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Biomedical subjects

R M McNamara

Publications and source records attributed to R M McNamara.

At least 19 recordsLinked to original sources
PubMed1998

Does volume of patients seen in an outpatient setting impact test scores?

BACKGROUND: Methods of teaching surgery in the outpatient setting and means to measure the effectiveness of these methods have not been defined. This study was designed to evaluate the impact of number of outpatient encounters on test scores for third-year medical students. METHODS: Students rotating on the required third-year surgery clerkship between July 1994 and June 1996 kept a log of their activities including number of patients seen in clinic, number of cases scrubbed, and pages read. At the end of the rotation the students were given an essay examination and a multiple-choice examination. The data were analyzed looking for correlation between examination scores and volume of patients seen. United States Medical Licensing Examination (USMLE) Step 1 scores were used as a baseline measure to compare the rotation groups. RESULTS: USMLE scores did not differ between groups. Mean essay examination scores varied significantly between some rotation groups, but did not follow a pattern. There was no correlation between the number of patients seen in clinic and essay examination scores. There was a significant correlation between essay score and USMLE Step 1 score (Pearson's r = 0.398) and between essay and multiple-choice examination scores (Pearson's r = 0.313). There was a significant negative correlation between number of patients seen in clinic and number of cases scrubbed (Pearson's r = -0.347). CONCLUSIONS: Participation in outpatient surgery clinics did not result in improved performance on written examinations in this surgery clerkship. To achieve the most benefit from the outpatient clinic, objectives of the experience need to be determined and appropriate tools used to measure their successful achievement.

Ambulatory Surgical Procedures↗
PubMed1998

Hypothermia from realistic fluid resuscitation in a model of hemorrhagic shock.

STUDY OBJECTIVE: To correlate changes in core body temperature with changes in mean arterial pressure (MAP) and cardiac output (CO) and with the administration of room-temperature intravenous fluids in a clinically relevant large-animal model of uncontrolled hemorrhage. METHODS: Ten swine were subjected to uncontrolled hemorrhage through a flow-monitored shunt placed between the femoral artery and the peritoneal cavity. Animals were randomly assigned to a treatment or a control group. The control group (n=5) received no intravenous fluids. The treatment group (n=5) received 80 mL/kg (3:1 crystalloid/blood loss) ambient-temperature lactated Ringer's solution over a 10-minute resuscitation phase initiated 10 minutes after injury. CO and core body temperature, measured with the use of a pulmonary artery catheter, and MAP were the primary outcomes. We analyzed differences between groups with the use of repeated-measures ANOVA. Change of temperature was analyzed against the change in CO, and against fluid infusion for each interval, by means of regression analysis. RESULTS: The unresuscitated control animals had no change in core temperature despite profound hemorrhagic shock and hypotension. The animals treated with fluids had a mean 2.6 degrees C decrease in core temperature during fluid resuscitation (95% confidence interval [CI], 1.8 to 3.5). A 1.5 degrees C decrease in core temperature (95% CI, .1 to 2.0) persisted at the end of 60 minutes (40 minutes after fluid resuscitation was discontinued). Core temperatures in control animals were 2.8 degrees C lower than those in treated animals after fluid resuscitation (95% CI, .8 to 4.8). Decreases in core temperature correlated with fluid infusion (beta=-35.2 mL/kg x degrees C, R2=.75) and increases in CO (beta=-1.46 L/min x degrees C, R2=.69). CONCLUSION: Ambient-temperature crystalloid resuscitation in a clinically relevant large-animal model of hemorrhagic shock causes small decreases in core body temperature. Resuscitation rather than shock is the main cause of decreased body temperature in this model.

Analysis of Variance↗
PubMed1998

Emergency medicine resident choice of practice location.

STUDY OBJECTIVE: To describe the geographic distribution of practice locations for 1995 emergency medicine residency graduates and factors that are important to residents in their choice of practice location. METHODS: Self-administered questionnaires were distributed to Emergency medicine residents who graduated in 1995. The survey ascertained practice city and state, resident employment characteristics, and the importance of factors that influenced the residents' selection of employment. RESULTS: Eighty-six of 87 programs and 441 (69.4%) of 635 eligible residents participated. Forty-three percent of graduates chose to practice in the city or metropolitan area in which they trained; 46% of these had no personal tie to the area before their residency training. Liking the city was cited as being more important (P<.001) than other factors in picking practice location. Group personality and coworkers' credentials were more important (P< or =.01) than contract and salary arrangement. Twenty percent of respondents were not practicing in the city or area of their first choice. CONCLUSION: Residency training location, regardless of prior ties to the geographical area, appears to be a major factor in the choice of practice location of emergency medicine residency graduates. Coworkers' personalities and credentials are more important factors in job selection than salary and employment arrangements.

Adult↗
PubMed1998

A national survey of board-certified emergency physicians: quality of care and practice structure issues.

The opinions and experiences of board-certified emergency physicians regarding employment structure and finances, professional society policies, and quality of patient care have never been formally studied. A survey questionnaire was sent to a random sample of 1,050 emergency physicians certified by the American Board of Emergency Medicine. The survey contained 29 multiple choice questions. Of the 1,050, 465 (44.3%) of the surveys were returned. Respondents averaged 13.5 years of emergency medicine practice, 83% were members of the American College of Emergency Physicians, and 44% were emergency medicine residency trained. Seventy-five percent felt they had been financially exploited by the emergency department contract holder and 49% considered leaving their employer because of unfair business practices. Fifteen percent have been terminated without due process/peer review, and 11% have been forced to leave a position, move, or pay compensation because of noncompete clauses. The majority reported encountering instances of substandard emergency medical care, most commonly in settings with multihospital contract company coverage. The majority also believe their specialty societies should address issues of employment structure and quality of patient care standards.

Data Collection↗
PubMed1997

Morningness-eveningness preferences of emergency medicine residents are skewed toward eveningness.

OBJECTIVE: To determine the morningness-eveningness (ME) distribution of emergency medicine (EM) residents. METHOD: A voluntary, modified ME questionnaire was administered to all EM residents in the United States at the time of the 1995 American Board of Emergency Medicine's annual In-Training Examination. RESULTS: Seventy-eight percent (2,047/2,614) of the surveys were returned. ME scores ranged from 24 to 76, with a median score of 49 (interquartile range 44, 56). The scores were distributed differently from those of the normal population (p < 0.001), being skewed toward eveningness. There was a correlation (r = 0.13, p < 0.0001) between resident age and ME score, with older residents being more morning-oriented. Males were more morning-oriented than females (p = 0.005), and respondents with children living at home also were significantly more morning-oriented (p < 0.001). Stepwise logistic regression showed that the influence of age, gender, and children was cumulative (r = 0.19) but accounted for only 4% of the observed variability. CONCLUSION: EM residents are distributed differently from the normal population in terms of their ME preferences, tending slightly toward eveningness. The importance of this distribution in EM residents in unknown. A longitudinal follow-up of this cohort may help to determine the association of ME preference with overall practice satisfaction, tolerance of shift work, and career longevity.

Adult↗
PubMed1996

Sudden severe barotrauma from self-inflating bag-valve devices.

Self-inflating bag-valve devices are commonly used for the ventilation of intubated patients, especially during resuscitation and transport. These devices are generally safe, but minor deviations in their recommended use can expose patients to airway pressures greater than 135 cm H2O. We present a patient in whom a sudden tension pneumothorax developed during ventilation with a bag-valve device. We believe that this complication resulted from high airway pressures generated in the bag-valve device. The ability of the device in question to cause barotrauma was confirmed by bench-top measurements of the peak airway pressures generated by minor deviations from proper use of the device.

Barotrauma↗
PubMed1996

A new model of uncontrolled hemorrhage that allows correlation of blood pressure and hemorrhage.

OBJECTIVE: To compare hemodynamics, mortality rates, and bleeding rates at 3 severities of hemorrhage in a new model of uncontrolled intra-abdominal bleeding that uses an injury of varying severity and geometry unfavorable to thrombosis. METHODS: Ten swine were bled through a flow-monitored shunt placed between the femoral artery and the peritoneal cavity. The shunt was connected to catheters of varying diameters placed in the femoral artery to create 3 rates of hemorrhage. Blood flow through the shunt was measured with an in-line Doppler probe. Arterial pressures, cardiac output (CO), and ECGs were monitored. Survival and blood loss were calculated. RESULTS: The model successfully produced 3 hemorrhage severities. At all 3 rates of bleeding, blood flow was linearly related to mean arterial pressure, with R2 > 0.72. Bleeding was continuous in all groups. The mean numbers of minutes until death were 53, 45, and 25, respectively, at the increasing shock severities. Blood pressure (BP) and CO decreased continuously in all groups, but did so more rapidly with increasing severity of hemorrhage. CONCLUSIONS: In this model of uncontrolled hemorrhage, bleeding was continuous and linearly related to BP. The hemodynamic response to uncontrolled bleeding in this model differs markedly from those in previous wire aortotomy models where wound geometry is favorable to thrombosis. Hence, when injury geometry is favorable to thrombosis (as in aortotomy), thrombosis formation affects hemorrhage rates and hemodynamic responses.

Analysis of Variance↗
PubMed1996

Effect of permissive hypotension in continuous uncontrolled intra-abdominal hemorrhage.

OBJECTIVE: To determine the effects of aggressive fluid administration vs permissive hypotension on survival, blood loss, and hemodynamics in a model of uncontrolled hemorrhage in which bleeding has been shown to be continuous. METHODS: In this porcine model, 10 animals were bled through a flow-monitored shunt placed between the femoral artery and the peritoneal cavity. The animals received either no fluid (n = 5) or 80 mL/kg lactated Ringer's solution (n = 5) during a resuscitation phase between 10 and 20 minutes postinjury, followed by a 40-minute evaluation phase. Arterial pressures, cardiac output (CO), and hemorrhage rate were measured. Survival and blood loss were calculated outcome measures. RESULTS: The difference in survival between the animals left hypotensive (40%) and those receiving normotensive resuscitation (20%) was not significant (p = 0.49). In the animals receiving fluid resuscitation, mean arterial pressure (MAP) and CO increased during the resuscitative phase, but all the animals suffered the same pattern of hemodynamic deterioration in the evaluation phase. Rate of hemorrhage during the resuscitative phase was 20 +/- 5 mL/min in the animals not receiving fluid and 56 +/- 9 mL/min in the animals receiving fluids. Total blood loss was subsequently 20 mL/kg greater in the animals receiving fluids than in the animals without fluid resuscitation. CONCLUSIONS: In this model of continuous uncontrolled hemorrhage, the difference in survival between the animals left hypotensive and the animals receiving fluid resuscitation was not statistically significant. Increases in MAP and CO with fluid resuscitation were transient and were offset by larger volumes of blood loss. In contrast to the aortotomy model (where thrombosis is likely and hypotensive resuscitation has proven beneficial), this model suggests that in continuous bleeding avoiding fluid resuscitation has a much smaller effect on outcome. Much of the benefit from hypotensive resuscitation may depend on having an injury that can stop bleeding.

Animals↗
PubMed1995

Requesting consent for an invasive procedure in newly deceased adults.

OBJECTIVE: Ethical concerns exist over the performance of medical procedures, such as endotracheal intubation, on newly deceased patients without family consent. This study examined the process of obtaining consent for the purpose of performing an invasive procedure in newly deceased adults. DESIGN: A prospective case series. PARTICIPANTS: The families of patients who died during a 5-month period were requested to provide consent to perform wire-guided retrograde tracheal intubation. MAIN OUTCOME MEASURES: Differences between success and failure in obtaining consent including information on the decreased, family reasons for their decision, and the experience of those requesting consent. RESULTS: Consent was requested from 44 families and 26 (59%) agreed to the procedure. This success rate was achieved despite the lack of a prior relationship with the family by the persons requesting consent. Consent was obtained more frequently in unexpected than expected deaths (77% vs 41%, P = .03). There were no differences in success rates for consent for age, race, sex, or do-not-resuscitate status of the deceased. Spouses consented more frequently than children (77% vs 50%, P = .25). The two physicians reported greater comfort in requesting consent than the nurse anesthetist investigator. In one instance, the consent process may have increased the emotional distress of the family. CONCLUSION: Consent can frequently be obtained from families for an invasive procedure in newly deceased adults. Physicians should reconsider the practice of performing postmortem procedures without obtaining family consent.

Adult↗
PubMed1995

Effect of gender on the emergency department evaluation of patients with chest pain.

OBJECTIVE: To assess chest pain evaluation as reflected in the documentation of the evaluation process for women vs men in one emergency department (ED). METHODS: In this retrospective case series, patient charts were reviewed for documentation in accordance with a clinical policy for chest pain evaluation. Patient demographics and the frequencies of inclusion of the following items were determined: five descriptors of chest pain, associated symptoms, risk factors for coronary artery disease, receipt of physical examination, and receipt of ECG. RESULTS: Over a three-month period, 132 men and 150 women were evaluated for chest pain and entered in the study. There was no significant difference in age between men and women overall, but in the subgroup of patients who were admitted to the hospital, the women were significantly older than the men by an average of five years (p = 0.04). Fifty-five percent of all the patients were admitted to the hospital. The men were admitted to the hospital significantly more often than were the women (p = 0.01), with a relative risk of admission for women vs men 0.76 (95% CI = 0.62-0.94). There was no significant difference between the men and the women for any of the process of evaluation items in the overall group or in the hospital-admission and release-home subgroups. CONCLUSION: The authors' findings do not support the existence of a gender difference in ED chest pain evaluations, as reflected by documentation of the evaluation process. However, men were more likely to be admitted to the hospital for evaluation of coronary artery disease than were women.

Adult↗
PubMed1994

Clinical characteristics of acute uvulitis.

Previous literature has identified uvulitis as a condition with serious implications. This report details a series of 15 patients with uvulitis whose clinical features were remarkable for a relatively benign course. This is the largest series of patients with uvulitis in the literature. The predominant symptoms were related to sore throat and pain or difficulty on swallowing. No patient had significant airway or infectious complications attributable to the uvulitis. The only patient admitted to the hospital required management of an associated peritonsillar abscess. Of the 14 patients discharged, 13 (93%) were followed-up and none required further care. Seven (50%) of the discharged patients received symptomatic treatment only, whereas the others were treated with medications including antibiotics, corticosteroids, diphenhydramine, and B-agonists. Further research into the etiology and management of uvulitis is warranted.

Acute Disease↗
PubMed1994

Chemical dependency in emergency medicine residency programs: perspective of the program directors.

STUDY OBJECTIVE: To evaluate the educational background, knowledge, and experiences regarding chemical dependency among emergency medicine program directors. The program directors' awareness of substance use and alcohol abuse among emergency medicine residents was examined by comparing their estimates with the actual rates reported by the residents. DESIGN: An anonymous survey mailed in March 1992. TYPE OF PARTICIPANTS: The program directors of all 86 Accreditation Council for Graduate Medical Education-approved emergency medicine residencies. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The 67 responding program directors represented 1,637 (77%) of the 2,130 emergency medicine residents on duty at the time of the survey. Thirty-three (49%) had suspected chemical dependency in a resident at least once, 22 (33%) had identified a chemically dependent resident, and nine (13%) hired a resident known to be in recovery. Substantial percentages reported no or slight knowledge regarding physician impairment issues. Twenty program directors (30%) received no education or only informal education regarding physician impairment. Compared to a February 1992 survey of emergency medicine residents, the program directors' estimates of resident use rates in the past year for seven substances were fairly accurate. However, the program directors estimated that only 16 (1.0%) of their current residents were impaired by alcohol; the resident survey yielded CAGE scores consistent with presumed or suspected alcoholism in 12.5% of emergency medicine residents. CONCLUSION: Emergency medicine program directors must be more attentive to potential alcohol abuse among emergency medicine residents and should receive additional education regarding chemical dependency.

Data Collection↗
PubMed1994

Doxapram reversal of respiratory failure in a patient refusing assisted ventilation.

A 75-year-old man with severe chronic obstructive pulmonary disease and epistaxis experienced progressive respiratory failure after receiving an injection of meperidine and hydroxyzine in preparation for nasal packing. The patient and his family refused endotracheal intubation; despite aggressive medical care, he continued to deteriorate toward an expected fatal outcome. An i.v. infusion of doxapram hydrochloride at 2 mg/min rapidly reversed his downhill course and hypercarbic coma. This case illustrates the potential usefulness of doxapram in the emergency setting. The mechanism of action, indications, dosing methods, and potential side effects of this agent are discussed.

Aged↗
PubMed1993

Intramuscular methylprednisolone acetate for the prevention of relapse in acute asthma.

STUDY OBJECTIVE: To examine the hypothesis that an IM long-acting steroid injection will decrease the relapse rate of asthma patients. DESIGN: A randomized, single-blind, placebo-controlled trial. SETTING: The emergency department of an urban academic medical center. TYPE OF PARTICIPANTS: Acute asthma patients aged 18 to 45 years who were treated successfully in the ED. INTERVENTIONS: Participants received either IM saline placebo or 240 mg methylprednisolone acetate suspension at the time of discharge. MEASUREMENTS AND MAIN OUTCOME: Relapse, defined as the need to seek nonroutine medical care for asthma within seven days of discharge, was the main outcome measure. Of 70 patients entered, 56 (80%) completed follow-up, including 30 in the steroid group and 26 in the placebo group. The groups had similar characteristics and peak expiratory flow values on arrival and at discharge. Relapse occurred in two steroid patients (6.7%) and eight placebo recipients (30.8%) (P < .05). There was one death in the placebo group. Reported side effects were similar. CONCLUSION: IM long-acting steroids reduced the rate of relapse in patients with acute asthma.

Adolescent↗
PubMed1993

Reduction of anterior shoulder dislocations by scapular manipulation.

STUDY OBJECTIVES: This study examined the success rate, time required, technical ease, and reported patient discomfort for the use of scapular manipulation in the reduction of anterior shoulder dislocation. This study included a new variation of this technique using the seated position. DESIGN: Prospective case series over a 19-month period. SETTING: The emergency departments of a university and a community hospital. TYPE OF PARTICIPANTS: Patients with anterior shoulder dislocations. INTERVENTIONS: Emergency medicine resident and attending physicians were instructed in the technique of scapular manipulation in a classroom setting and requested to use this method initially for the reduction of anterior shoulder dislocations. Premedication was at the physician's discretion. MEASUREMENTS AND MAIN RESULTS: There were 54 patients with 61 dislocations. Scapular manipulation was attempted by 19 residents and 12 attending physicians. The overall success rate of scapular manipulation was 79%, whereas that of physicians experienced with the technique was 86%. Of the successful reductions, 65% were performed in less than one minute, and physicians rated the technique as very easy or easy to perform in 74% of these cases. No premedication was used in 64% of the attempts at scapular manipulation, and these patients reported pain ratings similar to those of the premedicated groups. No complications were noted in this study. CONCLUSION: Scapular manipulation generally is a simple, rapid, and reliable technique for the reduction of anterior shoulder dislocation.

Adolescent↗