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Biomedical subjects

R E Fromm

Publications and source records attributed to R E Fromm.

At least 37 records · Page 2Linked to original sources
PubMed1996

Burnout in the internist--intensivist.

OBJECTIVES: Caring for acutely ill patients imposes significant demands on physicians. The environment and stresses of the ICU may lead to the burnout syndrome. The purpose of this study was to evaluate the prevalence of burnout among internal medicine intensivists and the contributing factors present in ICU practice. DESIGN: Mailed survey utilizing the Maslach Burnout Inventory (MBI). Increasing burnout has been shown to be associated with low levels on personal achievement and high scores on depersonalization and emotional exhaustion. SUBJECTS: Random sample of members of the Internal Medicine Section of the Society of Critical Care Medicine. MEASUREMENTS AND MAIN RESULTS: 248 people responded: 220 (88.7%) males and 28 females. Mean age of all respondents was 41.6 +/- 6.7 years. The majority (58.1%) worked in large hospitals (> 400 beds); 55.6% devoted more than 50% of their time to critical care. The emotional exhaustion subscale of the MBI averaged 22.2 +/- 9.5, with a third of respondents scoring in the high range. The depersonalization score averaged 7.1 +/- 5.1%, with 20.4% of respondents scoring in the high range. Similarly personal achievement subscores were poor, with a mean value of 30.9 +/- 6.4%, with 59% scoring in the low range. High levels of emotional exhaustion were associated with anticipating leaving critical care before retirement. CONCLUSIONS: Burnout as measured by the MBI appears to be common in internal medicine intensivists. High levels of emotional exhaustion and depersonalization are related not only to patient care issues but also to a poor support system.

Adult↗
PubMed1996

In-hospital resuscitation among the elderly: substantial survival to hospital discharge.

The appropriateness of aggressive resuscitation in many clinical settings has been questioned. Survival rates from cardiac arrest in the elderly are generally reported as poor, and satisfactory results from resuscitation attempts prolonged beyond 15 minutes are said to be rare. It was the purpose of this study to examine success rates for resuscitation in a cohort of elderly inpatients suffering cardiac arrest. We retrospectively reviewed 213 consecutive cardiac arrests occurring during a 12-month period in a large tertiary private hospital. Patient age, presenting rhythm, and survival to hospital discharge were recorded. Elderly was defined as 70 years or older. Cardiac arrests in the elderly totaled 89. Average age in this cohort was 76.2 +/- 4.5 years. Eighteen patients (20.2%) had return of spontaneous circulation and 8 patients survived to hospital discharge (44.4% of those with return of spontaneous circulation). No significant difference in age or presenting rhythm of survivors versus nonsurvivors could be demonstrated, although a trend to more frequent ventricular fibrillation or ventricular tachycardia was seen (P = .059, Fisher's exact). Time for resuscitation averaged 25.75 +/- 9.2 minutes for survivors and 32.6 +/- 22.1 minutes for nonsurvivors. Survival to hospital discharge occurs in 9% of in-hospital cardiac arrests in the elderly following average CPR times substantially in excess of 15 minutes.

Age Factors↗
PubMed1996

Hypertensive crises. The need for urgent management.

Although hypertensive crises are now relatively uncommon, they often are life-threatening when they do occur and demand early recognition and management to minimize morbidity and mortality. Most patients have essential hypertension, and withdrawal from an antihypertensive drug is the most common cause of acute elevation of blood pressure. Short-acting parenteral agents are generally recommended for management of hypertensive crises. In most patients with hypertensive emergencies, the mean arterial pressure is lowered 25% over 2 to 4 hours. Both cerebral and coronary hypoperfusion must be avoided.

Acute Disease↗
PubMed1995

Fish scale: an unusual foreign body.

Retained foreign bodies can be a source of infection and a cause of disability. A 63-year-old white man presented with a nonhealing wound of the right second finger of 1 month's duration. The injury occurred while cleaning fish. Radiographs and subsequent wound exploration showed a retained fish scale in a finger wound. In addition to foreign bodies, atypical infectious organisms must be considered in nonhealing wounds associated with fish or water.

Finger Injuries↗
PubMed1995

Comparison of the effect of intermittent administration and continuous infusion of famotidine on gastric pH in critically ill patients: results of a prospective, randomized, crossover study.

OBJECTIVES: To compare the effects of intermittent intravenous administration and continuous intravenous infusion of famotidine on gastric pH in critically ill patients. DESIGN: A prospective, randomized, crossover study of continuous infusion and bolus administration of famotidine in critically ill patients. SETTING: A 14-bed medical intensive care unit (ICU) of a 500-bed county hospital. PATIENTS: Medical ICU patients requiring stress ulcer prophylaxis. INTERVENTIONS: Patients were randomized to receive an equivalent dose of famotidine by continuous infusion or intravenous bolus for 24 hrs, and then were crossed over to the other arm of the study. MEASUREMENTS AND MAIN RESULTS: Critically ill patients who met the inclusion criteria were randomly assigned to receive famotidine 20 mg i.v. over 10 mins, every 12 hrs or a continuous infusion of 1.7 mg/hr for 24 hrs. After a 16-hr washout period, patients crossed over to the other arm of the study. Gastric pH was monitored continuously for 24 hrs. A total of 710 gastric pH measurements were obtained for each phase of the study. The mean area under the pH-time curve for a 24-hr period was higher for continuous infusion than bolus administration (p = .05). Continuous infusion of famotidine maintained a gastric pH of > or = 4 over a longer time period than bolus administration (20.8 hrs vs. 12.6 hrs, respectively; p < .01). Onset of therapeutic gastric pH for continuous infusion was slightly delayed as compared with bolus administration. CONCLUSIONS: Continuous infusion of famotidine is more effective than an equivalent dose given by intermittent bolus in maintaining the appropriate gastric pH necessary for prevention of stress ulceration. Delayed onset of effect may warrant a priming dose when famotidine is given by continuous infusion.

Adult↗
PubMed1995

CPAP machine performance and altitude.

UNLABELLED: STUDY RATIONALE AND OBJECTIVE: Sleep-disordered breathing is commonly treated with nasally applied continuous positive airway pressure (CPAP). Typically, pressures are titrated to pneumatically splint the airway to prevent its collapse in response to negative inspiratory pressure. This investigation was prompted by several patient complaints of sleep-related breathing difficulty associated with travel to high altitudes. CPAP devices create pressure with fan-generated airflow; therefore, CPAP performance should behave according to collective fan laws. MEASUREMENTS AND RESULTS: In the present study, we examined the effect of simulated altitude change on four commercially available CPAP machines. Machines were tested using anatomic airway mannequins in an altitude chamber. We made three simulated ascents to 12,000 feet with machines set at 5, 10, and 12 cm H2O sea level pressure equivalents. We measured pressure using water manometers at 2,000-foot increments during ascent and descent. Mask pressures varied systematically with changing altitude in three machines. One machine, equipped with a pressure regulation feature, maintained pressure within 1 mm H2O at all pressure and altitude combinations. CONCLUSIONS: Altitude significantly alters delivered pressure according to predictions made by the fan laws, unless a unit has pressure-compensating features. Clinicians should consider this factor when CPAP is prescribed for patients who live or travel to places located at significantly higher or lower elevations than the titration site.

Altitude↗
PubMed1995

Inadequacy of visual alarms in helicopter air medical transport.

BACKGROUND: Air medical programs use medical equipment primarily designed for hospital and/or ground transport settings. Many of these medical devices are equipped with auditory alarms of malfunction or deteriorating clinical status. The high ambient noise requires visual scanning of medical devices to detect alarm conditions in the helicopter cabin. PURPOSE: To evaluate the adequacy of visual scanning for alarm conditions in the helicopter air medical environment. METHODS: The helicopter transport program used in this study is staffed with two medical crewmembers. Flight nurse response time (RT) to a visual alarm was assessed during 25 air medical patient flights. RT was measured using a battery powered dual timer device with a red LED visual alarm placed in a fixed position among the medical instruments. The device was activated at a random time point unknown to the medical crew during each patient flight. RT was defined as the elapsed time from activation of the alarm until it was physically switched off by the flight nurse. RESULTS: RT was surprisingly lengthy for the study population with a mean RT of 81.2 +/- 78.4 s (95% CI 48.8-113.5 s). The variability of RT was also surprising ranging from 3 s to > 5 min. CONCLUSION: RT to visual alarms in the air medical environment is lengthy and quite variable. Recognition of malfunction of medical equipment or early signs of clinical instability prior to clinical deterioration cannot be assured by visual scanning for alarm conditions. Alternative alarming systems should be considered and investigated for air medical transport.

Air Ambulances↗
PubMed1995

Recognition, assessment, and treatment of anxiety in the critical care patient.

A multidisciplinary group of experts involved in the treatment of critically ill patients participated in a workshop conference designed to develop practice recommendations for the recognition, assessment, and treatment of anxiety in the critical care environment. Anxiety was identified as a ubiquitous problem in critical care that may interfere with healing and recovery. The faculty agreed that clinicians should be familiar with the signs and symptoms of anxiety and should be able to determine when interventions are necessary. Whenever possible, nonpharmacologic methods for anxiolysis should be incorporated into intensive care protocols. Intensive care personnel should be trained in those interventions that require specialized expertise, and they should become familiar with the drugs available for the treatment of anxiety. Protocols for determining the best agents to be used in a given setting and their most appropriate method of administration should be established. Pharmacologic and nonpharmacologic treatments are not mutually exclusive but should be complementary. Finally, procedures for obtaining psychiatric consultation, when necessary, should be in place.

Adaptation, Psychological↗
PubMed1994

Emergency department procedures and length of stay for critically ill medical patients.

STUDY OBJECTIVE: To date, the study of critical illness in the emergency department has been limited. The purpose of this study was to determine the ED length of stay and procedures performed in medical critical care patients. DESIGN: Descriptive study of a prospective single cohort. SETTING: Large urban public hospital. TYPES OF PARTICIPANTS: Fifty consecutive ED patients subsequently admitted to the medical ICU. MEASUREMENTS AND MAIN RESULTS: The study population consisted of 24 women and 26 men. The mean ED stay was 284.5 +/- 212.6 minutes (median, 255 minutes; interquartile range [IQR], 115 to 355 minutes). Patients remained in the ED after administrative transfer of their care to the medical ICU an average of 75 +/- 71.4 minutes (range, 10 to 375 minutes; median, 50 minutes; IQR, 25 to 105 minutes). Forty-one of these patients (82%) received one or more critical care procedures. The mean time to performance of first procedure was 92.8 +/- 180.6 minutes (median, 23 minutes; IQR, 11 to 82 minutes) from ED arrival. Death after ICU admission occurred in 11 patients. Mean ED length of stay was 291 +/- 269.8 minutes (range, 35 to 980 minutes; median, 135 minutes; IQR, 85 to 467 minutes) in nonsurvivors, and 91% of them received procedures in the ED. Survivors averaged 282.4 +/- 193.4 minutes (range, 15 to 230 minutes; median, 263 minutes; IQR, 126 to 355 minutes) (P = NS) and 79.5% (P = NS) received ED procedures. CONCLUSION: Critically ill patients spend a substantial amount of time in the ED before transfer to the ICU. Typical ICU procedures are commonly performed. Further study of the impact on patient outcome of ED stay and the procedures performed in critically ill medical patients should be conducted.

Adult↗
PubMed1994

Equivalence of litmus paper and intragastric pH probes for intragastric pH monitoring in the intensive care unit.

OBJECTIVE: To compare the accuracy of litmus paper-determined gastric pH to a nasogastric graphite antimony pH probe. DESIGN: A prospective clinical trial of gastric pH determination in patients enrolled in a study of histamine-2-receptor (H2) antagonists. SETTING: The medical intensive care unit (ICU) of a 450-bed county hospital. PATIENTS: Critically ill ICU patients requiring stress ulcer prophylaxis. INTERVENTIONS: Using a crossover design, the patients were randomized to initially receive an H2 antagonist by continuous infusion or intravenous bolus, and subsequently were crossed over to the other limb of the study. MEASUREMENTS AND MAIN RESULTS: Gastric pH was determined using pH-sensitive litmus paper at the initiation of each limb of the study and at 1, 2, 4, and 8 hrs after the initiation of H2 receptor antagonist therapy. In addition, gastric pH was continuously determined over the same time period utilizing a graphite antimony pH probe. Gastric pH measurements determined with litmus paper and intragastric pH probes demonstrated an excellent correlation (r2 = .93, p < .001). McNemar's test of correlated proportions could not demonstrate a significant difference between the two monitoring methods (chi-square = 0.5, p > .47), and the kappa statistic (0.95, p < .001) demonstrated excellent concordance. Bias measurement was 0.01 (95% confidence interval = -0.155 to 0.176). CONCLUSIONS: Measurement of intragastric pH, using pH-sensitive litmus paper, is both sensitive and specific when utilizing a graphite antimony nasogastric pH probe as a reference standard. Litmus paper-determined gastric pH testing is both easy to perform and inexpensive. Therefore, based on the current data, we believe this technique (i.e., litmus paper determined gastric pH testing) to be the method of choice for determination of intragastric pH in patients at risk for stress gastric ulcers in the medical ICU.

Adult↗
PubMed1994

Acute exacerbations of obstructive lung disease. What to do when immediate care is crucial.

Obstructive lung disease is a major cause of morbidity and mortality in the United States, and the mortality rate is rising. Successful treatment of acute exacerbations begins with appropriate assessment and intervention. Supplemental oxygen is appropriate for all patients with hypoxemia, and mechanical ventilation should be considered in those with clouded consciousness, profound acidosis, or severe hypoxemia. Inhaled beta 2 agonists are the first line of therapy in acute exacerbations. Anticholinergics, methylxanthines, and corticosteroids may also be useful. Alternative therapies (eg, magnesium, glucagon, calcium channel blockers, clonidine, helium) are receiving increased attention and are undergoing investigation.

Acute Disease↗
PubMed1993

Inadvertent administration of rtPA to a patient with type 1 aortic dissection and subsequent cardiac tamponade.

Administration of thrombolytic agents to patients with misdiagnosis of acute myocardial infarction can result in serious side effects. A case of aortic dissection that was misdiagnosed as acute myocardial infarction and received rtPA is reported. Within 1 hour of rtPA infusion, the patient developed cardiac tamponade. Type 1 aortic dissection was diagnosed by aortic angiogram. The patient underwent emergency resection of the dissection and evacuation of the pericardial and anterior mediastinal hematoma. Although he required massive transfusion of blood products intraoperatively, he is doing well 22 months after his surgery.

Aged↗
PubMed1993

Discrepancy in resuscitation beliefs among physicians at various levels of training.

Having previously described some of the attitudes of health care providers toward resuscitation for themselves, based on an individual's beliefs about the likelihood of success of cardiopulmonary resuscitation (CPR), the differences among attitudes of physicians at different levels of training have now been assessed. A multi-question survey was sent to medical students, house officers, and attending physicians at two university medical centers. Sociodemographic information, questions regarding beliefs about outcome after CPR, and personal desires were included. Respondents were asked to identify the clinical condition carrying the worst prognosis during cardiac arrest from among: metastatic cancer (MC), end-stage renal disease (ESRD), acquired immunodeficiency syndrome (AIDS), sepsis, and myocardial infarction (MI), and to specify their resuscitation desires should they be affected by these conditions. The preferences of each group regarding resuscitation given their least favored diagnosis were assessed using chi 2 analysis of trends for binomial proportions. Approximately 186 questionnaires were evaluated and consisted of 90 by medical students (MS), 67 by house officers (HOs), and 29 by attending physicians (APs). Resuscitation desires for each diagnosis were MC, 7 of 40; ESRD, 8 of 34; AIDS, 10 of 74; sepsis, 10 of 15; and MI, 20 of 23. chi 2 test for trend of desire to be resuscitated from the self-selected worst prognostic category by level of training demonstrated no significant decrease in desire to be resuscitated with increasing level of training. Physician's beliefs about CPR may be influenced by their experiences with particular patients and events.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗
PubMed1993

Cardiopulmonary resuscitation. New and controversial techniques.

Primary care physicians may need to perform cardiopulmonary resuscitation (CPR) from time to time. Knowledge regarding CPR has become extensive, and it is hoped that greater success will be achieved in the future with the advent of new methods. A number of techniques and devices have received attention in the lay and professional press. If appropriate care is to be delivered, practicing physicians must be aware of what is proven technology and what is investigational.

Cardiopulmonary Bypass↗
PubMed1993

Critical care in the emergency department: a time-based study.

OBJECTIVES: Emergency departments serve many functions in the current U.S. healthcare system, including initial management of patients with critical illnesses and primary care for a growing proportion of the population. Overcrowding of emergency departments is a growing problem. Delays in admitting patients to inpatient units have been reported as a contributing factor to overcrowding. To date, the effect of the critically ill patients on the emergency department has not been fully described. It was the purpose of this study to examine the incidence of critical illness in the emergency department and its total burden as reflected in emergency department length of stay. DESIGN: Prospective, cohort study in 17,900 emergency department patients. SETTING: Single, not-for-profit teaching hospital. PATIENTS: All patients admitted to the emergency department during the period of April 1, 1991 to March 31, 1992. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Date and time of arrival in the emergency department and time of discharge, death, or admission to an inpatient unit were recorded. Patients admitted to intensive care units/special care units from the emergency department were defined as critically ill. All other patients were classified as noncritically ill. Emergency department length of stay was calculated as the time from arrival in the emergency department until discharge, death, or admission to an inpatient unit. Differences in length of stay were determined using Kruskal-Wallis analysis by ranks. The study population totaled 17,900 patients: 8.5% (n = 1,527) critically ill patients, 61.1% (n = 10,930) discharged patients, and 30.4% (n = 5,443) noncritically ill admitted patients. Mean emergency department length of stay for the critically ill patients was 145.3 +/- 89.6 mins (maximum length of stay, 655 mins), and for the noncritically ill patients, mean stay was 153.1 +/- 91.9 mins (maximum length of stay, 781 mins) (p < .0003). During the study period, 154 patient-days of emergency department critical care were provided. CONCLUSIONS: Critically ill patients constitute an important proportion of emergency department practice and may remain in the emergency department for significant periods of time. Solutions to emergency department overcrowding may include alternatives for continuing management of critically ill patients. Given the realities of emergency department practice, emergency medicine practitioners should receive training in the continuing management of critically ill patients.

Cohort Studies↗