous contrast information from their emergency physician. After their educational sessions, all participants completed a 10-question intravenous contrast knowledge measure and 1 question rating satisfaction with the informed consent process. Mean scores were compared to assess whether the videos were superior to routine discussion for educating patients about intravenous contrast. Secondary outcomes included the proportion of satisfied patients and refusals to sign consent. RESULTS: Of the 112 patients enrolled, 56 were randomized to the video group and 56 to routine discussion. Five patients withdrew from the study, leaving 107 for analysis (video N=53; control N=54). Mean knowledge scores were higher in the video group (68.1%) compared to routine discussion (47.8%) (95% confidence interval [CI] for the difference 12.6% to 28.1%). Video-group patients exhibited greater satisfaction than routine-discussion patients (86.8% [95% CI 74.6% to 94.5%] versus 77.4% [95% CI 63.8% to 87.7%]). All patients signed consent to receive intravenous contrast. CONCLUSION: Using Spanish and English educational videos yielded higher intravenous contrast knowledge scores compared with routine informed consent procedures

OBJECTIVES: Prior evidence suggests that physicians may alter process of care based on race/ethnicity. The objective of this study was to determine whether race/ethnicity predicts whether a patient receives computed tomography of the head (head CT) during evaluation of blunt head injury. METHODS: This was a nonconcurrent cohort study set in an emergency department of a Level 1 trauma center in a university medical center. Consecutive patients presenting with blunt head injury from January 2000 to December 2000 were enrolled. The main outcome measure was whether or not a patient received head CT during evaluation of blunt head injury. RESULTS: The unadjusted probability of receiving head CT was similar among minority (33.9%; 95% confidence interval [CI] = 30.0% to 38.1%) and non-Hispanic white patients (36.4%; 95% CI = 33.5% to 39.3%). After adjusting for important clinical and socioeconomic predictors, minority patients had a probability of receiving head CT 0.84 times as high as that of non-Hispanic whites, but this result was not statistically significant (95% CI = 0.67 to 1.09). CONCLUSIONS: Minority and non-Hispanic white patients may not have significantly different rates of receiving head CT during evaluation of blunt head injury. A multicenter prospective study is necessary to confirm these preliminary findings