Letters to the Editor
long‑term MV patients will remain speculative until the large‑scale and adequately powered randomized, controlled trials. L Santana‑Cabrera, C Díaz Mendoza, M Sánchez‑Palacios, JD Martin‑Santana1, JR Hernández Hernández1 1
Intensive Care Unit, Universitary Hospital Insular in Gran Canaria, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain Address for correspondence: Dr. L. Santana‑Cabrera, Avenida Marítima Del Sur s/n, Las Palmas de Gran Canaria, Canary Islands 35016, Spain. E‑mail: [email protected]
REFERENCES Figure 1: Kaplan–Meier survival curves depending on the application or not of tracheostomy
We might have missed, in the present study, factors associated with the decision to perform a tracheostomy that might alter ICU and hospital outcomes as prolonged MV duration because of weaning failure, need for reintubation, nosocomial pneumonia, or aspiration.[4,5] Anyway, our results may not be applicable to patients receiving MV in other centers with different case‑mixes and different MV weaning strategies. Furthermore, we did not record decisions to withhold or withdraw life‑sustaining treatments either in our unit or after discharge from it. Such decisions might have affected the results. These data might be the focus of future studies.
1. 2. 3. 4. 5.
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long‑term mechanical ventilation? Crit Care Med 2007;35:802‑7. Frutos‑Vivar F, Esteban A, Apezteguía C, Anzueto A, Nightingale P, González M, et al. Outcome of mechanically ventilated patients who require a tracheostomy. Crit Care Med 2005;33:290‑8. Freeman BD, Borecki IB, Coopersmith CM, Buchman TG. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med 2005;33:2513‑20. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta‑analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243. Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714‑20. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124176
In conclusion, tracheostomy performed in our ICU for long‑term stay patients was associated with lower ICU mortality, but higher in‑hospital rates. Whether the tracheostomy really affects the outcomes of these
Patient care delays due to scene safety Sir, Recently, responding to a 911 call of ‘gunshots fired’, two law‑enforcement officers arrived within a minute and found an unresponsive victim but were unable to allow Emergency Medical Services (EMS) on the scene as a crowd of approximately 30 bystanders became increasingly hostile, both threatening and physically assaulting the officers. Within seven minutes, approximately 20 officers had arrived and the crowd was dispersed. Once the scene was secured, paramedics found a 31‑year‑old male with three gunshot wounds to his chest. The patient maintained palpable pulses until just prior to arrival in the hospital. In the emergency department, the
patient remained pulseless and unresponsive. Bilateral thoracotomies were performed and the patient was found to have penetration of the superior vena cava without injury to the heart. Open cardiopulmonary resuscitation (CPR) with intracardiac epinephrine was performed and massive blood and plasma transfusions were administrated, but the patient could not be resuscitated. It is well established that the response time of EMS has a significant effect on morbidity and mortality for patients with severe medical or traumatic conditions. Although EMS delays in patient care have many different causes, no studies examine delays from safety risks for EMS personnel.
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
287
Letters to the Editor
On‑scene violence and danger is real and not uncommon. Studies of urban EMS systems report violence occurring in 5% of all calls and immediately ending just prior to the arrival of EMS in another 14%.[1,2] When surveyed, 60-90% of EMS providers reported having been assaulted on the job.[3]
goal, decreasing violence ultimately, as a society, is the most effective way of protecting both our patients and ourselves. Jared N. Strote, H Range Hutson1
Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, 1Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
Responding to a shooting, the risks are increased, even if the perpetrator is no longer present. In gang‑related violence, there is, frequently, a risk of further attempts at harming the patient or a retaliatory act. In cities where tensions exist between the public and law enforcement, violence can erupt indiscriminately against all first responders.[4,5] In the case presented here, it is by no means clear whether the patient would have survived if EMS had been on the scene without delay. The case does serve as a reminder, however, that although we know that provider safety should always take precedence, there is no best practice for EMS security. Different EMS systems have facilities ranging from nothing at all to mandated body armor, police escorts, and armored personnel carriers.[3,4] Studies are needed to examine what protocols and systems‑level planning can maximize safety for both patient and provider. Simultaneously, health‑care providers have a responsibility to educate the public about the effects of crowd anger on limiting the access of care to a victim as well as inciting further violence. Although improving care under any circumstances should remain our
288
Address for correspondence: Dr. Jared N. Strote, Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
Grange JT, Corbett SW. Violence against emergency medical services personnel. Prehosp Emerg Care 2002;6:186‑90. Mock EF, Wrenn KD, Wright SW, Eustis TC, Slovis CM. Anxiety levels in EMS providers: Effects of violence and shifts schedules. Am J Emerg Med 1999;17:509‑11. Corbett SW, Grange JT, Thomas TL. Exposure of prehospital care providers to violence. Prehosp Emerg Care 1998;2:127‑31. Eckstein M, Cowen AR. Scene safety in the face of automatic weapons fire: A new dilemma for EMS? Prehosp Emerg Care 1998;2:117‑22. Krebs D. When violence erupts: A survival guide for emergency responders. Sudbury, MA: Jones and Bartlett; 2003. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124177
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
long‑term MV patients will remain speculative until the large‑scale and adequately powered randomized, controlled trials. L Santana‑Cabrera, C Díaz Mendoza, M Sánchez‑Palacios, JD Martin‑Santana1, JR Hernández Hernández1 1
Intensive Care Unit, Universitary Hospital Insular in Gran Canaria, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Canary Islands, Spain Address for correspondence: Dr. L. Santana‑Cabrera, Avenida Marítima Del Sur s/n, Las Palmas de Gran Canaria, Canary Islands 35016, Spain. E‑mail: [email protected]
REFERENCES Figure 1: Kaplan–Meier survival curves depending on the application or not of tracheostomy
We might have missed, in the present study, factors associated with the decision to perform a tracheostomy that might alter ICU and hospital outcomes as prolonged MV duration because of weaning failure, need for reintubation, nosocomial pneumonia, or aspiration.[4,5] Anyway, our results may not be applicable to patients receiving MV in other centers with different case‑mixes and different MV weaning strategies. Furthermore, we did not record decisions to withhold or withdraw life‑sustaining treatments either in our unit or after discharge from it. Such decisions might have affected the results. These data might be the focus of future studies.
1. 2. 3. 4. 5.
Combes A, Luyt CE, Nieszkowska A, Trouillet JL, Gibert C, Chastre J. Is tracheostomy associated with better outcomes for patients requiring long‑term mechanical ventilation? Crit Care Med 2007;35:802‑7. Frutos‑Vivar F, Esteban A, Apezteguía C, Anzueto A, Nightingale P, González M, et al. Outcome of mechanically ventilated patients who require a tracheostomy. Crit Care Med 2005;33:290‑8. Freeman BD, Borecki IB, Coopersmith CM, Buchman TG. Relationship between tracheostomy timing and duration of mechanical ventilation in critically ill patients. Crit Care Med 2005;33:2513‑20. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta‑analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243. Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med 1999;27:1714‑20. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124176
In conclusion, tracheostomy performed in our ICU for long‑term stay patients was associated with lower ICU mortality, but higher in‑hospital rates. Whether the tracheostomy really affects the outcomes of these
Patient care delays due to scene safety Sir, Recently, responding to a 911 call of ‘gunshots fired’, two law‑enforcement officers arrived within a minute and found an unresponsive victim but were unable to allow Emergency Medical Services (EMS) on the scene as a crowd of approximately 30 bystanders became increasingly hostile, both threatening and physically assaulting the officers. Within seven minutes, approximately 20 officers had arrived and the crowd was dispersed. Once the scene was secured, paramedics found a 31‑year‑old male with three gunshot wounds to his chest. The patient maintained palpable pulses until just prior to arrival in the hospital. In the emergency department, the
patient remained pulseless and unresponsive. Bilateral thoracotomies were performed and the patient was found to have penetration of the superior vena cava without injury to the heart. Open cardiopulmonary resuscitation (CPR) with intracardiac epinephrine was performed and massive blood and plasma transfusions were administrated, but the patient could not be resuscitated. It is well established that the response time of EMS has a significant effect on morbidity and mortality for patients with severe medical or traumatic conditions. Although EMS delays in patient care have many different causes, no studies examine delays from safety risks for EMS personnel.
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
287
Letters to the Editor
On‑scene violence and danger is real and not uncommon. Studies of urban EMS systems report violence occurring in 5% of all calls and immediately ending just prior to the arrival of EMS in another 14%.[1,2] When surveyed, 60-90% of EMS providers reported having been assaulted on the job.[3]
goal, decreasing violence ultimately, as a society, is the most effective way of protecting both our patients and ourselves. Jared N. Strote, H Range Hutson1
Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, 1Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
Responding to a shooting, the risks are increased, even if the perpetrator is no longer present. In gang‑related violence, there is, frequently, a risk of further attempts at harming the patient or a retaliatory act. In cities where tensions exist between the public and law enforcement, violence can erupt indiscriminately against all first responders.[4,5] In the case presented here, it is by no means clear whether the patient would have survived if EMS had been on the scene without delay. The case does serve as a reminder, however, that although we know that provider safety should always take precedence, there is no best practice for EMS security. Different EMS systems have facilities ranging from nothing at all to mandated body armor, police escorts, and armored personnel carriers.[3,4] Studies are needed to examine what protocols and systems‑level planning can maximize safety for both patient and provider. Simultaneously, health‑care providers have a responsibility to educate the public about the effects of crowd anger on limiting the access of care to a victim as well as inciting further violence. Although improving care under any circumstances should remain our
288
Address for correspondence: Dr. Jared N. Strote, Division of Emergency Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA. E‑mail: [email protected]
REFERENCES 1. 2. 3. 4. 5.
Grange JT, Corbett SW. Violence against emergency medical services personnel. Prehosp Emerg Care 2002;6:186‑90. Mock EF, Wrenn KD, Wright SW, Eustis TC, Slovis CM. Anxiety levels in EMS providers: Effects of violence and shifts schedules. Am J Emerg Med 1999;17:509‑11. Corbett SW, Grange JT, Thomas TL. Exposure of prehospital care providers to violence. Prehosp Emerg Care 1998;2:127‑31. Eckstein M, Cowen AR. Scene safety in the face of automatic weapons fire: A new dilemma for EMS? Prehosp Emerg Care 1998;2:117‑22. Krebs D. When violence erupts: A survival guide for emergency responders. Sudbury, MA: Jones and Bartlett; 2003. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.124177
International Journal of Critical Illness and Injury Science | Vol. 3 | Issue 4 | Oct-Dec 2013
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
