In this issue:

  Free Online CME

Mass CPR Training

EMS Week 2001

Are Physicians Current in Determining Prescription Doses?

Cardiac Care: Stents Vs. Bypass Surgery

Strep Bacteria Code Solved

FAA Orders Airlines to Carry Defibrillators and Upgraded Med Kits

Survival of Foot & Mouth Disease Virus in the Environment

Tidbits of Trivia

Web Sites of Possible Interest

Quotable Quotes

ERDOCS listserv

How to get in touch with us; questions; sponsorship

Free Online CME

A free online CME course on EMTALA basics for physicians is now available on the ACUTE CARE, INC. web site. With options for text-based or streaming audio narration, you can log on to the internet site, take a pretest, complete the program, and forward your posttest and evaluation-- receiving up to one category 1 CME---all online and in a paperless fashion. Your CME certificate is sent via e-mail; you can print this out if you wish, for your records.

The program is the first in a series of EMTALA-related topics and is jointly sponsored by ACUTE CARE, INC. and Steven Frew, JD, a nationally-known EMTALA consultant and expert. Other topics of interest for emergency care providers are planned, as well. One CEH for prehospital emergency care providers successfully completing the program, was recently approved by Mobile Intensive Care Services, Mary Greeley Medical Center, located in Ames, Iowa.

Mass CPR Training

On April 28-29, 2001, the American Heart Association hosts a national mass CPR training event in more than 100 sites across the USA. In a two-hour timeframe, participants will learn "CPR for Family and Friends." The event is sponsored nationally by the Discovery Health Channel and supported by ACEP. This new, abbreviated lay public CPR video-based course is also now recommended as a tool for physicians to offer to concerned relatives and friends of higher risk cardiac patients. For
information regarding mass CPR training in April, call (877) AHA-4CPR.

EMS Week 2001

National EMS Week is May 20-26. This year's theme, "EMS: Answering the Call, "emphasizes the responsiveness of emergency medical services around the US, and also underscores the importance of the 911 system. Special this year, child-oriented activities and events focusing on child safety and injury prevention will be offered May 23, which is National EMSC Day. ACEP, the American College of
Emergency Physicians, develops and distributes EMS Week planning kits annually to help communities plan and promote activities for the week. Kits include an EMS Week Planning Guide, plus numerous fact sheets addressing: Scooters and In-line Skating Safety; Pediatric Education for Pre-hospital Professionals; Children's Safety Fun Fact Sheet; Update on the EMS Agenda for the Future; EMS Week Clip Art Fact Sheet; and the Do's and Don'ts of Transporting Children in an Ambulance.

Plan your EMS Week now!

For further information or to obtain an EMS Week kit, call (800) 798-1822 (ext. 6), or visit ACEP's
EMS Week web site at www.acep.org/emsweek.

Are Physicians Current in Determining Prescription Doses?

The April 9th issue of the Archives of Internal Medicine cites a study by Dr. Jay Cohen (University of California San Diego, La Jolla) in raising the question on how up-to-date physicians are on dosing information for many medications. Cohen's contention is that reliance on the Physicians' Desk Reference for dosing often leads to higher amounts than what is advocated in the medical literature. The study looked at 48 commonly prescribed drugs.

Cohen notes that "for many types of medications, physicians are frequently advised to use the lowest effective doses of drugs, especially initially. Effective lower doses [that may be determined in other aspects of the drug testing process] are often omitted from the PDR, even when they have been recommended by expert panels."

The study offered estrogen as one example. With concerns for adverse reactions and possible links to increases in certain types of cancer, many studies and resources recommend doses as low as 0.3 mg/day; from 1964 until 1999, 1.25 mg/day was the recommended dose listed in the PDR. In 2000, it was finally reduced to 0.625 mg/day (still much higher than suggested by many sources). 48 million women had estrogen prescribed to them in 1998.

The New Jersey-based Medical Economics Company publishes the PDR and states that it only prints FDA-approved prescribing information, relying exclusively on the drug manufacturers to submit
updated information. The PDR is published once each year, with two updated supplements (June and September). The online version of the PDR--which is identical to the print version--is updated each month.

"But if drug manufacturers choose not to send the information to the PDR or doctors do not continually educate themselves about new dosage information, patients may not be receiving optimal care,"
the study's author explained.

Cardiac Care: Stents Vs. Bypass Surgery

Implanting a wire mesh stent to keep coronary arteries open is nearly as effective as bypass surgery for preventing a heart attack during the first year, according to a recent study published in the New England Journal of Medicine. "At one year, there was no significant difference between the two groups in terms of the rates of death, stroke or myocardial infarction (heart attack)," the researchers concluded. The findings are similar to those from previous studies.

In this study, researchers randomly assigned 1,205 cardiac patients at 67 medical centers around the world to receive bypass surgery or stents to keep their arteries open after angioplasty. While outcomes (cases of AMI or stroke) at one year were nearly identical between groups, it was
noted that nearly 21 percent of stent recipients needed to have bypass surgery within a year, compared to just 3.8 percent of the people in the urgery group who needed a second operation. Also, relief from angina-related pain was less likely in the stent group.

In this international study, the cost of implanting the stent was $6,441 - while bypass surgery averaged $10,653. With the additional costs of surgery (for the 21 percent that initially received stents then needed bypass surgery) added to the stent-receiving group, there was still an overall cost-savings difference that averaged just under $3,000 less per patient, according to the researchers. (Note--the American Heart Association quotes the average 1995 price of bypass surgery in the US at $44,820 and says it cost just over $20,000 or the procedure used to implant a stent).

In three out of five patients, the choice between stenting or bypass surgery is not clear-cut, and "the most appropriate treatment remains a matter of debate," said research spokesperson Dr. Patrick W. Serruys, of Erasmus University in Rotterdam.

More than 600,000 bypass operations are performed in the United States each year and an estimated 300,000 to 400,000 patients had at least one stent implanted last year, according to the American Heart Association.

Cordia Corp., a Johnson & Johnson company that makes stents, paid for the study.

Strep Bacteria Code Solved

A five-year mapping project, funded by the National Institute of Allergy and Infectious Disease, has succeeded in spelling out the genetic code or the Streptococcus bacteria. The bacteria cause thousands of human illnesses each year, including strep throat, impetigo, pneumonia, toxic shock syndrome, blood poisoning, scarlet fever, rheumatic fever and flesh-eating necrotizing fasciitis. Millions of cases of strep throat and impetigo occur each year in the United States. Of the 10,000 cases of flesh-eating disease in the United States last year, 13 percent resulted in death.

``We've got the complete dictionary on this bug,'' University of Oklahoma microbiologist and researcher Joseph Ferretti said. ``That's really exciting. Now that we know some of its secrets, we can find a way to combat it.'' The genetic sequence was published in the Proceedings of the National Academy of Sciences and is now available online.

It is up to researchers now to develop new antibiotics and vaccinations now that the germ's complete DNA sequence has been determined. During the study, researchers also discovered six toxins caused by Streptococcus that were previously unknown.

FAA Orders Airlines to Carry Defibrillators and Upgraded Med Kits

U.S. airlines will be required to carry defibrillators and to upgrade their emergency medical kits within the next three years under a rule issued Thursday by the Federal Aviation Administration. The rule applies to U.S. airlines' domestic and international flights.

Nine airlines currently either carry defibrillators and enhanced kits or have made a commitment to do so.

The FAA rule also requires flight attendant training on the use of defibrillators and CPR. Passengers with medical training are frequently aboard aircraft and can help fellow passengers during
emergencies, if they can provide proper identification, the FAA said. A "Good Samaritan" provision in the Aviation Medical Assistance Act of 1998 limits the liability of air carriers and non-employee passengers offering assistance.

The FAA rule also orders other items added to the emergency medical kits. The total estimated cost to the airline industry over 10 years for the equipment, medications, and training is $16 million.

In addition to the defibrillators, airlines must add the following items to their the emergency medical kits: oral antihistamine; non-narcotic analgesic; aspirin; atropine; a bronchodilator inhaler; lidocaine and saline; an IV administration kit with connectors; a bag to assist respiration after defibrillation; CPR masks.

Emergency medical kits already include: a sphygmomanometer; a stethoscope; three sizes of "breathing tubes"; syringes; needles; 50 percent dextrose; epinephrine (for asthma or acute allergic reactions); diphenhydramine; sublingual nitroglycerin; and latex gloves.

Survival of Foot & Mouth Disease Virus in the Environment

With much publicity overseas and the onset of another travel season soon upon us, the following is provided for inquiring patients, families, and concerned friends.

This is an extract from the USDA Aphis "Survival of Foot and Mouth Disease Virus (FMDV) and Spread by International Travelers." The complete article is available as an Adobe Acrobat file at:
http://www.aphis.usda.gov/vs/ceah/cei/travrisk.pdf

The article states that FMDV can persist for up to 9 weeks on clothing, luggage, and shoes. FMDV is very hardy. It survives freezing temperatures, and has also been found to be viable in contaminated
milk after pasteurization at 72 degrees C for 15 seconds (Pirtle 1991). The virus can survive for extended periods outside the host in protected locations. FMDV has been recovered from cattle stalls 14 days after removal of infected cattle, from urine after 39 days, from soil after 28 days in autumn and after 3 days in summer, and from dry hay at 22 degrees C after 20 weeks storage (Pirtle 1991). The virus is rendered inactive by sunlight, extremes of pH, and high temperatures.

Humans can play a role in the transmission of FMDV. The virus can be carried by people for up to approximately 14 days after contact with the disease. People can inhale the virus, trapping it in the respiratory tract for as long as 36 hours (Hyslop 1973). The virus can then be expelled in the saliva or breath, and become a source of infection to susceptible animals. (From a news release on the Pro-Med web-site)

Tidbits of Trivia

Twinkie, Twinkie, Little Star
Up until World War II, Twinkie snack cakes had banana cream filling.
Following the attack on Pearl Harbor, a banana shortage occurred, and Twinkies have had plain vanilla filling ever since.

Say What?
The average person speaks some 4,800 words per day.

Mind Drain
The extra openings found in sinks that help prevent overflow, are called porcelators.

Unlucky Number
Any month that begins on a Sunday will have a Friday the 13th. The year 2001 has one in April and one in July.

Web Sites of Possible Interest

Emergency Medicine Resource Site
http://www.emedhome.com/

This recommendation comes from our very own webmaster--Paul.
This week's featured article is on ED management of hemophilia by Dr. Ralph Gruppo of the Children's hospital of Cincinnati. This recently redesigned site features a number of topics and resources for the ED practitioner.

Pharmaceutical Lexicon
http://www.pharma-lexicon.com/

Our webmaster is on a roll-Paul also gives high marks to this site. Look up the most popular pharmaceutical acronyms/abbreviations. This site's authors claim they have 24,000 pharmaceutical/medical Acronyms and abbreviations online so far, in their one-year project to
catalogue them from the fields of pharmacy, agrochemicals, biology, veterinary medicine, chemicals, public health, toxicology, biology, medical devices/diagnostics,biochemistry, general medicine, biotechnology, lab equipment, public health, dentistry, geriatrics, pediatrics, nursing, physiotherapy (physical therapy), psychology, and epidemiology.

It's About Time
http://www.time.gov/

At this, the Official US Time Clock Web site, you'll find a giant Java-animated clock with the current time as agreed upon by the United States Department of Commerce, the National Institute of Standards And Technology, and the US Naval Observatory. And listen to this - "The time maintained ... should never differ by more than 0.0000001 seconds from Coordinated Universal Time." (Though this site display professes to be only within 0.8 seconds.)

Quotable Quotes

"Time was only invented to keep everything from happening at once."
Tom Robbins

"There are two mistakes one can make along the road to truth - not going all the way, and not starting."
Buddha

ERDOCS e-mail group (listserv)

As a Clinician providing acute and emergency medical care, you are invited to visit and participate in our new ERDOCS group at eGroups, a free, easy-to-use email group service! You have plenty of experiences to share, questions to ask, concerns and opinions to voice, suggestions, news to post, tips to offer, etc. and can do so within this framework. this is a versatile system for posting things to be sent to a group to peruse, respond to, or simply be aware of. It eliminates conventional mail delays and allows you to review and post at your leisure. (We still have the more open-ended [any visitor can observe/post] discussion group at the ACUTE CARE, INC. web site). Our goal is to give you a variety of feedback and communication tools.

The manager/moderator for this ERDOCS egroup is the webmaster for the ACUTE CARE, INC. website (www.acutecare.com), Paul Hudson. You can subscribe by sending an e-mail indicating your wish to be included to Paul at paul@acutecare.com

As this site grows, it will feature news, calendars, links to references, resources, and other useful features. We hope you will support this effort to foster ongoing communication amongst EM providers.