scispace - formally typeset
Search or ask a question

Showing papers in "Maryland medical journal in 1997"


Journal Article•
TL;DR: Most of the patients (61%) had mixed tumors at diagnosis or had a history of adenocarcinoma of the prostate, and 70% of patients had metastatic disease.
Abstract: Primary small cell carcinoma of the prostate is rare. A case of primary small cell prostate cancer treated with radiation and chemotherapy is presented, and 33 previously published case reports are reviewed. Most of the patients (61%) had mixed tumors (small cell and adenocarcinoma) at diagnosis or had a history of adenocarcinoma of the prostate. Prostate specific antigen (PSA) data was available in 11 patients and was abnormal in 4 (36%). Once small cell carcinoma was diagnosed, 70% of patients had metastatic disease. Visceral metastases were common. Only one of seven patients responded to hormonal therapy, and two of eight patients responded to chemotherapy. Overall prognosis was poor.

26 citations


Journal Article•
TL;DR: A case report is presented and followed by a review of the literature on incidentally detected cystic neoplasms of the pancreas, and the ability to definitively differentiate between these two classes of cystic necrosis is limited.
Abstract: Cystic neoplasms of the pancreas are rare, accounting for less than 1% of all pancreatic tumors Since the advent of computerized tomography (CT), an increasing number of these lesions are being discovered incidentally. Compagno and Oertel were the first to thoroughly describe and differentiate the benign serous cystadenoma from the potentially or overtly malignant mucinous cystadenoma/cystadenocarcinoma spectrum. At present, our ability to definitively differentiate between these two classes of cystic neoplasms is limited. Because of this, controversy exists as to their appropriate surgical management. A case report is presented and followed by a review of the literature on incidentally detected cystic neoplasms of the pancreas.

24 citations


Journal Article•
TL;DR: As demonstrated by this study, ELBW infants are at risk for significant developmental problems, which supports the need for targeted outreach, developmental monitoring, early intervention services, and parent support and education.
Abstract: The survival rate of extremely low birth weight (ELBW; i.e. < 1001 grams) infants has significantly improved in the past 10 years secondary to the numerous advances in neonatology. There have been many favorable reports of the neurodevelopmental outcomes of survivors, but the studies often span several years to collect sufficient number of subjects. This study assesses the outcome of 100 ELBW infants born in Maryland in 1990 and analyzes factors that may have contributed to their outcomes at one year corrected age. Of this group, 72% had no evidence of severe disability (e.g., cerebral palsy (CP) or mental retardation (MR); however, 51% of the children had abnormal or suspect neurological examinations, and 24% had CP. Eighteen percent of the children were more than one standard deviation below the mean cognitively; 30% were below normal for motor abilities, and 33% were below normal for language abilities. Prior to this study, many of these children were not recognized by their primary physician as having any developmental problems. Many of these children were not followed in neonatal intensive care unit (NICU) follow-up programs, and most were not receiving appropriate early intervention services (EIS). Previous studies have associated different neonatal events with the risk of developmental delay. Bronchopulmonary dysplasia (BPD) and periventricular leukomalacia (PVL) accounted for most of the variance of this sample's developmental outcome. Of these 100 ELBW infants, 56 received surfactant. Analysis demonstrated no significant differences in developmental outcomes between those who received surfactant and those who did not. However, those who received rescue surfactant were more likely to acquire a diagnosis of BPD. As demonstrated by this study, ELBW infants are at risk for significant developmental problems. This supports the need for targeted outreach, developmental monitoring, early intervention services, and parent support and education.

21 citations


Journal Article•
TL;DR: The results of this study indicated that 12-lead ECG acquisition by district officers did not extend the on-scene time.
Abstract: The purpose of this evaluation was to determine if a prehospital 12-lead electrocardiogram (ECG) led to a delay in transportation when compared to non-12-lead ECG, and if it led to improved "door to drug" time. A quasi-experimental design was used to compare on-scene times for suspected acute myocardial infarction (AMI) patients; a comparison was made between advanced life support (ALS) units without 12-lead ECG and those who were augmented by equipped EMS district officer units. Our control group had an on-scene time of 22.05 minutes; the mean on-scene time for the experimental group was 21.85 minutes. The results of this study indicated that 12-lead ECG acquisition by district officers did not extend the on-scene time.

20 citations


Journal Article•
TL;DR: Results showed that cTnT was the most useful marker for risk stratification of acute coronary syndrome patients and was reported to be able to predict which patients will benefit from treatment with regimens of low molecular weight heparin.
Abstract: Biochemical markers provide clinicians with an important tool for the assessment of acute coronary syndromes. Biochemical markers, including total creatine kinase (total CK), creatine kinase-MB (CK-MB), the MB isoforms, and myoglobin, as well as the troponins--cardiac troponin T (cTnT) and cardiac troponin I (cTnI)--are all used for assessment of the suspected acute myocardial infarction (AMI) patient. In the context of myocardial infarction (MI) diagnosis, total CK is a relatively sensitive marker, but it lacks myocardial specificity because skeletal muscle contains high concentrations of CK. CK-MB is the benchmark for biochemical markers and has both high sensitivity and specificity; however, CK-MB is also present in skeletal muscle and is not diagnostic until eight to twelve hours after onset of symptoms. The MB isoforms are diagnostic earlier but have the same cardiac specificity issues as CK-MB. Myoglobin becomes abnormal about one hour after onset of symptoms and is a sensitive marker for MI; however, myoglobin is cleared quickly and is not cardiac specific. Both cTnT and cTnI are cardiac specific and show high sensitivity and specificity for MI. Risk stratification of acute coronary syndrome patients is another role for biochemical markers; CK-MB, cTnT and cTnI have all been proposed for this function. Compared with CK-MB, both cTnT and cTnI are better able to predict short-term mortality following the index event. Analysis using a logistic regression model that included the electrocardiogram, cTnT, and cTnI showed that cTnT was the most useful marker for risk stratification. Finally, cTnT was reported to be able to predict which patients will benefit from treatment with regimens of low molecular weight heparin.

18 citations


Journal Article•
TL;DR: A patient on chronic hemodialysis presenting with shortness of breath and dysphagia was found to have massive hemomediastinum, a review of the world's literature prompted by this case reveals that this rare entity can be classified into three general groups.
Abstract: A patient on chronic hemodialysis presenting with shortness of breath and dysphagia was found to have massive hemomediastinum. A review of the world's literature prompted by this case reveals that this rare entity can be classified into three general groups: (1) hemomediastinum secondary to underlying bleeding disorder, (2) hemomediastinum secondary to hemorrhage into a mediastinal organ or gland, without underlying bleeding disorder and (3) idiopathic hemomediastinum, without underlying bleeding disorder. Therapy depends upon the underlying etiology and the severity of symptoms.

17 citations



Journal Article•
C Adamson1, T Cymet•
TL;DR: Primary rehabilitation, functional rehabilitation, and performance testing and the assessment of efficacy for each of these modalities are critical parts of proper treatment for ankle sprains.
Abstract: Ankle sprains are a common, costly, and potentially disabling problem. The proper history and physical examination will determine the need for radiological evaluation and treatment. Complications of ankle trauma like osteochondral fractures, peroneal tendon injuries, fracture of the os trigonum, synovial impingement, tarsal tunnel syndrome, Achilles tendon inflammation or rupture, and nerve injury are reviewed. The treatment of ankle sprains is based on the severity of the injury. Treatment begins with rest, ice, compression, and elevation. Casting and orthotics may be needed to facilitate healing. Primary rehabilitation, functional rehabilitation, and performance testing and the assessment of efficacy for each of these modalities are critical parts of proper treatment for ankle sprains.

16 citations


Journal Article•
TL;DR: Patients have memory losses, cognitive impairments, headaches, skin rashes, abdominal pain, secretory diarrhea, conjunctival irritation, and bronchospasm, and not all patients have all elements of the syndrome.
Abstract: The first case reports of human illness caused by exposure to Pfiesteria piscicida toxin(s) acquired outside of a laboratory are reported. Though Pfiesteria, a toxin-forming dinoflagellate, is responsible for killing billions of fish in estuaries in North Carolina, its role in human illness has remained controversial, in part due to lack of identification of the toxin. A recent fish kill in the rivers of the lower Eastern Shore has permitted careful investigation and identification of a distinct clinical syndrome resulting from exposure to the Pfiesteria toxin--Pfiesteria human illness syndrome (PHIS). Patients have memory losses, cognitive impairments, headaches, skin rashes, abdominal pain, secretory diarrhea, conjunctival irritation, and bronchospasm. Not all patients have all elements of the syndrome.

15 citations


Journal Article•
Dike Gl1•
TL;DR: A 23-year-old pregnant Pakistani female presented with hemichorea and hemiballismus at six weeks gestational age after similar symptoms had occurred during a previous pregnancy resulting in a spontaneous abortion.
Abstract: A 23-year-old pregnant Pakistani female presented with hemichorea and hemiballismus at six weeks gestational age. Similar symptoms had occurred during a previous pregnancy resulting in a spontaneous abortion. Chorea gravidarum, a disorder characterized by choreiform and athetoid movement presenting during pregnancy, is rare. In the past, rheumatic disease was generally the etiology, but today, collagen vascular disease should also be considered. Treatments include neuroleptics for symptomatic relief and therapies targeted toward the underlying pathology.

14 citations


Journal Article•
J L Tatum1•
TL;DR: The acute cardiac team developed a comprehensive evaluation and triage strategy based on risk, including a reduction in overall costs through the use of perfusion imaging, and the data suggest that it has been able to accomplish all four goals.
Abstract: The cost of evaluation and treatment of patients presenting to the emergency department with chest pain is estimated in billions of dollars. Current standards of practice, however, cannot reliably distinguish between high- and low-risk patients. Efficient management of this population requires that we reduce: 1) delays in therapy, 2) soft admissions, 3) inappropriate dispositions, and 4) cost. In a multidisciplinary effort, the acute cardiac team developed a comprehensive evaluation and triage strategy based on risk. Our data suggest that we have been able to accomplish all four goals, including a reduction in overall costs through the use of perfusion imaging.

Journal Article•
TL;DR: Carotid endarterectomy can be performed with an acceptable neurologic complication rate under either type of anesthesia, and use of regional anesthesia decreases intraoperative shunting and may decrease the rate of cardiopulmonary complications.
Abstract: Purpose The study compares the outcome of carotid endarterectomy in the community hospital setting using regional versus general anesthesia. Methods Two hundred thirty-six consecutive operations performed on 200 patients (99 operations using superficial and deep cervical block with local supplementation, and 137 procedures using general anesthesia) during a three-year period were analyzed retrospectively. Noncontinuous data were analyzed using Pearson chi-square, continuous data using Student's t-test. Results Demographic data and risk factors were similar for both groups. However, patients in the regional anesthesia group had a higher incidence of contralateral stroke and a lower incidence of peripheral vascular disease than patients in the general anesthesia group. Shunts were used less frequently for the regional anesthesia group. The neurologic complication rate was 2.2% for the general anesthesia group and 2.0% for the regional anesthesia group. The single death (fatal stroke) occurred in the general anesthesia group. Four of five major cardiopulmonary complications occurred in the general anesthesia group. Conclusions Carotid endarterectomy can be performed with an acceptable neurologic complication rate under either type of anesthesia. Use of regional anesthesia decreases intraoperative shunting and may decrease the rate of cardiopulmonary complications.

Journal Article•
TL;DR: Toxic activity of a Pfiesteria-like organism occurred for much of 1997 in the waters of the lower Pocomoke River on Maryland's Eastern Shore, and findings on examination were limited to neurocognitive deficits in short-term memory and learning difficulties.
Abstract: Toxic activity of a Pfiesteria-like organism occurred for much of 1997 in the waters of the lower Pocomoke River on Maryland's Eastern Shore. Maryland's experience with these toxic blooms of dinoflagellates, current knowledge of their potential human health effects, and the actions taken by state government agencies in response to a potential public health threat are reviewed. A medical diagnostic team commissioned by the Department of Health and Mental Hygiene evaluated a group of persons with intense exposures to lesioned fish or the waters from which they came and/or prominent symptoms following exposure to affected waters or lesioned fish. The principal findings of the team included consistent complaints of memory problems, acute burning of the skin following direct contact with water, and respiratory irritation. Findings on examination were limited to neurocognitive deficits in short-term memory and learning difficulties. Physicians and citizens are asked to continue to report, through their local health departments, illnesses thought to be related to exposure to lesioned fish or the waters from which they are taken. Persons with questions or wishing to report finding lesioned fish should call the state Pfiesteria hotline at 1-888-584-3110.

Journal Article•
TL;DR: Physicians should consider dengue in the differential diagnosis of a patient with a febrile illness and a history of recent travel to a tropical area as well as travellers to endemic areas.
Abstract: An outbreak of dengue fever occurred among a small group of Maryland and Pennsylvania residents following a trip to the British Virgin Islands in January 1996. Dengue fever is a mosquito-borne viral illness that occurs primarily in tropical urban areas. Most dengue infections are benign and self-limited, but some produce severe and fatal hemorrhagic disease. Although dengue is not endemic in the continental United States, travelers may acquire the infection during visits to the tropics. Physicians should consider dengue in the differential diagnosis of a patient with a febrile illness and a history of recent travel to a tropical area. Travelers to endemic areas should be advised to take precautions to prevent mosquito bites.

Journal Article•
TL;DR: Several types of basal cell carcinomas are described, as well as squamous cell carcinoma, which can be locally destructive, and removal can cause significant disfigurement and functional impairment.
Abstract: Nonmelanoma skin cancer is the most common cancer in the United States, and its incidence is increasing dramatically. Although mostly caused by sun exposure, less common causes are also discussed. Several types of basal cell carcinomas are described, as well as squamous cell carcinoma. While these carcinomas rarely cause death, they can be locally destructive, and removal can cause significant disfigurement and functional impairment. The value of early detection is emphasized.

Journal Article•
TL;DR: To facilitate patient assessments, enhance compliance with health care instructions, and thus achieve the best possible medical outcomes and levels of satisfaction, practitioners must acknowledge and respect the cultural differences patients bring to medical care environments.
Abstract: As cultural and ethnic diversity increase within American society, physicians face new challenges in recognizing patients' culturally defined expectations about medical care and the cultural/ethnic dictates that influence physician-patient interactions. Patients present to practitioners with many mores related to concepts of disease and illness, intergenerational communication, decision-making authority, and gender roles. In addition, many cultural groups follow folk medicine traditions, and an increasing number of Americans seek treatment by practitioners of alternative therapies before seeking traditional western medical attention. To facilitate patient assessments, enhance compliance with health care instructions, and thus achieve the best possible medical outcomes and levels of satisfaction, practitioners must acknowledge and respect the cultural differences patients bring to medical care environments.

Journal Article•
TL;DR: There is insufficient evidence to recommend these hormones as therapies for aging, and there are potential risks from their use, according to this review of the scientific literature.
Abstract: Since ancient times, humans have been concerned with developing and preserving youthful vigor. Today, there is enough understanding of the aging process to attempt to delay it. This review considers four popular and easily obtainable anti-aging hormones: melatonin, growth hormone, testosterone, and dehydroepiandrosterone (DHEA). Many of the benefits of using these hormones, which are promoted in the lay literature, are based on animal studies and weak associations. This review critically examines the scientific literature. At this time, there is insufficient evidence to recommend these hormones as therapies for aging, and there are potential risks from their use. The information provided here will help physicians discuss the use of these hormones with inquiring patients.

Journal Article•
Stavrakis P1•
TL;DR: The theoretical justification for bloodletting is provided, followed by a detailed description of the treatment Washington received, reflecting the role played by heroic medicine in the American president's demise.
Abstract: Bloodletting was an established medical treatment for more than two millennia, yet its greatest impact in the United States is undoubtedly the role it played in the treatment of President George Washington. The theoretical justification for bloodletting is provided, followed by a detailed description of the treatment Washington received, reflecting the role played by heroic medicine in the American president's demise. The arguments of bloodletting's critics emerge as well founded; indeed, Washington and many others might have suffered less had heroic medicine not been applied.

Journal Article•
TL;DR: There are presently no data in the United States that support the prehospital administration of thrombolytic therapy once in the emergency department, and future consideration may be given to purchasing defibrillators with integrated 12-lead electrocardiographic capability.
Abstract: Maryland has a pioneering and sophisticated system of prehospital emergency medical care. Approximately 44,000 patients with chest pain and/or acute myocardial infarction were transported last year by emergency medical service (EMS) providers who also responded to approximately 5,000 out-of-hospital cardiac arrests. Funding has recently been prioritized to enable EMS providers to be trained and equipped with automated external defibrillators. Future consideration may be given to purchasing defibrillators with integrated 12-lead electrocardiographic capability. These devices have been shown to reduce the time required to initiate thrombolytic therapy once in the emergency department. There are presently no data in the United States that support the prehospital administration of thrombolytics.

Journal Article•
TL;DR: Recognition of risk factors and examination of the optic nerve are key strategies to identify individuals at risk of glaucoma and aid in reducing the potential of irreversible blindness.
Abstract: Glaucoma is a leading cause of blindness within the United States and the leading cause of blindness among African-Americans. Measurement of intraocular pressure only is no longer considered adequate for screening. Recognition of risk factors and examination of the optic nerve are key strategies to identify individuals at risk. Medical and surgical treatment of glaucoma have significantly improved in recent years. Early diagnosis and appropriate therapy will aid in reducing the potential of irreversible blindness.

Journal Article•
TL;DR: This is a case of a Maryland child who sustained transanal suction which resulted in prolapse and avulsion of the small intestine from its blood supply.
Abstract: Wading pools with displaced drain covers and single drain outlets can lead to life-threatening injuries This is a case of a Maryland child who sustained transanal suction which resulted in prolapse and avulsion of the small intestine from its blood supply Because the injury would likely have been prevented if at least one of three safety precautions had been followed, standards for pool operation and pool design are reviewed

Journal Article•
TL;DR: The physician must remain alert to its possibility when confronted with emergency care of patients having received neuroleptics, particularly when hypermetabolic states are etiologically consequential in the development of other disease processes, for example, acute myocardial infarction.
Abstract: The neuroleptic malignant syndrome (NMS) is a potentially life threatening reaction usually observed following administration of dopaminergic antagonists (neuroleptic medications, eg, phenothiazines, thioxanthenes, and haloperidol) NMS is characterized by mental status changes, muscle rigidity (and movement disorders such as dyskinesias and akathisias), leukocytosis, hyperthermia, and autonomic dysfunction Because of the variants of this disease, the physician must remain alert to its possibility when confronted with emergency care of patients having received neuroleptics, particularly when hypermetabolic states are etiologically consequential in the development of other disease processes, for example, acute myocardial infarction

Journal Article•
TL;DR: Establishing comprehensive medical management for the critically ill obstetrical patient and understanding the legal rights of both patients (mother and fetus) will help avoid conflicts and potentially improve survival.
Abstract: Postmortem cesarean sections are rare events, but modern technology is forcing society to explore the definition of viability and the legal rights of both mother and fetus that ultimately will affect the frequency and use of this rare operation. Since the Human Immunodeficiency Virus (HIV) prevalence rate and the number of critically ill obstetrical patients with Acquired Immunodeficiency Syndrome (AIDS) continues to rise, it is reasonable to assume more patients and physicians may be confronted by issues concerning fetal and maternal rights and other considerations in perimortem delivery. A 33-year-old woman, at 27 weeks' gestation, with fulminant AIDS was admitted to the intensive care unit (ICU) in respiratory distress. As her condition deteriorated the complex problem of caring for both mother and fetus emerged. A patient advisory panel explored the issues with the patient, her family, and her health care team. Eventually a peri/postmortem cesarean section was performed on the mother when she suffered an acute fatal cardiorespiratory arrest. With the prevalence of AIDS increasing and with most women not being tested prior to pregnancy, many obstetricians will be confronted with new medical and legal challenges. Establishing comprehensive medical management for the critically ill obstetrical patient and understanding the legal rights of both patients (mother and fetus) will help avoid conflicts and potentially improve survival.

Journal Article•
TL;DR: Can the known evidence-based data on heart attacks be interpreted and applied in a systematic way that will unite efforts to reduce the significant heart attack deaths within the state?
Abstract: The focus of this symposium is Maryland's heart attack problem. The question is: Can the known evidence-based data on heart attacks be interpreted and applied in a systematic way that will unite efforts to reduce the significant heart attack deaths within the state? To determine this we need to go beyond what is currently being done and aim at a higher level of performance. Despite the medical advances in clot-dissolving therapies and minimally invasive surgeries, the acute prevention of heart attack death and damage has not been substantial. However, significant progress is possible. Better delivery systems, linking hospitals and communities, are needed. To accomplish this, emergency physicians and nurses, cardiologists, and paramedics need to form part of a team and have the support of the individual hospitals and the emergency medical system. Chest pain centers must function efficiently and cost effectively and bring about a community involvement that can significantly reduce heart attack deaths locally and, when combined with other hospitals, statewide.

Journal Article•
TL;DR: The physiologic conditions associated with menopause, including osteoporosis, cardiovascular disease, and breast cancer, are considered, with specific assessment of risks and benefits of hormone replacement therapy.
Abstract: A woman at the age of 50 in the United States has a life expectancy of approximately 30 years. The menopausal years, the symptoms associated with menopause, and concurrent conditions associated with these age groups are of major importance, since women may live up to one third of their lives in menopause. In this discussion, the physiologic conditions associated with menopause, including osteoporosis, cardiovascular disease, and breast cancer, are considered, with specific assessment of risks and benefits of hormone replacement therapy. Specific hormone replacement regimens are reviewed, along with non-estrogenic approaches to osteoporosis therapy. The long-term benefits of estrogen on female life expectancy are reviewed, balancing cardiovascular and osteoporosis benefits within the context of long-term effects on breast cancer risk.

Journal Article•
TL;DR: The evidence linking dietary fat, fruits and vegetables, and fiber to the incidence of numerous cancers warrants physicians making strong dietary recommendations to reduce their patients' risk of developing cancer.
Abstract: Unhealthy diets are a major cause of cancer. Extensive scientific research implicates three components of diet as being particularly important in the etiology of various cancers: dietary fat, fruits and vegetables, and fiber. The evidence linking these components to the incidence of numerous cancers warrants physicians making strong dietary recommendations to reduce their patients' risk of developing cancer.


Journal Article•
Skouge Jw1•
TL;DR: The history of Mohs surgery, the technique, and the indications for its use are described; and Mohs micrographic surgery offers the greatest potential for cure of difficult tumors, while providing for maximal preservation of healthy tissue.
Abstract: Most skin cancers can be managed effectively using standard therapeutic methods. However, specific subsets of skin cancers--including tumors that are recurrent, large, or aggressive, along with tumors located at sites of functional and cosmetic concern--provide a significant therapeutic challenge. Mohs micrographic surgery offers the greatest potential cor cure of difficult tumors, while providing for maximal preservation of healthy tissue. This paper describes the history of Mohs surgery, the technique, and the indications for its use.

Journal Article•
TL;DR: In this paper, the problem of administering the tests is addressed by interviewing people who are knowledgeable about the person being evaluated; this method is limited by the actual knowledge of the person interviewed.
Abstract: Intelligence (IQ) tests and scales of adaptive behavior are typically used to evaluate adults with mental retardation. Personality tests and instruments designed to measure behavior problems and psychopathology are also used. Repeated IQ testing is common but not useful for adults. Adaptive behavior scales and measures of psychopathology do appear useful, although the latter are relatively new and not widely used in clinical practice. Tests requiring skilled language responses are not useful for people with severe and profound disabilities. The problem of administering the tests is addressed by interviewing people who are knowledgeable about the person being evaluated; this method is limited by the actual knowledge of the person interviewed. Neuroimaging, still in the research stage, may be especially relevant in the future.

Journal Article•
TL;DR: This study reports the task force recommendations and describes those implemented thus far, including changes to the EMS system are quantified, descriptive data from the system are reported, and future goals are presented.
Abstract: Patients experiencing ischemic chest pain represent one of the most common emergencies in prehospital emergency medical service (EMS) systems. Recent national guidelines for emergency department and EMS care of chest pain and acute myocardial infarction (AMI) patients have quantified standards for time to evaluation and treatment. Prehospital EMS systems and hospitals will need to change their processes of care for chest pain patients to meet or exceed these national guidelines. In addition, the EMS system and the hospital will need to work more closely and seamlessly to integrate chest pain care for the maximum benefit of the patient. The Howard County Department of Fire and Rescue Services (DFRS) recognized the need for change in its EMS system. Its unique approach involved chartering a multidisciplinary task force to assess the current EMS system. The task force analyzed the literature to decide evidence-based standards for EMS system performance, and evaluated public and private EMS systems that possessed state-of-the-art processes for providing patient care. Based upon the information gathered and considering qualities essential to future performance, the task force made recommendations for changes to Howard County's EMS system. This study reports the task force recommendations and describes those implemented thus far. Changes to the EMS system are quantified, descriptive data from the system are reported, and future goals are presented.