A Crew Resource Management Program Tailored to Trauma Resuscitation Improves Team Behavior and Communication

BACKGROUND: Crew Resource Management (CRM) is a team-building communication process first implemented in the aviation industry to improve safety. It has been used in health care, particularly in surgical and intensive care settings, to improve team dynamics and reduce errors. We adapted a CRM process for implementation in the trauma resuscitation area. STUDY DESIGN: An interdisciplinary steering committee developed our CRM process to include a didactic classroom program based on a preimplementation survey of our trauma team members. Implementation with new cultural and process expectations followed. The Human Factors Attitude Survey and Communication and Teamwork Skills assessment tool were used to design, evaluate, and validate our CRM program

Natural skeletal levels of lead in Homo sapiens sapiens uncontaminated by technological lead

Lead, Ba and Ca concentrations were determined in tooth enamel, femur and rib from buried skeletons of PreColumbian Southwest American Indians, 10 subjects who lived 1000 years ago on the Pacific coast at 34°N, and 13 subjects who lived 700 years ago in a desert valley tributary of the Colorado River at 37°N 111°W, both groups living in environments uncontaminated by technological Pb. For the coastal tribe, average Pb/Ca ratios were 1.1 × 10^(−7) in enamel, 2.3 × 10^(−7) in femur and 4.7 × 10^(−7) in rib, while Ba/Ca ratios were 1.2 × 10^(−5) in enamel, 32 × 10^(−5) in femur and 38 × 10^(−5) in rib (wt ratios). For the desert tribe, average Pb/Ca ratios were 4 × 10^(−7) in enamel, 11 × 10^(−7) in femur and 37 × 10^(−7) in rib, while Ba/Ca ratios were 1.1 × 10^(−5) in enamel, 7.5 × 10^(−5) in femur and 6.2 × 10^(−5) in rib. It is shown that biologic levels of Pb and Ba in buried femur and rib at both burial sites and in buried enamel at the Arizona site are obscured by excessive diagenetic additions of Pb and Ba from soil moisture. It is shown that one-third of the Pb in enamel at the Malibu site is biologic, yielding a skeletal Pb/Ca (wt) ratio of 4 × 10^(−8). This is equivalent to a mean skeletal concentration of 13 ng Pb g^(−1) bone ash, and a mean natural body burden of 40 μg Pb/70 kg adult Homo sapiens sapiens, uncontaminated by technological Pb. This value is about one-thousandth of the mean body burden of 40 mg industrial Pb/70 kg adult American today, which indicates the probable existence within most Americans of dysfunctions caused by poisoning from chronic, excessive overexposures to industrial Pb

Comparative increases of lead and barium with age in human tooth enamel, rib and ulna

Lead and Ba in postmortem tooth enamel, rib and ulna of six contemporary people (67–96 years; ave. 80) were shown to exhibit similar accumulations with age in the three different types of osseous tissue: Pb/Ca (wt) = 3.0, 5.2, and 3.9 × 10^(−5) in rib, ulna, and tooth enamel; and Ba/Ca (wt) = 2.4, 2.4, and 1.8 × 10^(−5) in rib, ulna, and tooth enamel, respectively. Mean concentrations of Pb were 11, 19, and 14 μg g^(−1) in rib (ash), ulna (ash), and enamel (dry), respectively. Means for Ba were 8.7, 8.9, and 6.4 μg g^(−1) in rib (ash), ulna (ash), and enamel (dry), respectively. Comparison of Ba in ulna of our 80-year-old subjects with Ba determined by other investigators in bones of younger contemporary populations indicated that Ba accumulates with age at about half the rate of Pb accumulation in bone. Concentrations of Ba in rib, ulna and enamel were positively correlated and similar within an individual, but varied among subjects in proportion to variations in absorptive uptake in portal blood. Barium may diffuse from a blood-dentine source into enamel, where it replaces Ca and accumulates with age. Because of extreme Pb pollution of our 80-year-old subjects and its variation of intake with age, the correlation of Pb in tooth enamel with Pb in bone was more scattered than for Ba. It is shown by means of stable Pb isotopic tracers that: (i) among the three types of osseous tissue, the residence time of Pb is longest in enamel, where it apparently accumulates with age by diffusion with little loss through exchange; and (ii) the residence time of Pb is longer in compact ulna than in trabecular rib, as it accompanies Ca in its osteoblastic transfer from blood to bone and then in its osteoclastic transfer back to blood from bone

Depression is common and precludes accurate assessment of functional status in elderly patients with congestive heart failure.

BACKGROUND: Congestive heart failure (CHF) and depression are independently known to result in physical decline and diminished functional capacity in the general population. The prevalence and relationship of depressive symptoms in CHF to physical limitations has not been objectively examined. METHODS AND RESULTS: The Center for Epidemiological Studies Depression Scale (CES-D) was used to ascertain depressive symptoms in 33 elderly ambulatory individuals with CHF. Self-report assessment of functional status, cardiopulmonary exercise testing (CPX), and measurement of energy expenditure by doubly labeled water and Caltrac Accelerometer (Muscle Dynamics, Torrance, CA) were performed. Depressed and nondepressed groups were compared. Forty-two percent of the patients scored in the depressed range (CES-D score of 16 or greater). There were no differences in demographic variables or severity of illness between the depressed and nondepressed patients. Energy expenditure was comparable across groups. Although obtaining similar maximal heart rate and maximal oxygen consumption (VO2max) on CPX, the depressed group showed less exertion on exercise testing with a significantly lower respiratory quotient (P = .017). CONCLUSION: Depressive symptoms were common and unrelated to the severity of CHF. Although depressed individuals tended to report worse physical functioning than nondepressed individuals, objective assessment of energy expenditure was comparable. Depressed patients appear to underestimate their functional ability. Subsequently, inaccurate assessment of functional status may occur

Effects of exercise training on peak performance and quality of life in congestive heart failure patients.

BACKGROUND: Exercise programs for patients with heart failure have often enrolled and evaluated relatively healthy, young patients. They also have not measured the impact of exercise performance on daily activities and quality of life. METHODS AND RESULTS: We investigated the impact of a 6-month supervised and graded exercise program in 33 elderly patients with moderate to severe heart failure randomized to usual care or an exercise program. Six of 17 patients did not tolerate the exercise program. Of those who did, peak oxygen consumption increased by 2.4 +/- 2.8 mL/kg/min (P \u3c .05) and 6-minute walk increased by 194 ft (P \u3c .05). However, outpatient energy expenditure did not increase, as measured by either the doubly labeled water technique or Caltrac accelerometer. Perceived quality of life also did not improve, as measured by the Medical Outcomes Study, Functional Status Assessment, or Minnesota Living With Heart Failure questionnaires. CONCLUSION: Elderly patients with severe heart failure can safely exercise, with an improvement in peak exercise tolerance. However, not all patients will benefit, and daily energy expenditure and quality of life do not improve to the same extent as peak exercise