Medical residents in hospitals are often required to be on duty for long hours. In 2003 the organization overseeing graduate medical education adopted common program requirements to restrict resident workweeks, including limits to an average of 80 hours over 4 weeks and the longest consecutive period of work to 30 hours in order to protect patients and residents from unsafe conditions resulting from excessive fatigue.Resident Duty Hours provides a timely examination of how those requirements were implemented and their impact on safety, education, and the training institutions. An in-depth review of the evidence on sleep and human performance indicated a need to increase opportunities for sleep during residency training to prevent acute and chronic sleep deprivation and minimize the risk of fatigue-related errors. In addition to recommending opportunities for on-duty sleep during long duty periods and breaks for sleep of appropriate lengths between work periods, the committee also recommends enhancements of supervision, appropriate workload, and changes in the work environment to improve conditions for safety and learning.All residents, medical educators, those involved with academic training institutions, specialty societies, professional groups, and consumer/patient safety organizations will find this book useful to advocate for an improved culture of safety.

Resident Duty Hours: Enhancing Sleep, Supervision, and Safety

Objectives: Motor vehicle crash fatality rates have been consistently higher in rural areas than in urban areas. However, the explanations for these differences are less clear. In this study the decomposition method was used to explore the factors associated with increased fatal crash involvement rates in rural communities. Design: Using national databases, the fatal crash incidence density was decomposed into the product of three factors: the injury fatality rate, the crash injury rate, and the crash incidence density. Results: As expected, the fatal crash incidence density was more than two times higher in rural than in urban areas. This was driven primarily by the injury fatality rate, which was almost three times higher in rural areas. Conclusions: Further research should examine the relative roles of crash severity and the timely receipt of definitive medical care after a crash.

https://injuryprevention.bmj.com/content/injuryprev/11/1/24.full.pdf

Fatal motor vehicle crashes in rural and urban areas: decomposing rates into contributing factors

Vascular injury complicating lumbar disc surgery. A systematic review.

Objective:Uncontrolled exposure hypothermia is believed to be deleterious in the setting of major trauma. Prevention of hypothermia in the injured patient is currently practiced in both prehospital and in-hospital settings. However, this standard is based on studies of limited patient series that we

Admission hypothermia and outcome after major trauma

Objective To examine the relative benefits and disadvantages of non-steroidal anti-inflammatory drugs (NSAIDs) and opioids for the management of acute renal colic. Data sources Cochrane Renal Group9s specialised register, Cochrane central register of controlled trials, Medline, Embase, and reference lists of retrieved articles. Review methods Randomised controlled trials comparing any opioid with any NSAID in acute renal colic if they reported any of the following outcomes: patient rated pain, time to pain relief, need for rescue analgesia, rate of recurrence of pain, and adverse events. Results 20 trials totalling 1613 participants were identified. Both NSAIDs and opioids led to clinically important reductions in patient reported pain scores. Pooled analysis of six trials showed a greater reduction in pain scores for patients treated with NSAIDs than with opioids. Patients treated with NSAIDs were significantly less likely to require rescue analgesia (relative risk 0.75, 95% confidence interval 0.61 to 0.93). Most trials showed a higher incidence of adverse events in patients treated with opioids. Compared with patients treated with opioids, those treated with NSAIDs had significantly less vomiting (0.35, 0.23 to 0.53). Pethidine was associated with a higher rate of vomiting. Conclusions Patients receiving NSAIDs achieve greater reductions in pain scores and are less likely to require further analgesia in the short term than those receiving opioids. Opioids, particularly pethidine, are associated with a higher rate of vomiting.

https://www.bmj.com/content/bmj/328/7453/1401.full.pdf

Systematic review of the relative efficacy of non-steroidal anti-inflammatory drugs and opioids in the treatment of acute renal colic

The effect of working serial night shifts on the cognitive functioning of emergency physicians

https://www.annemergmed.com/article/S0196-0644(86)80186-X/pdf

Rural interhospital helicopter transport of motor vehicle trauma victims: Causes for delays and recommendations

INTRODUCTION: Emergency medical services vehicle collisions (EMVCs) associated with the use of warning "lights and siren" (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport. DESIGN: During four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed. SETTING: Countywide suburban/rural EMS system. RESULTS: Ninety-two percent (1,495 of 1,625) of patients were transported nonemergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport. CONCLUSION: This medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports. Language: en

Patient outcome using medical protocol to limit "lights and siren" transport

Use of prehospital fluids in hypotensive blunt trauma patients.

Ketorolac is a nonsteroidal anti-inflammatory medication that is used widely for pain management. Its effects are mediated through the inhibition of prostaglandins, which makes it uniquely different from opioids in relieving pain. We conducted a randomized, prospective, double blind study of patients presenting to our Emergency Department (ED) with a diagnosis of acute biliary colic. Study patients were randomized into one of two treatment groups, meperidine 1.5 mg/kg with a maximum dose of 100 mg or ketorolac 60 mg given intramuscularly (i.m.). The patients rated their pain before and 30 min after medication on a scale of 1 to 10 using a Visual Analog Pain Scale. Overall pain relief was compared between the two groups using a two-sample t test. Thirty patients were enrolled in the study, 16 in the ketorolac group and 14 in the meperidine group. Patients ranged in age from 18 to 71 years and 6 (20%) were male. The average pain score at time 0 was 7.6 for the ketorolac group and 7.3 for the meperidine group. Pain relief at time 30 min was 3.8 in the ketorolac group and 3.9 in the meperidine group, which was not statistically different. The mean global pain score and need for an emergency cholecystectomy were similar in the two groups. Rescue medication for additional analgesia at 30 min was needed in 4 patients in the meperidine group and in 2 patients in the ketorolac group (28.6% versus 12.5%, respectively; NS). In this study of patients with acute biliary colic there was no significant difference in the pain relief achieved by using either ketorolac or meperidine.

David J. Dula

Papers

The effect of working serial night shifts on the cognitive functioning of emergency physicians

Rural interhospital helicopter transport of motor vehicle trauma victims: Causes for delays and recommendations

Patient outcome using medical protocol to limit "lights and siren" transport

Use of prehospital fluids in hypotensive blunt trauma patients.

A prospective study comparing i.m. ketorolac with i.m. meperidine in the treatment of acute biliary colic