An Unusual Case Report of COVID-19 Presenting with Meningitis Symptoms and Shingles

INTRODUCTION: As severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) spreads across the globe, physicians face the challenges of a contagious pandemic including which patients to isolate, how to conserve personal protective equipment, and who to test. The current protocol at our hospital is to place anyone with new cough, dyspnea, or fever into airborne and contact precautions and consider them for testing. Unfortunately, the symptomatic presentations of coronavirus disease 2019 (COVID-19) are proving more variable than previously thought. CASE REPORT: Our case of COVID-19 presented with headache and then progressed to a meningitis-like illness with co-existing shingles rash. CONCLUSION: COVID-19 can have a variety of initial presentations that are not the classic respiratory symptoms and fever. These presenting symptoms of COVID-19 can include a meningitis-like illness, as our case report indicates. The wide variety of presentations of COVID-19 may warrant widespread testing to identify cases, protect healthcare workers, and prevent the spread of this pandemic

Time is Money: The True Cost of Helicopter EMS (HEMS)

Background: Multiple studies have been published that attempt to examine relevant outcomes of utilizing helicopter transport over traditional ground-based emergency medical services (EMS). Unfortunately, these studies suffer from poor methodology and are confounded by substantial differences in training and expertise of the personnel involved in the medical transfer. The EMS system in Central Massachusetts is unique in that when a physician from an outside hospital calls for an HEMS transport, the pilot determines if weather conditions permit to fly without having any further knowledge about the patient. If flying is deemed unsafe, the helicopter personnel will retrieve the patient by traditional ground ambulance. This allowed us to compare these two transfer modalities while eliminating the confounder of crew expertise. We hypothesize that the overall mortality of these inter-facility transfers is comparable, regardless of mode of transport and diagnoses, if accompanied by highly-trained and experienced personnel. Purpose: This study aimed to delineate the advantages of helicopter transport (HEMS) over ground transport (GEMS) of critically ill patients undergoing inter-facility transfers. Methods: We performed a retrospective chart review of 2,129 patients that were transferred from an outside hospital to our tertiary care center in Central Massachusetts by a Helicopter EMS (HEMS) crew between January of 2010 and April of 2017. These patients were either transferred by ground ambulance or helicopter ambulance. Transfers occurred by ground ambulance in limited cases where HEMS was grounded due to poor weather. In these instances, the Helicopter crew, consisting of a paramedic and flight nurse, staffed a ground ambulance to complete the transfer. Furthermore, we identified 655 patients that were transferred directly from the scene of the emergency, but these patients were excluded due to inability to standardize for transport distance. After categorizing 1,323 patients that were transferred by HEMS and 151 patients that were transferred by GEMS, patients were matched to their respective All Patients Refined Diagnosis Related Group (APR-DRG) and In-Hospital Mortality data. Scalar and categorical outcomes were analyzed T-Test or Fishers exact test respectively. Sub-group analyses were completed by categorizing patients by diagnosis or APR-DRG severity level. Results: The use of Helicopter EMS significantly reduced the time to definitive care over Ground EMS by at least twenty-one minutes, but no-more than one hour and seventeen minutes depending on the location of the requesting hospital. We found no statistical difference in the age or gender of the population transferred by either HEMS or GEMS. However, the population transferred by GEMS had significantly increased APR-DRG Severity and Risk of Mortality scores over the population transferred by HEMS. Despite this finding, there was no difference in in-hospital mortality between the two transfer modalities. Subgroup analysis did not show any significant difference in mortality based on diagnosis or APR- DRG classification. Conclusions: Despite the significant reduction in the time to definitive care through the utilization of HEMS, there was no statistically significant survival benefit conferred to critically ill patients undergoing inter-facility transfers. This suggests that the transport methodology may be of secondary importance to the level of training of the providers who are delivering the care en route

Knowledge and Beliefs of EMS Providers toward Lights and Siren Transportation

INTRODUCTION: The use of warning lights and siren (WLS) increases the risk of ambulance collisions. Multiple studies have failed to demonstrate a clinical benefit to the patients. We sought to investigate the degree to which providers understand the data and incorporate it into their practice. METHODS: The authors distributed an anonymous survey to prehospital providers under their medical direction at staff and quality assurance meetings. The surveys asked the providers\u27 degree of agreement with four statements: transport with lights and siren shortens transport times; transport with lights and siren improves patient outcome; transport with lights and siren increases the risk of collision during transport; and transport with lights and siren reduces the utilization of mutual aid service. We compared responses between providers who had been in prior ambulance collisions and those who had not. RESULTS: Few responses reached statistical significance, but respondents tended towards agreement that WLS use shortens transport times, that it does not improve outcomes, and that it increases the risk of collision. Despite the overall agreement with the published literature, respondents report \u3e 80% of transports are conducted using WLS. CONCLUSION: The data demonstrate the surveyed providers are aware of the risk posed by WLS to themselves, their patients, and the public. Nevertheless, their practice in the absence of rigid protocols suggests they disregard this knowledge. Despite a large number of prior ambulance collisions among the surveyed group, a high number of transports are conducted using WLS

Altitude-Related Change in Endotracheal Tube Cuff Pressures in Helicopter EMS

INTRODUCTION: Over-inflation of endotracheal tube (ETT) cuffs has the potential to lead to scarring and stenosis of the trachea.1, 2,3, 4 The air inside an ETT cuff is subject to expansion as atmospheric pressure decreases, as happens with an increase in altitude. Emergency medical services helicopters are not pressurized, thereby providing a good environment for studying the effects of altitude changes ETT cuff pressures. This study aims to explore the relationship between altitude and ETT cuff pressures in a helicopter air-medical transport program. METHODS: ETT cuffs were initially inflated in a nonstandardized manner and then adjusted to a pressure of 25 cmH2O. The pressure was again measured when the helicopter reached maximum altitude. A final pressure was recorded when the helicopter landed at the receiving facility. RESULTS: We enrolled 60 subjects in the study. The mean for initial tube cuff pressures was 70 cmH2O. Maximum altitude for the program ranged from 1,000-3,000 feet above sea level, with a change in altitude from 800-2,480 feet. Mean cuff pressure at altitude was 36.52 +/- 8.56 cmH2O. Despite the significant change in cuff pressure at maximum altitude, there was no relationship found between the maximum altitude and the cuff pressures measured. CONCLUSION: Our study failed to demonstrate the expected linear relationship between ETT cuff pressures and the maximum altitude achieved during typical air-medical transportation in our system. At altitudes less than 3,000 feet above sea level, the effect of altitude change on ETT pressure is minimal and does not require a change in practice to saline-filled cuffs

Retrospective Analysis of Emergency Medical Services (EMS) Physician Medical Control Calls

INTRODUCTION: Although emergency medical services (EMS) standing-order protocols provide more efficient and accurate on-scene management by paramedics, online medical direction (OLMD) has not been eliminated from practice. In this modern era of OLMD, no studies exist to describe the prevalence of reasons for contacting OLMD. OBJECTIVES: The primary goal of this study was to describe the quantity of and reasons for calls for medical direction. We also sought to determine time diverted from emergency physicians due to OLMD. Finally, we hoped to identify any areas for potential improvement or additional training opportunities for EMS providers. METHODS: This was a descriptive study with retrospective data analysis of recorded OLMD calls from January 1, 2016, to December 31, 2016. Data were extracted by research personnel listening to audio recordings and were entered into a database for descriptive analysis. We abstracted the date and length of call, patient demographic information (age and gender), category of call (trauma, medical, cardiac, or obstetrics), reason for call, and origin of call (prehospital, interhospital, nursing home, or discharge). RESULTS: The total number of recordings analyzed was 519. Calls were divided into four categories pertaining to their nature: 353 (68.5%) medical; 70 (13.6%) trauma; 83 (16.1%) cardiac; and 9 (8%) were obstetrics related. Repeat calls regarding the same patient encounter comprised 48 (9.4%) of the calls. Patient refusal of transport was the most common reason for a call medical direction (32.3% of calls). The total time for medical direction calls for the year was 26.6 hours. The maximum number of calls in a single day was seven, with a mean of 2.04 calls per day (standard deviation [SD] +/- 1.18). The mean call length was 3.06 minutes (SD +/- 2.51). CONCLUSION: Our analysis shows that the use of OLMD frequently involves complex decision-making such as determination of the medical decision-making capacity of patients to refuse treatment and transport, and evaluation of the appropriate level of care for interfacility transfers. Further investigation into the effect of EMS physician-driven medical direction on both the quality and time required for OLMD could allow for better identification of areas of potential improvement and training

High accuracy CO2_2 line intensities determined from theory and experiment

Atmospheric CO$_2$ concentrations are being closely monitored by remote sensing experiments which rely on knowing line intensities with an uncertainty of 0.5\%\ or better. Most available laboratory measurements have uncertainties much larger than this. We report a joint experimental and theoretical study providing rotation-vibration line intensities with the required accuracy. The {\it ab initio} calculations are extendible to all atmospherically important bands of CO$_2$ and to its isotologues. As such they will form the basis for detailed CO$_2$ spectroscopic line lists for future studies.Comment: 5 pages, 2 figures, 1 tabl

Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services

Introduction: Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified-those arriving by private vehicle. Methods: We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of \u3c /=15 minutes, controlling for a variety of clinical factors. Results: Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27-0.96) for achieving DTA \u3c /= 15 minutes. Conclusion: Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition

Airbnb, Technological Change and Disruption in Barbadian Tourism: A Theoretical Framework

This paper focuses on how Airbnb, an internet platform which has created the possibility for mass participation in the tourism market, is resulting in class conflict between new entrants and the ‘traditional’ tourism industry. Specifically, it studies how traditional tourism interests in Barbados have responded to Airbnb by seeking to restrict participation in the industry and presents this as a microcosm of broader class transitions and conflicts associated with new technologies. The paper utilises a Marxist theoretical perspective buttressed by Joseph Schumpeter’s theory of ‘creative destruction’ – places emphasis on the process of destroying productive systems to understand how specific industries expand and survive – and Clayton Christensen’s notion of ‘disruptive innovation’ – a process by which a disruptive product transforms a market – for studying how transformations in technology are impacting the tourism industry in Barbados. Its aim is to provide an account of how the process of disruption is unfolding in Barbados by highlighting the reactions of the main hotel lobby group to Airbnb, while also applying the ideas of Marx, Schumpeter and Christensen as useful theoretical lenses through which to examine the unfolding of the process of disruption of settled class and historical control of a dominant economic sector by new technologies

Airbnb, Technological Change and Disruption in Barbadian Tourism: A Theoretical Framework

This paper focuses on how Airbnb, an internet platform which has created the possibility for mass participation in the tourism market, is resulting in class conflict between new entrants and the ‘traditional’ tourism industry. Specifically, it studies how traditional tourism interests in Barbados have responded to Airbnb by seeking to restrict participation in the industry and presents this as a microcosm of broader class transitions and conflicts associated with new technologies. The paper utilises a Marxist theoretical perspective buttressed by Joseph Schumpeter’s theory of ‘creative destruction’ – places emphasis on the process of destroying productive systems to understand how specific industries expand and survive – and Clayton Christensen’s notion of ‘disruptive innovation’ – a process by which a disruptive product transforms a market – for studying how transformations in technology are impacting the tourism industry in Barbados. Its aim is to provide an account of how the process of disruption is unfolding in Barbados by highlighting the reactions of the main hotel lobby group to Airbnb, while also applying the ideas of Marx, Schumpeter and Christensen as useful theoretical lenses through which to examine the unfolding of the process of disruption of settled class and historical control of a dominant economic sector by new technologies

MARVEL analysis of the measured high-resolution rovibrational spectra of C2H2

Rotation-vibration energy levels are determined for the electronic ground state of the acetylene molecule, $^{12}$C$_2$H$_2$, using the Measured Active Rotational-Vibrational Energy Levels (MARVEL) technique. 37,813 measured transitions from 61 publications are considered. The distinct components of the spectroscopic network linking ortho and para states are considered separately. The 20,717 ortho and 17,096 para transitions measured experimentally are used to determine 6013 ortho and 5200 para energy levels. The MARVEL results are compared with alternative compilations based on the use of effective Hamiltonians.Comment: 55 pages, 8 figures, JQSRT, 201