Current opinion in critical care
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The changing landscape of health care has resulted in an increase in the delivery of critical care in the emergency department. Although the emergency department duration is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. The care provided during the emergency department stay for critically ill patients has been shown to significantly impact the progression of organ failure and mortality. ⋯ The need to maximize patient throughput in frequently overcrowded emergency departments hinders the provision of optimal care to the critically ill patient. Methodologies should be developed to examine the quality of patient care and objectively measure the impact of clinical interventions. The potential to improve outcome through educational initiatives and resource allocation should not be viewed as a burden of delivering a higher level of care in this setting but as a significant opportunity to effectively mitigate the socioeconomic consequences.
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Curr Opin Crit Care · Dec 2002
Role of the physician in prehospital management of trauma: North American perspective.
To some extent or another, physicians have been involved in emergency medical services (EMS) systems in North America for decades. Over the years, physicians from different specialties have been involved with EMS, occasionally as full-time or part-time employees of the EMS system but more often on a voluntary or small contractual basis. Regardless of the employment relationship, most states and provinces now require by statute that each EMS system, particularly those providing advanced life support (ALS) services, have a designated EMS medical director. ⋯ However, by becoming an intermittent participating member of the EMS team in the unique out-of-hospital setting, these on-scene physicians can help to better scrutinize the care rendered and thus more effectively modify applicable protocols and training as needed. Historically, such practices have helped many EMS systems-not only in terms of reforming traditional protocols but also by helping to establish improved medical care priorities and even system management changes that affect patient care. In addition, active participation helps the accountable EMS physician not only to identify weaknesses in personnel skills and system approaches, but it also provides an opportunity for role modeling, both medically and managerially.
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The evaluation and management of acute renal failure in the ICU patient remains a formidable task because of the complexity of this condition. Clinical and physiologic assessment and complementing laboratory and imaging tests are currently insufficient to differ between true renal parenchymal damage (acute tubular necrosis; it is important to realize that this term does not necessarily imply widespread injury, because whole organ dysfunction in humans has often been associated with very limited parenchymal cellular necrosis) and prerenal azotemia (decreased renal blood flow with altered glomerular hemodynamics and subsequently diminished glomerular filtration, without significant epithelial cell injury). Moreover, tubular damage and altered glomerular hemodynamics may coexist or lead to each other, and their relative contribution to the evolving renal dysfunction has not been unequivocally established. ⋯ Because of the difficulties in analyzing the pathophysiology in humans, clinicians continue to rely largely on animal models to guide understanding and rationale for the identification of therapeutic targets. Data from such animal studies are complemented by studies in isolated perfused kidneys, isolated tubules, and tubular epithelial cell cultures. In this report, we summarize some concepts of acute tubular necrosis that have evolved as a result of these studies, evaluate available animal models, and underscore controversies regarding experimental acute tubular necrosis.