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Biomedical subjects

T A Schmidt

Publications and source records attributed to T A Schmidt.

At least 55 records · Page 3Linked to original sources
PubMed1993

Human skeletal muscle digitalis glycoside receptors (Na,K-ATPase)--importance during digitalization.

The aims of the present study were to evaluate in humans the putative importance of skeletal muscle digitalis glycoside receptors (Na,K-ATPase) in the volume of distribution of digoxin and to assess whether therapeutic digoxin exposure might cause digitalis receptor upregulation in skeletal muscle. Samples of the vastus lateralis were obtained postmortem from 11 long-term (9 months to 9 years) digitalized (125-187.5 micrograms daily) and eight undigitalized subjects. In intact samples from digitalized patients, vanadate-facilitated 3H-ouabain binding increased 15% (p < 0.02) from 150 +/- 18 to 173 +/- 13 pmol/g wet wt. (mean +/- SEM) after clearing receptors of bound digoxin by washing samples in excess specific digoxin antibody fragments. 3H-ouabain binding in the untreated group was 257 +/- 28 and 274 +/- 26 pmol/g wet wt. (7%, p > 0.30) before and after washing in specific digoxin antibody fragments, respectively. Thus, the present study indicates a approximately 13% occupancy of skeletal muscle digitalis glycoside receptors with digoxin during digitalization. In light of the large skeletal muscle contribution to body mass, this indicates that the skeletal muscle Na,K-ATPase pool constitutes a major volume of distribution for digoxin during digitalization. The results gave no indication of skeletal muscle digitalis glycoside receptor upregulation in response to digoxin treatment. On the contrary, there was evidence of significantly lower (37%, p < 0.005) digitalis glycoside receptor concentration in the vastus lateralis of the digitalized patients, which may be of importance for skeletal muscle incapacity in heart failure.

Aged↗
PubMed1993

Job satisfaction of paramedics: the effects of gender and type of agency of employment.

STUDY OBJECTIVES: To document specific factors important in paramedic job satisfaction and job performance. DESIGN AND TYPE OF PARTICIPANTS: A cohort analysis sampled 63 male public-agency paramedics and 131 private-agency paramedics (90 male, 41 female). METHODS: Three scales from the Michigan Organizational Assessment Questionnaire measured total job satisfaction. A four-item scale assessed attitudes toward paramedic job performance. RESULTS: Fire paramedics reported highest levels of overall satisfaction, followed by male and female private-agency paramedics. Fire paramedics reported higher levels of intrinsic job satisfaction (eg, opportunity to learn new things) than private-agency paramedics. Differences in extrinsic job satisfaction (eg, pay, benefits) were even greater between fire paramedics and private-agency paramedics. Fire paramedics reported higher satisfaction than female private-agency paramedics with the social rewards of work (eg, the way they are treated by their coworkers). These findings were not explained by age, race, education level, and years on the job. Analysis of the attitudes toward paramedic job performance scale suggested that male paramedics are more likely to believe that female paramedics are not as capable of performing certain job functions. CONCLUSION: Type of agency and gender affect job satisfaction. Male public-agency paramedics are most satisfied, and female private-agency paramedics are least satisfied with their jobs.

Adult↗
PubMed1993

Sprint training increases human skeletal muscle Na(+)-K(+)-ATPase concentration and improves K+ regulation.

This study investigated the effects of sprint training on muscle Na(+)-K(+)-adenosinetriphosphatase (ATPase) concentration, plasma [K+] regulation, muscle performance, and fatigue during severe intermittent exercise. Six untrained male subjects underwent intensive cycle-sprint training for 7 wk. Muscle biopsies were taken at rest from the vastus lateralis muscle before and after 7 wk of training and were assayed for Na(+)-K(+)-ATPase concentration using vanadate-facilitated [3H]ouabain binding to intact samples. Before and after the training period, subjects performed four maximal 30-s exercise bouts (EB) on a cycle ergometer, each separated by a 4-min recovery. Arterialized venous blood samples were drawn immediately before and after each sprint bout and were analyzed for plasma [K+]. The work output was significantly elevated (11%) across all four EBs after training. The muscle [3H]ouabain binding site concentration was significantly increased (16%) from 333 +/- 19 to 387 +/- 15 (SE) pmol/g wet wt after training but was unchanged in muscle obtained from three control subjects. Plasma [K+] rose by 1-2 mmol/l with each EB and declined rapidly by the end of each recovery period. The increases in plasma [K+] resulting from each EB were significantly lower (19%) after training. The ratios of rise in plasma [K+] relative to work output during each EB were also significantly lower (27%) after training. The increased muscle [3H]ouabain binding site concentration and the reduced ratio of rise in [K+] relative to work output with exercise are both consistent with improved plasma and skeletal muscle K+ regulation after sprint training.

Adolescent↗
PubMed1992

Na,K-ATPase expression in normal and failing human left ventricle.

The expression of the Na,K-ATPase was studied in both normal and failing human myocardium which was collected within 5 min of cardiac explantation in preparation for orthotopic transplantation or at the time of organ harvest. Abundance of mRNA for all three catalytic alpha subunits of the Na,K-ATPase was analyzed in samples from patients with end-stage heart failure due to either ischemic or dilated cardiomyopathy, as well as from normal controls. Vanadate facilitated 3H-ouabain binding before and after a Digibind wash was analyzed on tissue from a subset of these patients. mRNA analysis demonstrated that all three catalytic Na,K-ATPase alpha subunits were expressed in human heart and that there was no evidence for change in relative expression or abundance induced by disease. The specific digitalis receptor concentration was 760 +/- 58 and 614 +/- 47 pmol/g wet weight in the samples from normal and failing hearts, respectively (p = NS). From these studies it can be concluded that, whereas there is a tendency for a decrease in the number of ouabain receptors in heart failure, there is no significant alteration in the expression of Na,K-ATPase message or protein caused by chronic heart failure.

Binding Sites↗
PubMed1992

Quantification of rat cerebral cortex Na+,K(+)-ATPase: effect of age and potassium depletion.

Na+,K(+)-ATPase concentration in rat cerebral cortex was studied by vanadate-facilitated [3H]ouabain binding to intact samples and by K(+)-dependent 3-O-methylfluorescein phosphatase activity determinations in crude homogenates. Methodological errors of both methods were evaluated. [3H]Ouabain binding to cerebral cortex obtained from 12-week-old rats measured incubating samples in buffer containing [3H]ouabain, and ouabain at a final concentration of 1 x 10(-6) mol/L gave a value of 11,351 +/- 177 (n = 5) pmol/g wet weight (mean +/- SEM) without any significant variation between the lobes. Evaluation of affinity for ouabain was in agreement with a heterogeneous population of [3H]ouabain binding sites. K(+)-dependent 3-O-methylfluorescein phosphatase activity in crude cerebral homogenates of age-matched rats was 7.24 +/- 0.14 (n = 5) mumol/min/g wet weight, corresponding to a Na+,K(+)-ATPase concentration of 12,209 +/- 236 pmol/g wet weight. It was concluded that the present methods were suitable for quantitative studies of cerebral cortex Na+,K(+)-ATPase. The concentration of rat cerebral cortex Na+,K(+)-ATPase showed approximately 10-fold increase within the first 4 weeks of life to reach a plateau of approximately 11,000-12,000 pmol/g wet weight, indicating a larger synthesis of Na+,K+ pumps than tissue mass in rat cerebral cortex during the first 4 weeks of development. K+ depletion induced by K(+)-deficient fodder for 2 weeks resulted in a slight tendency toward a reduction in K+ content (6%, p > 0.5) and Na+,K(+)-ATPase concentration (3%, p > 0.4) in cerebral cortex, whereas soleus muscle K+ content and Na+,K(+)-ATPase concentration were decreased by 30 (p < 0.02) and 32% (p < 0.001), respectively. Hence, during K+ depletion, cerebral cortex can maintain almost normal K+ homeostasis, whereas K+ as well as Na+,K+ pumps are lost from skeletal muscles.

Aging↗
PubMed1991

Rebound cue state following a single dose of haloperidol.

It has been reported that chronic administration of haloperidol produces an amphetamine-like rebound cue state. The experiments reported here were designed to assess whether a similar rebound phenomenon would result from a single dose of haloperidol. Rats were trained to discriminate .5 mg/kg amphetamine from distilled water. Five groups were formed to allow testing of haloperidol's effect at 12, 18, 24, 30, and 36 hr postinjection. Each animal was given 0, .5, 1.0, and 1.5 mg/kg haloperidol at its appropriate injection time in a counterbalanced fashion with one week between each test. A shift in the dose-response function of amphetamine that occurred during these weeks, however, precluded appropriate analysis of haloperidol's effects. Given this result, a second experiment was conducted using a between-subjects design. Half of the animals were injected with 1 mg/kg haloperidol 23 hr prior to testing, whereas the others were injected with distilled water. When tested, the haloperidol group responded 33% of the time on the amphetamine-correct lever, whereas the control group responded at 20%. The observation of posthaloperidol rebound in the between-subjects study and the failure to find significant temporal patterns of rebound phenomena using a within-subjects design have both theoretical and methodological importance.

Amphetamine↗
PubMed1991

No upregulation of digitalis glycoside receptor (Na,K-ATPase) concentration in human heart left ventricle samples obtained at necropsy after long term digitalisation.

STUDY OBJECTIVE: The aim was to evaluate the hypothesis that digitalis glycosides increase the concentration of their specific receptor (Na,K-ATPase) in human myocardial tissue, thereby possibly reducing the inotropic effect of long term digitalis treatment. DESIGN: Intact samples of left ventricle were obtained at necropsy from patients who had been on long term treatment with digoxin and from patients not previously given digoxin. Digitalis glycoside receptors were quantified using vanadate facilitated 3H-ouabain binding before and after washing samples in buffer containing excess digoxin antibody fragments for 16 h at 30 degrees C. This washing procedure has previously been shown to reduce prior specific digoxin binding in human left ventricle by 95% and to allow subsequent vanadate facilitated complete quantification of 3H-ouabain binding sites. In this context it was performed to reduce occupancy of digitalis glycoside receptors by digoxin, caused by digitalisation before 3H-ouabain binding. SUBJECTS: 11 patients who had been on long term treatment with digoxin and eight who had not previously been given digoxin were studied. Left ventricle samples were obtained at necropsy at around 15 h after death. MEASUREMENTS AND MAIN RESULTS: Standard 3H-ouabain binding was 39% less in samples from digitalised than from undigitalised subjects (p less than 0.001). Washing samples in buffer containing excess digoxin antibody fragments induced an increase in 3H-ouabain binding from 174(SEM 10) to 265(20) pmol.g-1 wet weight (n = 11, p less than 0.001) in samples from digitalised patients. After washing, the digitalis glycoside receptor concentration in left ventricle samples showed a tendency to a lower value (14%, p greater than 0.10) in patients exposed to digoxin compared to left ventricle samples from individuals unexposed to digitalis glycoside treatment. Calculating 3H-ouabain binding relative to dry ventricular muscle weight confirmed the results obtained using wet weight as reference. CONCLUSIONS: The results suggest that digoxin treatment in life is associated with a 34% occupancy of digitalis glycoside receptors with digoxin. In the human heart there was no evidence for upregulation of digitalis glycoside receptor concentration due to long term digitalisation. Thus at receptor level there was no evidence for development of tolerance to digoxin therapy. The lower digitalis glycoside receptor concentration in the left ventricle observed in the heart failure patients may support the report of a relationship between Na,K-ATPase concentration as evaluated by 3H-ouabain binding and left ventricular function.

Aged↗
PubMed1991

Enhanced clearance of specifically bound digoxin from human myocardial and skeletal muscle samples by specific digoxin antibody fragments: subsequent complete digitalis glycoside receptor (Na,K-ATPase) quantification.

The effect of digoxin antibody fragments (Fab) on clearance of specifically bound digoxin from its specific receptor (Na, K-ATPase) was studied in human heart left ventricle (LV) and vastus lateralis skeletal muscle (SK) samples obtained postmortem. Initially, [3H]digoxin was bound to samples at conditions giving high relative occupancy of receptor. Half-life (t1/2) for its net release from LV in buffer was 32.2, 6.7, and 0.9 h at 0 degrees, 30 degrees, and 37 degrees C, respectively. For SK, t1/2 was 5.4 h in buffer at 30 degrees C. Inhibition of rebinding of digoxin by addition of specific digoxin Fab (5 x 10(-7) M) or excess unlabeled digoxin (1 x 10(-4) M) to buffer at 30 degrees C increased net release rate for specifically bound digoxin 2.5- to 3.0-fold in heart and SK. [3H]Digoxin was also bound to samples at conditions giving low relative occupancy. Samples were subsequently washed in buffer containing 5 x 10(-7) M specific digoxin Fab for 16 h at 30 degrees C. This wash reduced occupancy of receptors by digoxin from 10 to 0.5% in LV and from 9 to 0.3% in SK, respectively. At variance with wash at 37 degrees C, this procedure allowed subsequent vanadate-facilitated complete quantification of Na,K-ATPase by [3H]ouabain binding; values were 378 +/- 13 and 370 +/- 12 pmol/g wet weight (p greater than 0.6) in LV and 309 +/- 19 and 315 +/- 16 pmol/g wet weight (p greater than 0.7) in SK with and without previous wash, respectively (mean +/- SEM, n = 12).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Emergency physicians' responses to families following patient death.

Responses of emergency physicians when they interact with families after a death and their subsequent contact with survivors were examined. Questionnaires were sent to 138 Oregon emergency physicians and completed by 114 (83%). The number of deaths (mean +/- SD) encountered by emergency physicians was 17 +/- 15 per year. The majority of physicians (76%) usually notified the family in person and spent an average of 15 +/- 11 minutes with the family. Subsequent contact with survivors, such as sending sympathy cards, making follow-up calls, or reporting autopsy results, was relatively infrequent. While 94% of our sample group reported a need for training in this area, less than one half received any training during medical school or residency. We suggest implementation of educational programs for physicians and development of outreach programs for survivors.

Attitude to Death↗
PubMed1975

On slit-lamp microscopy.

Theoretically the contact lens with a refractive power of -64 dioptres is superior to the concave pre-set lens (Hruby lens) or the convex lens (Bayadi). In practice the results are as follows: With the convex lens the examination of the vitreous is unsatisfactory. The reversed image with the convex lens will become familiar with some experience as one will also get used to the mirror images of the three-mirror contact lens. However, the abnormal curvature of the image is really a nuisance. On the other hand the large field of view is an advantage. The convex lens is only practically useful when it can be firmly attached to the slit-lamp microscope, as otherwise the new adjustment necessary for searching the fundus is too difficult. Attachment to the microscope is also of advantage with the Hruby lens. The concave contact lens of 64 dioptres is best suited for detailed examination of vitreous and fundus and for measurements. When no value is placed on a minute examination and a quick simple orientation suffices, the concave pre-set lens (Hruby lens) has the advantage that the lens does not have to be placed on the eye. If it is centred to the middle axis of the microscope, it facilitates especially quick observation. There will be cases where the pre-set lens will be the only answer, especially shortly after an operation or with very sensitive patients. Furthermore, the Hruby lens is preferable to the Bayadi lens because the vitreous can be better examined. The Hruby lens is also advantageous for examination of the region in the middle, lateral periphery of the fundus, 30 degrees - 60 degrees, and is superior in this area to the simple concave contact lens. The Bayadi lens seems to us only indicated for fundus examination of extremely high myopes. There it definitely offers advantages over and above the concave lens. For the most peripheral fundus, expecially below and above, the three-mirror lens with its modification is so far the best method. Especially for examination of the vitreous good brightness of the slit image is required for stereoscopic examination with as large an angle as possible between microscope and illumination. The lateral parts of the most peripheral fundus cannot be examined with the vertical slit in connection with the three-mirror lens. However, this is possible with the horizontal and tilted position of the slit and intermediate positions with an oblique slit. The slit must form an angle with the microscope in order to examine vitreous and fundus in optical section. With the indentation contact lenses ciliary processes and pars plana are now accessible to slit-lamp microscopy.

Fundus Oculi↗
PubMedDate not supplied

Reduced 3H-ouabain binding site (Na,K-ATPase) concentration in ventricular myocardium of dogs with tachycardia induced heart failure.

The present study evaluates 3H-ouabain binding site (Na,K-ATPase) concentration in left ventricular myocardium of dogs with heart failure induced by tachycardia as a result of ventricular pacing. Samples of left ventricle were obtained from 10 dogs exposed to pacing of 240 beats/min for 3 to 4 weeks and eight sham-operated controls. Na,K-ATPase was quantified using vanadate facilitated 3H-ouabain binding to intact samples. At time of sacrifice paced dogs showed clinical signs of heart failure, a significant 257% increase in left ventricular end diastolic pressure and a significant 46% decrease in left ventricular dP/dt compared with control. There was no significant change in left ventricular mass. 3H-ouabain binding concentration was significantly reduced by 16%. Evaluation of 3H-ouabain binding kinetics revealed no significant difference between myocardium from paced and control dogs: Equilibrium binding conditions were at the various concentrations used obtained after similar incubation time; nonspecific uptake and retention of 3H-ouabain was 0.9-0.8% of total uptake and retention obtained in the standard assay; apparent dissociation constant (KD) was 6.5 x 10(-8)-6.6 x 10(-8) mol/l; loss of specifically bound 3H-ouabain during washout at 0 degrees C occurred with a half-life time (T1/2) of 120 and 121 h. Hence, total 3H-ouabain binding site concentration in left ventricular myocardium was (mean +/- SEM) 1110 +/- 56 and 1317 +/- 68 pmol/g wet weight, 8.54 +/- 0.43 and 10.05 +/- 0.52 pmol/mg protein, and the total amount of 3H-ouabain binding sites in the entire left ventricle 121 +/- 6 and 162 +/- 8 nmol in paced (n = 10) and control (n = 8) dogs (p < 0.05), respectively. In conclusion, the present study reports a significant reduction in left ventricular myocardium 3H-ouabain binding site concentration in tachycardia induced heart failure. This observation supports the concept of a relationship between Na,K-ATPase concentration and contractile capacity and may be of pathophysiological importance in tachycardia and heart failure.

Animals↗
PubMedDate not supplied

Quantification of the total Na,K-ATPase concentration in atria and ventricles from mammalian species by measuring 3H-ouabain binding to intact myocardial samples. Stability to short term ischemia reperfusion.

Na,K-ATPase concentration was measured by vanadate facilitated 3H-ouabain binding to intact samples taken from various parts of porcine and canine myocardium. In porcine and canine heart 3H-ouabain binding site concentration in ventricles was 1.4-2.5 times larger than in atria. Evaluation of 3H-ouabain binding kinetics revealed no major difference between atria and ventricles: Equilibrium was obtained after the same incubation time in right atrium (RA) as in left ventricle (LV), both in porcine and canine heart. Unspecific uptake and retention of 3H-ouabain was for porcine heart RA and LV 1.5 and 1.4, respectively, and for canine heart RA and LV, both 1.2% filling (i.e., volume (ml) of incubation medium 3H-radioactivity taken up per mass unit (g wet wt.) of tissue multiplied by 100). The apparent dissociation constant (KD) was 1.4 x 10(-8) and 1.9 x 10(-8) in porcine RA and LV and 2.6 x 10(-8) and 6.1 x 10(-8) mol/l in canine RA and LV. Loss of specifically bound 3H-ouabain during the washout procedure occurred with a half-life time (T1/2) of 16.7 and 28.6 in RA and LV of porcine heart and 91.2 and 151.6 h in RA and LV of canine heart. Duly corrected for these errors of the method--factor 1.16 and 1.13, respectively, for porcine RA and LV, and factor 1.11 and 1.13 for canine RA and LV, total 3H-ouabain binding site concentration was found to be 553 +/- 74 and 1037 +/- 45 pmol/g wet wt. (means +/- SEM, n = 5) in porcine RA and LV, and 569 +/- 37 and 1410 +/- 40 pmol/g wet wt. (means +/- SEM, n = 5) in the canine RA and LV. These values were confirmed by measurements of 3H-digoxin binding to the porcine heart. The present quantification of myocardial Na,K-ATPase gives values up to 154 times higher than measurements based upon Na,K-ATPase activities in membrane fractions where the recovery of Na,K-ATPase may be less than 1% due to loss during purification. A higher Na,K-ATPase concentration is found in small animals than in large animals. A relationship between higher concentration of Na,K-ATPase and larger pressure work in ventricles compared to atria is suggested. Myocardial 3H-ouabain binding sites were found to be stable for 20 min of ischemia, followed by 1 h of reperfusion, supporting the concept that myocyte injury induced by short term ischemia may be reversible and that reperfusion may result in normalization.

Animals↗
PubMedDate not supplied

Functional airway obstruction presenting as stridor: a case report and literature review.

We report the case of a young man who presented to 3 emergency departments with apparent upper airway obstruction and was intubated each time before being diagnosed with paradoxical vocal cord motion. His previous discharge diagnoses were laryngeal edema secondary to anaphylaxis, even though he had no other objective findings of IgE-mediated disease. Flexible fiberoptic laryngoscopy demonstrated tight apposition of the vocal cords during inspiration while symptomatic, but normal movement when asymptomatic. Psychiatric evaluation revealed severe posttraumatic stress disorder. Of the approximately 41 reported cases of functional airway obstruction in the medical literature, only two have been adult males and none have been associated with posttraumatic stress disorder. The current literature is reviewed, and an approach to evaluation and management of such patients is provided.

Adult↗
PubMedDate not supplied

Sudden death in the ED: educating residents to compassionately inform families.

We describe a program used in our emergency medicine residency to help teach residents new skills in interacting with survivors following a patient's sudden death in the emergency department. This teaching module requires about two and a half hours to complete. It includes a brief presentation of new skills, videotapes of family notification, resident role play experiences, and a summary. Trained volunteers are used as simulated survivors in the role plays. Although labor intensive and time consuming, the program offers educational advantages. The residents have an opportunity to practice their communication skills in a protected setting. In addition, they receive immediate and specific feedback from the faculty facilitator, fellow residents, and, most importantly, the simulated survivor. Following the role play sessions, residents feel they are more skillful in meeting survivors' needs.

Clinical Protocols↗
PubMedDate not supplied

The strength of specific EMS dispatcher questions for identifying patients with important clinical field findings.

INTRODUCTION: There is growing interest in more efficiently matching emergency medical services (EMS) resources to patient need. Emergency medical services dispatchers may be asked to distinguish between callers with an immediate need for EMS and those who may safely use alternative services. New dispatcher protocols are required or existing protocols must be shown to be reliable for this new task. OBJECTIVE: To examine whether answers to currently asked dispatcher questions in one urban center can identify callers with important clinical field findings (ICFFs). METHODS: Audio recordings of EMS dispatcher-caller conversations within three nature codes (falls, sick, trauma) were retrospectively reviewed. Specifically scripted "cardinal" questions, asked of all callers, identify what happened, whether the patient is breathing okay, and whether the patient is conscious. "Key" questions are specific to each nature code and further specify patient circumstances. Compliance with protocol and caller answers were documented. Researchers developed a list of ICFFs that, if present on the corresponding EMS record, were judged to justify an immediate EMS response. Logistic regression was used to analyze the relationship between caller answers and the presence of ICFFs. A p-value of 0.10 was used. RESULTS: Of 430 recordings, 383 (89%) were usable. Falls: 103 (26%); trauma: 136 (37%); sick: 144 (37%). The caller was the patient 41 (11%) times. There were 198 (52%) females in the sample. There was no matching EMS record for 96 (25%) cases. An ICFF was determined to be present in 191 (67%) of the 287 recordings with matching EMS data. Compliance across the cardinal and key questions ranged from 62% to 88%. Age alone was suggestive of a patient who may be identified at dispatch as having an ICFF [adjusted OR 1.01 (90% CI: 0.999-1.025), p < 0.10]. No other key or cardinal questions were related to ICFFs. CONCLUSION: Cardinal questions are most often asked. Implied or volunteered information is often relied upon to answer key questions. Key questions for certain nature codes are not answered about one third of the time. Increasing age may suggest a stronger likelihood for an ICFF to be identified at dispatch. Otherwise, in this sample, caller answers to currently asked questions do not appear useful if the goal is to identify at dispatch those without an ICFF.

Clinical Protocols↗
PubMedDate not supplied

Hospital follow-up of patients categorized as not needing an ambulance using a set of emergency medical technician protocols.

OBJECTIVE: Using hospital outcomes, this study evaluated emergency medical technicians' (EMTs') ability to safely apply protocols to assign transport options. METHODS: Protocols were developed that categorized patients as: 1) needs ambulance; 2) may go to emergency department (ED) by alternative means; 3) contact primary care provider (PCP); or 4) treat and release. After education on application of the protocols, EMTs categorized patients at the scene prior to transport but did not change current practice. Hospital charts were reviewed to determine outcome of patients whom EMTs categorized as not needing an ambulance. Category 2 patients were assumed to need the ambulance if they were admitted to a monitored bed or intensive care unit. Category 3 and 4 patients were assumed to need the ED if they were admitted. RESULTS: The EMTs categorized 1,300 study patients: 1,023 (79%) ambulance transport, 200 (15%) alternative means, 63 (5%) contact PCP, and 14 (1%) treat and release. Hospital data were obtained for 140 (51%) patients categorized as not needing ambulance transport. Thirteen of 140 (9%) patients who transporting EMTs determined did not need the ambulance were considered to be undertriaged: five in category 2, six in category 3, and one in category 4. Six of 13 (46%) undertriaged patients had dementia or a psychiatric disorder as one of their presenting complaints. CONCLUSION: These protocols led to a 9% undertriage rate. Patients with psychiatric complaints and dementia were at high risk for undertriage.

Adult↗
PubMedDate not supplied

State insurance commissioner actions against health maintenance organizations for denial of emergency care.

OBJECTIVE: Concerns have emerged from two west coast communities that health maintenance organizations (HMOs) may deter their members from calling 911. One means of influence is retrospective denial of emergency department (ED) or emergency medical services (EMS) claims. The study objective was to systematically assess legal action taken to contest HMO denial of claims. METHODS: Telephone survey of all state insurance commissioners (SICs). The specific question asked was: "What actions, if any, have been taken by the Office of Insurance Commissioner since 1990 against HMOs for denying claims for emergency department care or care provided by paramedics after a person has called 911?" Each office was contacted at least three times. RESULTS: Representatives from 49 states were interviewed. Three states (6%, Oregon, Texas, and Virginia) have taken formal action since 1990. Oregon fined two HMOs a total of $25,000 for inappropriate systematic claim denial of ED care. Texas fined one HMO $1,000,000 for similar practices. Virginia, with no authority to fine, has issued citations. No action had been taken for denying EMS claims. Thirty-eight states (78%) reported no formal actions. Eight (16%) state SICs could not easily retrieve these data and did not report. Fourteen (29%) representatives reported receiving these complaints. Most of these complaints were resolved without formal SIC action. CONCLUSIONS: Three health plans in two states received financial penalties for systematic denial of ED claims. A fourth was cited. This may underrepresent the true incidence of appealed ED and EMS claim denials. While complaints occurred in 29% of states, recent actions by SICs are relatively rare (6% of states). These results speak more to the extent systematic claim denials are discovered by SICs than to the true incidence of this practice.

Emergency Medical Services↗