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Cardiovascular Medicine, Emergency Medicine, Patient Care, Pregnancy, Research, Stanford News

Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms

Cardiac arrest in pregnancy: New consensus statement addresses CPR for expectant moms

pregnantbelly2When a pregnant woman’s heart stops, two lives are threatened. Yet few caregivers know how to modify their cardiopulmonary resuscitation technique for the expectant mom and her fetus, and few hospitals are optimally prepared for such an event.

To fill the knowledge gap, the Society for Obstetric Anesthesia and Perinatology commissioned a Stanford-led team of experts from several medical disciplines to write a consensus statement of expert recommendations, publishing in the May issue of Anesthesia & Analgesia, that describes best practices for CPR on a pregnant patient. The new statement is one of many examples of Stanford leadership in helping to save the lives of pregnant women around the world; our experts have also helped to develop widely-adopted protocols for dealing with massive hemorrhage during delivery and for treatment of pre-eclampsia, for example.

I asked two Stanford scientists who helped prepare the statement, lead author Steven Lipman, MD, and senior author Brendan Carvalho, MD, for their perspectives on the challenges of resuscitation in pregnancy. Both are obstetric anesthesiologists at Lucile Packard Children’s Hospital Stanford, where Carvalho is chief of obstetric anesthesia.

“The good news is that cardiac arrest in pregnancy is very rare, and also that rates of survival are higher than for the non-pregnant population,” Lipman said. Only about one in every 20,000 women with access to modern obstetric care experiences cardiac arrest while pregnant. Higher survival among pregnant patients may be partly due, he said, to the fact that many maternal cardiac arrests are witnessed: They tend to occur during labor or delivery, when the woman is already in a hospital and being closely monitored by trained medical staff who can begin CPR right away.

But rarity creates challenges. Because maternal cardiac arrests happen infrequently, obstetric caregivers have less experience in performing resuscitation than people who work in other parts of the hospital, such as the emergency room or intensive care unit. And it’s impossible to conduct randomized clinical trials – usually considered the gold standard for evidence-based medicine – on these emergencies to determine what works best.

“Also, in pregnancy, there is an asymmetry between people’s expectations and the reality of the risk,” Lipman said. “People think, ‘Oh, I’m just having my baby, it’s just natural.’ But if you look at third-world countries with no developed medical infrastructure, the rates of maternal mortality are extremely high. Yes, it’s natural and people expect an easy delivery and a healthy baby, but the reality is that it can be a risky process, and people can become critically ill very quickly.”

The physiology of pregnancy also presents challenges for resuscitation. During the second half of pregnancy, when a pregnant woman lies flat on her back, the fetus and the enlarged uterus compress the large vein that returns most of the blood to her heart. This decreases the amount of blood available to the heart and makes it harder to provide effective chest compressions in CPR. And resuscitators also must think about how to balance the needs of the mother with those of the fetus.

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Emergency Medicine, Global Health, Patient Care, Stanford News, Videos

SEMPER team reflects on relief work after Typhoon Haiyan

SEMPER team reflects on relief work after Typhoon Haiyan

As previously reported on Scope, the Stanford Emergency Medicine Program for Emergency Response sent 1o medical professionals to the Philippines last year to relieve Typhoon Haiyan victims. “There was so much medical need that it was necessary to split up SEMPER into two teams: One team went to Guiuan and the other was in Talcoban,” said Linda Jordan, PA-C, who was among those providing services. Setting up makeshift clinics, the Stanford affiliates teamed with Filipino doctors and nurses to provide primary care and help people suffering from traumatic illness, infected wounds and severe injuries who had not been treated in the immediate aftermath of the storm.

In the recently posted video above, members of the SEMPER team reflect on their experiences from the ground and what they took away. “You start to see qualities in people that you work with and I think you realize that you can stretch beyond what you’re doing,” said Julie Pacioppi, RN.

Previously: “I’m glad that we were there”: Stanford emergency-response team returns home from the PhilippinesOn the ground in post-typhoon Philippines, Post-typhoon Philippines: “It is all becoming real and sinking in” and Stanford emergency-response team heads to the Philippines

Cancer, Emergency Medicine, Medicine and Society

An emergency medicine physician's take on honoring your emotions

But how do you really feel? Over on KevinMD.com, Anoop Kumar, MD, reflects on his personal and professional experiences with cancer. The emergency physician cares for people with acute complications from cancer and related treatments. In the post, Kumar describes his journey through the death of his grandmother when he was in seventh grade, the bursting of a dam of emotional supression later on, and the continued leaking of grief as he confronts his confusion, sadness and loss around the event.

Inspired by a 2010 article in The Guardian, Kumar urges readers dealing with hardship to “be positive. Or be negative. Or be confused. But whatever you are, be yourself.”

Previously: Becoming Doctors: Stanford med students reflect and share experiences through podcasts

Emergency Medicine, Health Disparities, Research, Stanford News

Insurance status might perversely affect the kind of trauma care you get: Stanford study

Insurance status might perversely affect the kind of trauma care you get: Stanford study

trauma centerGiven how much my health insurance checks eat into my income, I shouldn’t need to worry about the kind of trauma care I’d get if I were ever in a car accident (knock on wood). But should I?

A new School of Medicine study reveals that even insured patients might be at risk for getting poor trauma care for severe injuries – possibly at greater risk than uninsured patients.

Why? Simply because emergency doctors at hospitals lacking a trauma center decide to keep them there instead of sending them to a hospital with more expertise.

Ironically, insured trauma patients are admitted at non-trauma hospitals at higher rates than uninsured patients are, researchers find. Ergo, insured patients may end up missing out on critical resources that trauma centers are equipped with for severe injuries.

Our press release on the study published online today reports on the researchers’ findings from analyzing more than 4,500 nationwide reported trauma cases.

Why would non-trauma hospitals want to hold on to insured patients? One possible reason is that sometimes emergency doctors fail to recognize conditions that need extra care, lead author M. Kit Delgado, MD, suggests. Hospitals may also be used to taking care of certain severe injuries on their own.

But there might also be other reasons. As Delgado elaborates in the release:

Doctors working in the trenches most often strive to do what’s best for patients. But these findings are concerning and suggest that non-trauma centers are considering admitting some patients with life-threatening injuries based on whether or not they can be paid, when research has shown these patients fare better if transferred to a trauma center.

Delgado carried out the research when he was an emergency medicine instructor at Stanford. He is currently an emergency care research scholar at University of Pennsylvania.

Calling the finding “very disturbing,” Nancy Wang, MD, senior author – and an emergency physician herself – says researchers must call attention to such disparities in trauma care. She and colleagues previously discovered disparities in access to trauma care at California hospitals between children with and without insurance.

“I believe in health care as a right,” Wang wrote to me. “I never believed that there would be disparities in access to emergency trauma care based on insurance status.”

The authors suggest closer monitoring of emergency room encounters and splitting costs between hospitals and trauma centers as potential ways to curb such practices.

In follow-up studies, they also hope to figure out how much patients know about their options, and whether their preferences are being taken into account. As Delgado says in the press release, “People who have insurance may not realize that they could do better if they are transferred.”

Previously: Comparing the cost-effectiveness of helicopter transport and ambulances for trauma victims
Photo by Seattle Municipal Archives

Emergency Medicine, Health Costs, Research, Technology

Can sharing patient records among hospitals eliminate duplicate tests and cut costs?

566748316_7b72d5b777A recent analysis of the impact of health information exchanges, which allow health-care providers to share patient records electronically and securely, shows the systems hold promise for reducing health costs and unnecessary care in emergency departments.

For the study (subscription required), University of Michigan researchers examined information on hospital health information exchange participation and affiliation from the Health Information Management Systems Society’s annual survey as well as data the  California and Florida state emergency department databases from 2007 through 2010. Both states were early adopters of health information exchanges. According to a university release:

The findings show that the use of repeat CT scans, chest X-rays and ultrasound scans was significantly lower when patients had both their emergency visits at two unaffiliated hospitals that took part in a [health information exchange]. The data come from two large states that were among the early adopters of [health information exchanges]: California and Florida.

Patients were 59 percent less likely to have a redundant CT scan, 44 percent less likely to get a duplicate ultrasound, and 67 percent less likely to have a repeated chest X-ray when both their emergency visits were at hospitals that shared information across an [health information exchange].

More research is needed to determine the value of health information exchanges on patient care and health-care costs. But in order to conduct future analysis, said study authors, more states need to report relevant data to the Healthcare Cost and Utilization Project system  to allow researchers to view the activity of individual patients across their different medical encounters, while preserving patient privacy.

Previously: Experts brainstorm ways to safely reduce health-care costs, U.S. Olympic team switches to electronic health records and A new view of patient data: Using electronic medical records to guide treatment
Photo by Tabitha Kaylee Hawk

Cardiovascular Medicine, Emergency Medicine, Patient Care, Pediatrics, Research

New approach to resuscitation training saves more kids

New approach to resuscitation training saves more kids

Heart-2014Children whose hearts stop while they are in the hospital need fast, well-coordinated resuscitation to give them the best chance of surviving their cardiac arrest. But because pediatric cardiac arrests are (fortunately) rare, pediatric physicians, nurses and other caregivers have few opportunities to experience a real response to this life-threatening emergency. And rehearsing what to do in educational settings outside the hospital may not give responders the chance to practice for unexpected problems that can arise in real life.

To solve this problem, a team at Lucile Packard Children’s Hospital Stanford implemented a new training approach. Lynda Knight, RN, MSN, the hospital’s pediatric resuscitation program educator, wanted to make sure that every person responding to emergency “codes” broadcast through the hospital when a patient’s heart stops – from attending physicians to security guards – had regular opportunities to practice working together. Knight and Deborah Franzon, MD, led a group that staged mock “codes” to simulate cardiac arrests in many locations throughout the hospital.

After the new training was implemented, the hospital’s survival rate for cardiac arrest patients jumped from 40 percent (a figure similar to the national average for children’s hospitals) to 60 percent. The findings were published this week in Critical Care Medicine.

From our press release about the study:

One key goal of the training package was for one person to quickly assume the role of the code team leader, and for others to take on specific, pre-defined roles in the team’s response. The roles were based on American Heart Association guidelines about best practices for resuscitation.

“It’s sort of like an orchestra,” Franzon said. “Everyone has a really important part to play.” For instance, one physician or nurse stood at the code cart, distributing equipment. A social worker comforted the patient’s parents. Security guards directed unnecessary foot traffic away from the area. A nursing supervisor made sure all essential roles were filled quickly.

“With this training in place, responding to codes becomes muscle memory for the whole team,” Knight said. “That’s what’s going to save lives.”

Photo by dev null

Emergency Medicine, Stanford News, Videos

"I'm glad that we were there": Stanford emergency-response team returns home from the Philippines

"I'm glad that we were there": Stanford emergency-response team returns home from the Philippines

Time for another (feel-good) video? The SEMPER team that’s been in the Philippines for the last few weeks made it home safely yesterday; in this piece, the group is greeted at the airport by friends and family. “We saw [about] 200 patients a day. It was very difficult – I have to tell you that,” said one of the returnees, later adding, “Our presence actually made them feel good, and they’re very grateful for that. And I’m glad that we were there.”

Previously: On the ground in post-typhoon Philippines, Post-typhoon Philippines: “It is all becoming real and sinking in”, Providing medical care to typhoon survivors in the Philippines and Stanford emergency-response team heads to the Philippines

Emergency Medicine, In the News, Pediatrics, Pregnancy, Stanford News, Women's Health

Russian doctors visit Packard Children's Hospital for childbirth-crisis training

Russian doctors visit Packard Children's Hospital for childbirth-crisis training

operationSome believe “The Trauma of Birth” is part of the human condition even during a healthy delivery. But sometimes entry into the world comes with unexpected medical complications – for mother as well as baby. Stanford’s Center for Advanced Pediatric and Perinatal Education at Lucile Packard Children’s Hospital trains health professionals on best practices for handling childbirth emergencies. An article in the San Francisco Chronicle spotlights experiences of the first Russian visitors to the center, which has been training medical experts from all over the world since 2002.

From the piece:

The simulation room looked a lot like a hospital room, with a couple of significant differences. Behind a two-way mirror, technicians sat in a control room video-recording the doctors’ every movement on seven cameras. They manipulated the vital signs shown on the bedside monitor of the mother, who was played by a hospital employee. They controlled the pumping lungs and warm breath of the baby mannequin.

After the childbirth simulation, the four Russian doctors involved in the scenario sat before a television and watched themselves on instant replay. Cringing a bit, the obstetricians admitted that they could have worked more efficiently by splitting up, with one monitoring the woman’s vital signs and the other guiding the delivery. One of the neonatologists who assisted with the newborn remarked that she should have called for help from a colleague sooner.

One of the participating doctors, Yulia Vorontsova, a neonatologist, said with the assistance of an interpreter, “When you look at a situation from the outside, it gives you a richer experience.”

Previously: “Preparation is everything:” More on how Stanford and Packard got ready for the Asiana crash, Whiz Kids: Research looks at handling pediatric crises effectively and Improving treatment for infant respiratory distress in developing countries
Photo by phalinn

Emergency Medicine, Global Health, Patient Care, Stanford News

Providing medical care to typhoon survivors in the Philippines

Providing medical care to typhoon survivors in the Philippines

SEMPER - smallYesterday we wrote about a Stanford team who had traveled to the Philippines to provide medical assistance to survivors of Typhoon Haiyan. Members of SEMPER, each carrying an average of 160 lbs of equipment, arrived on Saturday and completed their first full day of providing medical care on Monday.

The team, pictured to the right, reports that there are “clear signs of recovery” but says the devastation from the typhoon is enormous. They’re chronicling their experiences on a blog, which you can read here.

Previously: Stanford emergency-response team heads to the Philippines
Photo courtesy of SEMPER

Emergency Medicine, Global Health, Patient Care, Stanford News, Videos

Stanford emergency-response team heads to the Philippines

Stanford emergency-response team heads to the Philippines

On Friday, several members of Stanford’s emergency-response team headed to the Philippines to provide medical assistance in the aftermath of Typhoon Haiyan. Stanford Hospital videographer Todd Holland was on the scene as the team prepared, and he captured the beginning of their journey in the video above.

Previously: New Stanford Hospital team ready to mobilize for disaster relief, Treating the injured amid the apocalypse of Haiti, Reports from Stanford medical team in Haiti and Stanford sends medical team to Haiti

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