ECMO : the clinician’s view

Background: Extra corporeal membrane oxygenation (ECMO) is a complex rescue therapy used to provide cardiac and/or respiratory support for critically ill patients who have failed maximal conventional medical management. ECMO is based on a modified cardiopulmonary bypass (CPB) circuit, and can provide cardiopulmonary support for up-to several months. It can be used in a veno venous configuration for isolated respiratory failure, (VV-ECMO), or in a veno arterial configuration (VA-ECMO) where support is necessary for cardiac +/- respiratory failure. The ECMO circuit consists of five main components: large bore cannulae (access cannulae) for drainage of the venous system, and return cannulae to either the venous (in VV-ECMO) or arterial (in VA ECMO) system. An oxygenator, with a vast surface area of hollow filaments, allows addition of oxygen and removal of carbon dioxide; a centrifugal blood pump allows propulsion of blood through the circuit at upto 10 L/minute; a control module and a thermoregulatory unit, which allows for exact temperature control of the extra corporeal blood. Methods: The first successful use of ECMO for ARDS in adults occurred in 1972, and its use has become more commonplace over the last 30 years, supported by the improvement in design and biocompatibility of the equipment, which has reduced the morbidity associated with this modality. Whilst the use of ECMO in neonatal population has been supported by numerous studies, the evidence upon which ECMO was integrated into adult practice was substantially less robust. Results: Recent data, including the CESAR study (Conventional Ventilatory Support versus Extra corporeal membrane oxygenation for Severe Respiratory failure) has added a degree of evidence to the role of ECMO in such a patient population. The CESAR study analysed 180 patients, and confirmed that ECMO was associated with an improved rate of survival. More recently, ECMO has been utilized in numerous situations within the critical care area, including support in high-risk percutaneous interventions in cardiac catheter lab; the operating room, emergency department, as well in specialized inter-hospital retrieval services. The increased understanding of the risk:benefit profile of ECMO, along with a reduction in morbidity associated with its use will doubtless lead to a substantial rise in the utilisation of this modality. As with all extra-corporeal circuits, ECMO opposes the basic premises of the mammalian inflammation and coagulation cascade where blood comes into foreign circulation, both these cascades are activated. Anti-coagulation is readily dealt with through use of agents such as heparin, but the inflammatory excess, whilst less macroscopically obvious, continues un-abated. Platelet consumption and neutrophil activation occur rapidly, and the clinician is faced with balancing the need of anticoagulation for the circuit, against haemostasis in an acutely bleeding patient. Alterations in pharmacokinetics may result in inadequate levels of disease modifying therapeutics, such as antibiotics, hence paradoxically delaying recovery from conditions such as pneumonia. Key elements of nutrition and the innate immune system maysimilarly be affected. Summary: This presentation will discuss the basic features of ECMO to the nonspecialist, and review the clinical conundrum faced by the team treating these most complex cases.

Development of clinical competencies for emergency nurse practitioners : a pilot study

Background: Nurse practitioner education and practice has been guided by generic competency standards in Australia since 2006. Development of specialist competencies has been less structured and there are no formal standards to guide education and continuing professional development for specialty fields. There is limited international research and no Australian research into development of specialist nurse practitioner competencies. This pilot study aimed to test data collection methods, tools and processes in preparation for a larger national study to investigate specialist competency standards for emergency nurse practitioners. Research into specialist emergency nurse practitioner competencies has not been conducted in Australia. Methods: Mixed methods research was conducted with a sample of experienced emergency nurse practitioners. Deductive analysis of data from a focus group workshop informed development of a draft specialty competency framework. The framework was subsequently subjected to systematic scrutiny for consensus validation through a two round Delphi Study. Results: The Delphi study first round had a 100% response rate; the second round 75% response rate. The scoring for all items in both rounds was above the 80% cut off mark with the lowest mean score being 4.1 (82%) from the first round. Conclusion: The authors collaborated with emergency nurse practitioners to produce preliminary data on the formation of specialty competencies as a first step in developing an Australian framework.

Funding : Australia’s grant system wastes time

We found that scientists in Australia spent more than five centuries' worth of time preparing research-grant proposals for consideration by the largest funding scheme of 2012. Because just 20.5% of these applications were successful, the equivalent of some four centuries of effort returned no immediate benefit to researchers and wasted valuable research time. The system needs reforming and alternative funding processes should be investigated...

Communicating in the pre-hospital emergency environment

Aim. To develop and evaluate the implementation of a communication board for paramedics to use with patients as an augmentative or alternative communication tool to address communication needs of patients in the pre-hospital setting. Method. A double-sided A4-size communication board was designed specifically for use in the pre-hospital setting by the Queensland Ambulance Service and Disability and Community Care Services. One side of the board contains expressive messages that could be used by both the patient and paramedic. The other side contains messages to support patients’ understanding and interaction tips for the paramedic. The communication board was made available in every ambulance and patient transport vehicle in the Brisbane Region. Results. A total of 878 paramedics completed a survey that gauged which patient groups they might use the communication board with. The two most common groups were patients from culturally and linguistically diverse backgrounds and children. Staff reported feeling confident in using the board, and 72% of interviewed paramedics agreed that the communication board was useful for aiding communication with patients. Feedback from paramedics suggests that the board is simple to use, reduces patient frustration and improves communication. Conclusion. These results suggest that a communication board can be applied in the pre-hospital setting to support communication success with patients. What is known about the topic? It is imperative that communication between patient and paramedic is clear and effective. Research has shown that communication boards have been effective with people with temporary or permanent communication difficulties. What does this paper add? This is the first paper outlining the development and use of a communication board by paramedics in the pre-hospital setting in Australia. The paper details the design of the communication board for the unique pre-hospital environment. The paper provides some preliminary data on the use of the communication board with certain patient groups and its effectiveness as an alternative communication tool. What are the implications for practitioners? The findings support the use of the tool as a viable option in supporting the communication between paramedics and a range of patients. It is not suggested that this communication board will meet the complete communication needs of any individual in this environment, but it is hoped that the board’s presence within the Queensland Ambulance Service may result in paramedics introducing the board on occasions where communication with a patient is challenging.

Australia's disabling income support system : tracing the history of the Australian disability income support system 1908 to 2007 : disablism, citizenship and the basic income proposal

The present study examined the historical basis of the Australian disability income support system from 1908 to 2007. Although designed as a safety net for people with a disability, the disability income support system within Australia has been highly targeted. The original eligibility criteria of "permanently incapacitated for work", medical criteria and later "partially capacitated for work" potentially contained ideological inferences that permeated across the time period. This represents an important area for study given the potential consequence for disability income support to marginalise people with a disability. Social policy and disability policy theorists, including Saunders (2007, Social Policy Research Centre [SPRC]) and Gibilisco (2003) have provided valuable insight into some of the effects of disability policy and poverty. Yet while these theorists argued for some form of income support they did not propose a specific form of income security for further exploration. Few studies have undertaken a comprehensive review of the history of disability income support within the Australian context. This thesis sought to redress these gaps by examining disability income support policy within Australia. The research design consisted of an in-depth critical historical-comparative policy analysis methodology. The use of critical historical-comparative policy analysis allowed the researcher to trace the construction of disability within the Australian disability income support policy across four major historical epochs. A framework was developed specifically to guide analysis of the data. The critical discourse analysis method helped to understand the underlying ideological dimensions that led to the predominance of one particular approach over another. Given this, the research purpose of the study centred on: i. Tracing the history of the Australian disability income support system. ii. Examining the historical patterns and ideological assumptions over time. iii. Exploring the historical patterns and ideological assumptions underpinning an alternative model (Basic Income) and the extent to which each model promotes the social citizenship of people with a disability. The research commitment to a social-relational ontology and the quest for social change centred on the idea that "there has to be a better way" in the provision of disability income support. This theme of searching for an alternative reality in disability income support policy resonated throughout the thesis. This thesis found that the Australian disability income support system is disabling in nature and generates categories of disability on the basis of ableness. From the study, ableness became a condition for citizenship. This study acknowledged that, in reality, income support provision reflects only one aspect of the disabling nature of society which requires redressing. Although there are inherent tensions in any redistributive strategy, the Basic Income model potentially provides an alternative to the Australian disability income support system, given its grounding in social citizenship. The thesis findings have implications for academics, policy-makers and practitioners in terms of developing better ways to understand disability constructs in disability income support policy. The thesis also makes a contribution in terms of promoting income support policies based on the rights of all people, not just a few.

Intern underperformance is detected more frequently in emergency medicine rotations

Objective: To determine the frequency and nature of intern underperformance as documented on in-training assessment forms. Methods: A retrospective review of intern assessment forms from a 2 year period (2009–2010) was conducted at a tertiary referral hospital in Brisbane, Queensland. The frequency of interns assessed as ‘requiring substantial assistance’ and/or ‘requires further development’ on mid- or end-of-term assessment forms was determined. Forms were analysed by the clinical rotation, time of year and domain(s) of clinical practice in which underperformance was documented. Results: During 2009 and 2010 the overall documented incidence of intern underperformance was 2.4% (95% CI 1.5–3.9%). Clinical rotation in emergency medicine detected significantly more underperformance compared with other rotations (P < 0.01). Interns predominantly had difficulty with ‘clinical judgment and decision-making skills’, ‘time management skills’ and ‘teamwork and colleagues’ (62.5%, 55% and 32.5% of underperforming assessments, respectively). Time of the year did not affect frequency of underperformance. A proportion of 13.4% (95% CI 9.2–19.0%) of interns working at the institution over the study period received at least one assessment in which underperformance was documented. Seventy-six per cent of those interns who had underperformance identified by mid-term assessment successfully completed the term following remediation. Conclusion: The prevalence of underperformance among interns is low, although higher than previously suggested. Emergency medicine detects relatively more interns in difficulty than other rotations.

The growing demand for emergency healthcare

Emergency health is a critical component of health systems; one increasingly congested from growing demand and blocked access to care. The Emergency Health Services Queensland (EHSQ) study aimed to identify the factors driving increased demand for emergency healthcare. This study examined data on patients treated by the ambulance service and Emergency Departments across Queensland. Data was derived from the Queensland Ambulance Service’s (QAS) Ambulance Information Management System and electronic Ambulance Report Form and from the Emergency Department Information System (EDIS). Data was obtained for the period 2001-02 through to 2009-10. A snapshot of users for the 2009-10 year was used to describe the characteristics of users and comparisons made with the year 2003-04 to identify trends. Per capita demand for EDs has increased by 2% per annum over the decade and for ambulance by 3.7% per annum. The growth in ED demand is most significant in more urgent triage categories with decline in less urgent patients. The growth is most prominent amongst patients suffering injuries and poisoning, amongst both men and women and across all age groups. Patients from lower socioeconomic areas appear to have higher utilisation rates and the utilisation rate for indigenous people exceeds those of other backgrounds. The utilisation rates for immigrant people is less than Australian born however it has not been possible to eliminate the confounding impact of age and socioeconomic profiles. These findings contribute to an understanding of the growth in demand for emergency health. It is evident that the growth is amongst patients in genuine need of emergency healthcare and public rhetoric that congested emergency health services is due to inappropriate attendees is unsustainable. The growth in demand over the last decade reflects not only on changing demographics of the Australian population but also changes in health status, standards of acute health care and other social factors.

The potential contributions of traditional Chinese medicine to emergency medicine

BACKGROUND: Despite the fact that traditional Chinese medicine (TCM) has been developed and used to treat acute and urgent illness for many thousands of years. TCM has been widely perceived in western societies that TCM may only be effective to treat chronic diseases. The aim of this article is to provide some scientific evidence regarding the application of TCM in emergency medicine and its future potential. METHODS: Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) were searched using the terms: Traditional Chinese Medicine/ Chinese Medicine, Emergency Medicine, China. In addition, three leading TCM Journals in China were searched via Oriprobe Information Services for relevant articles (published from 1990—2012). Particular attention was paid to those articles that are related to TCM treatments or combined medicine in dealing with intensive and critical care. RESULTS: TCM is a systematic traditional macro medicine. The clinical practice of TCM is guided by the TCM theoretical framework – a methodology founded thousands of years ago. As the methodologies between TCM and Biomedicine are significantly different, it provides an opportunity to combine two medicines, in order to achieve clinical efficacy. Nowadays, combined medicine has become a common clinical model particular in TCM hospitals in China. CONCLUSIONS: It is evident that TCM can provide some assistance in emergency although to combine them in practice is stillits infant form and is mainly at TCM hospitals in China. The future effort could be put into TCM research, both in laboratories and clinics, with high quality designs, so that TCM could be better understood and then applied in emergency medicine.

General practice patients in the emergency department

One of the mysteries of public policy is that at times the public discourse settles on a perspective that is based on flimsy or even contradictory evidence. One such discussion relates to the factors that contribute to the congestion of hospital emergency departments (EDs) in Australia.

Validation and consistency in the application of a trauma team activation system at a level 1 trauma centre

- The RAH was activated over 2500 trauma calls in 2009. This figure is over twice the number of calls put out by similar services. - Many trauma calls (in particular L2 trauma calls) from the existing system do not warrant activation of the trauma team - Sometimes trauma calls are activated for nontrauma reasons (eg rapid access to radiology, departmental pressures etc) - The excess of trauma calls has several deleterious effects particularly on time management for the trauma service staff: ward rounds/tertiary survey rounds, education, quality improvement, research

An approach for identifying the limit states of resilience of a water supply system

This paper presents an approach for identifying the limit states of resilience in a water supply system when influenced by different types of pressure (disturbing) forces. Understanding of systemic resilience facilitates identification of the trigger points for early managerial action to avoid further loss of ability to provide satisfactory service availability when the ability to supply water is under pressure. The approach proposed here is to illustrate the usefulness of a surrogate measure of resilience depicted in a three dimensional space encompassing independent pressure factors. That enables visualisation of the transition of the system-state (resilience) between high to low resilience regions and acts as an early warning trigger for decision-making. The necessity of a surrogate measure arises as a means of linking resilience to the identified pressures as resilience cannot be measured directly. The basis for identifying the resilience surrogate and exploring the interconnected relationships within the complete system, is derived from a meta-system model consisting of three nested sub-systems representing the water catchment and reservoir; treatment plant; and the distribution system and end-users. This approach can be used as a framework for assessing levels of resilience in different infrastructure systems by identifying a surrogate measure and its relationship to relevant pressures acting on the system.

Improved ultra-performance liquid chromatography with electrospray ionization quadrupole-time-of-flight high-definition mass spectrometry method for the rapid analysis of the chemical constituents of a typical medical formula: Liuwei Dihuang Wan

Liuwei Dihuang Wan (LWD), a classic Chinese medicinal formulae, has been used to improve or restore declined functions related to aging and geriatric diseases, such as impaired mobility, vision, hearing, cognition and memory. It has attracted increasingly much attention as one of the most popular and valuable herbal medicines. However, the systematic analysis of the chemical constituents of LDW is difficult and thus has not been well established. In this paper, a rapid, sensitive and reliable ultra-performance liquid chromatography with electrospray ionization quadrupole time-of-flight high-definition mass spectrometry (UPLC-ESI-Q-TOF-MS) method with automated MetaboLynx analysis in positive and negative ion mode was established to characterize the chemical constituents of LDW. The analysis was performed on a Waters UPLCTM HSS T3 using a gradient elution system. MS/MS fragmentation behavior was proposed for aiding the structural identification of the components. Under the optimized conditions, a total of 50 peaks were tentatively characterized by comparing the retention time and MS data. It is concluded that a rapid and robust platform based on UPLC-ESI-Q-TOF-MS has been successfully developed for globally identifying multiple-constituents of traditional Chinese medicine prescriptions. This is the first report on systematic analysis of the chemical constituents of LDW. This article is protected by copyright. All rights reserved.

Evaluating patient presentations for care delivered by emergency nurse practitioners : a retrospective analysis of 12 months

Background The delivery of quality patient care in the emergency department (ED) is emerging as one of the most important service indicators to be measured in health services today. The emergency nurse practitioner role was implemented as a service innovation in a Emergency & Trauma Centre (ETC), Melbourne, Australia, in July 2004 .The primary aim of the role was intended to enhance healthcare services, improve the efficiency and timely delivery of high quality care to patients. Aim To conduct a retrospective study of patient presentations at the ETC to obtain a profile of the characteristics of patients managed by emergency nurse practitioners. Specifically the objectives of the study were to: 1) examine the demographics of the patient population 2) evaluate data on emergency department service indicators for this patient cohort Method All patients presenting to the ETC from January 01 2011 to December 31 2011 and managed by emergency nurse practitioners were included in the review. Data collection included baseline demographics, waiting times to be seen, length of stay, emergency department discharge diagnoses and referral patterns. Data were extracted and imported directly from the emergency department Patient Information System (Cerner log), for the specified time frame. Results A total of 5212 patients were reviewed in the study period. The median age of patients was 35 years and 61% of patients were male. The most common discharge diagnosis was open wounds to hand/wrist. Waiting times to be seen by the emergency nurse practitioner were 14 minutes and length of stay for patients with a discharge disposition of home were 122 minutes. Conclusions This study has provided information on patient baseline characteristics and performance on important service indicators for this patient sample that will inform further research to evaluate specific outcomes of the emergency nurse practitioner service.

Brake system performance requirements of a lightweight electric/hybrid rear wheel drive vehicle

Investigates the braking performance requirements of the UltraCommuter, a lightweight series hybrid electric vehicle currently under development at the University of Queensland. With a predicted vehicle mass of 600 kg and two in-wheel motors each capable of 500 Nm of peak torque, decelerations up to 0.46 g are theoretically possible using purely regenerative braking. With 99% of braking demands less than 0.35 g, essentially all braking can be regenerative. The wheel motors have sufficient peak torque capability to lock the rear wheels in combination with front axle braking, eliminating the need for friction braking at the rear. Emergency braking levels approaching 1 g are achieved by supplementation with front disk brakes. This paper presents equations describing the peak front and rear axle braking forces which occur under straight line braking, including gradients. Conventionally, to guarantee stability, mechanical front/rear proportioning of braking effort ensures that the front axle locks first. In this application, all braking is initially regenerative at the rear, and an adaptive ''by-wire'' proportioning system presented ensures this stability requirement is still satisfied. Front wheel drive and all wheel drive systems are also discussed. Finally, peak and continuous performance measures, not commonly provided for friction brakes, are derived for the UltraCommuter's motor capability and range of operation.